Health and Sanitation

Development in the Philippines:

Potential for Stakeholder Cooperation

and Education

Hayashi Seminar

Faculty of Economics

Faculty Linkage Program

Chuo University

February 2012
Preface

This volume is a collection of academic papers written by my third-year undergraduate

seminar students at Chuo University as a product of their one-year research project in the
2011 school year. In the process of this project, my students conducted their field survey
in the Philippines during two weeks from 28 August to 9 September 2011.
This one-year study project was staged for the seventh time this school year, and the
countries my students dealt with in the past were Laos, Indonesia and the Philippines. The
current third-year students decided to tackle the Philippines again and investigate its
poverty and development.
Similar to the previous four years, I commissioned almost all tasks to the participating
students wherever possible, because I would like to foster their initiatives and reflect their
wishes. In February 2011, my seminar students launched full preparations toward their
research project, starting with a series of discussions on the selection of the country and
academic fields to be investigated.
As in past years, the project team in this school year has consisted of two different
Hayashi seminars. Out of 21 members in total, 13 are from Hayashi seminar of the
Faculty of Economics and the remaining 8 from Hayashi seminar of Chuo-specific
Faculty Linkage Program (FLP). This combined team with the large number of
participants has carried out the student-led and tough study project.
In such challenging conditions, the economics-FLP joint team as a whole and four
individual study teams fully prepared their research project, actively executed their field
survey in Manila and the surrounding areas, and finally produced this thesis. For the first
time ever in my seminar, the current batch student set up a unified theme within a single
sector and investigated further detailed research topics by four teams. Specifically, in the
context of “health and development through cooperation among stakeholders and
education,” four research teams, respectively, examined: 1) improvement of adolescent's
knowledge on reproductive health through peer education; 2) development of sanitation
facilities and diffusion of its use through education and awareness activities; 3)
public-private partnership (PPP) in nutritional improvement; and 4) relationships among
stakeholders in the TB control programs.
Overall, I have highly appreciated representatives of economics/FLP seminars for
i
their leadership and good management, team leaders for their academic initiatives and
good coordination, and all participating members for the quality of this study through
their hard work.
Finally, I would like to express my strong gratitude to all those who extended a
helping hand to my students when they worked for this research project. In particular, I
am so grateful to organizations/individuals that kindly received my students in Laos and
Japan and warmly provided them with valuable information/materials. Also, my deepest
appreciation goes to Mr. Toshifumi SUZUKI, Mr. Tsuyoshi MIYATA, and Chuo
University for their financial assistance.

Mitsuhiro HAYASHI
Faculty of Economics, Chuo University
Tokyo, Japan
28 January 2012

ii
Acknowledgements

This paper was written by the students of Hayashi seminar in Chuo University, Japan.

The main theme of our survey is “Health and Sanitation development in the

Philippines: potential of education and stakeholder cooperation” and we carried out our

on-the-spot survey for approximately two weeks from 28th of August to 9th of

September 2011.

It is a pleasure to thank those who made this thesis possible for the warmest

understandings and supports of our study and giving thorough knowledge. We owe our

deepest gratitude to following people:

Mr. Ahl Aquino, Dr. A.Kaptiningsih, Dr. Akihiro Ohkado, Mr. Akira Matsumoto ,

Mr. Alan Baird, Mr. Andrew D.Ong, Mr. Angelito L. Umali, Ms. Arianne Dumayas, Ms.

Arlene Calaguian Alano, Mr. Apol T. Jimenez Ms. Ashlee Pattinson, Ms. Belle Nabor,

Mr. Brayant B. Gonzales, Professor Cristine DLR. Villagonzalo, Ms. Czarina Martinez,

Mr. Dan Lapid, Ms. Dinna Sane, Ms. Ecille Go, Ms. Eiko Ohori, Sr. Eline Pascaldo, Mr.

Gerard Servais, Mr. Gessen Rocas. Ms. Harumi Kodama, Ms. Helen Q. Lim, Mr. Hideaki

Noma, Mr. Hisashi Tajima , Ms. Irene Mercado, Ms. Jackeline Acosta, Mr.

James“Bong”Gordon, jr, Mr. James Bryan B. de Guzman, Dr. Jun Nakagawa, Dr.

Kayako Sakisaka, Mr. Kazuki Tsumagari, Dr. Kenji Amamoto, Dr. Kenneth Ronquilo,

Mr. Kiyoshi Nakamitsu, Ms. Lilia GC Casanova, Ms. Lyn N. Capistrano, Ms. Mami Kon,

Ms. Mari Nishino, Ms. Maria Lourdes A. manuel, Ms. Maria Lourdes A.Vega, Mr.

Mario Balibago, Dr. Mario V. Capanzana, Mr. Marlou T. Palomar, Ms. Mary Kristine

Segovia-Sionson, Mr. Melf Kuehl, Ms. Mien Ling Chong, Mr. Naoteru Honda, Ms.

iii
Natsuko Terauchi, Ms. Nheyshiel Grace Salalila, Dr. Nobuyuki Nishikiori, Mr. Percival

M. Abad, Mr. Rhenz Faustino, Mr. Rolando, Ms. Roxas Anzaira, Ms. Ryoko Nishida, Mr.

Sadakazu Ikawa, Ms. Sakiko Tanaka, Mr. Tadashi Tamura, Mr. Takashi Saito, Mr.

Timothy Grieve, Ms. Ugochi Daniels, Ms. Yolanda S. Quijano, Ms. Yoshie Tonohara,

Mr. Yousuke Tanaka, Ms. Yukiyo Nomura, Ms. Yuriko Oda.

Also, this thesis would not have been possible without support of Suzuki Toshifumi

scholarship.

Finally, we would especially like to thank our Professor, Mr. Mitsuhiro Hayashi for

his continuous support and direction which guided us to a completion of the elaborate

thesis.

iv
Table of Contents

Preface i

Acknowledgements iii

Table of Contents v

List of Table xi

List of Figure xii

Summary of the Study xiv

Introduction to the Study as a Whole: Background, Fields and Focal points 1

Background of the study 3

Previous study of the studies 5

Setting 4 fields in order to proceed our study 5

Focal point 1: Relationship between stakeholders 7

Focal point 2 Education 8

References 10

Chapter 1 Improving Adolescent’s Knowledge on Reproductive Health:

Effectiveness and Challenge of Peer Education 11

Introduction 13

Background of our study 13

1.1 Importance of RH 15

1.1.1 Maternal mortality ratio 15

1.1.2 Universal access to RH 17

1.1.3 Adolescent RH 19

1.2 Peer education 22

v
 1.2.1 What peer education is 22

1.2.2 The possibility of peer education 23

1.2.3 The challenges and limits of peer education 27

1.3 Adolescent RH in the Philippines 28

1.3.1 Politics and religion of the Philippines 28

1.3.2 The policy of the Philippines government 31

1.3.3 Adolescent RH in the Philippines 33

1.4 Peer education in the Philippines 35

1.4.1 Research outline 35

1.4.2 Case example 36

1.5 Analyzing case example 38

1.5.1 Analytical method 38

1.5.2 Conclusion of the interviews and questionnaires 39

1.6 Conclusion 63

1.6.1 Summary and conclusion 63

1.6.2 Issues and foresight 68

Appendix 70

Reference 73

Chapter 2 Direction of Expanding Sanitation Coverage and Its Customary

Usage: Considering the Effect of Awareness Program 76

Introduction 77

2.1 State of the world 79

2.1.1 Rate of achievement of the MDGs 79

2.1.2 Relation between defect of sanitation facilities and water-borne

vi
 disease 81

2.1.3 Economical loss which defect of sanitation brings about 82

2.1.4 A spread of the concept of WASH 85

2.1.5 Previous study 86

2.1.6 Overseas previous research 88

2.2 Condition in the Philippines 92

2.2.1 The sanitation condition 92

2.2.2 The sanitation condition at the school 93

2.2.3 The facing problem of sanitation 93

2.3 Outline of the Case Study in the Philippines 95

2.3.1 Research Outline 95

2.3.2 The definition of awareness program and accustoming themselves

to use facilities 96

2.4 Research cases in the Philippines 100

2.4.1 Case study WASH 100

2.4.2 Case study Fit for school 102

2.5 Consideration from cases focusing on the awareness programs 103

(1) Community participation 105

(2) The collaboration of the stakeholders 107

(3) Low cost 108

2.6 Conclusion 113

References 117

Chapter 3 The Possibility and Limitation of Public-Private Partnership in

Nutritional Improvement 121

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 Introduction 123

3.1 Nutrition problems and the state of nutritional improvement activities 125

3.1.1 The relationship between nutrition problems and poverty 125

3.1.2 The nutritional condition in the world 126

3.1.3 The symptoms resulting from malnutrition 128

3.1.4 The approaches for nutrition improvement in the world 130

3.2 Public-Private Partnerships 131

3.2.1 The background of Public-Private Partnerships 132

3.2.2 The classification of the forms of PPP approaches 134

3.2.3 The previous studies 135

3.3 Nutrition problems in the Philippines 140

3.3.1 The problems of the poor and the rich 140

3.3.2 Nutritional problems in the Philippines 142

3.4 Approaches for improving nutrition situation in the Philippines 144

3.4.1 Investigation 145

3.4.2 National Nutrition Council 145

3.4.3 Philippine Plan of Action for Nutrition (PPAN) 147

3.4.4 PPP for nutritional improvement 149

3.4.5 Analysis 154

3.5 Conclusion 158

References 160

Chapter 4 Potential of Relationships among Stakeholders of the TB Control

Programs : A Case Study Focused on the Difference of Network 163

4.1 Introduction 165

viii
 4.1.1 Background of our study 165

4.1.2 Limit of our Study 167

4.1.3 The organization of the paper 167

4.2 About TB 167

4.2.1 Basic knowledge of TB 168

4.2.2 TB and poverty 169

4.3 The Philippine with TB 174

4.3.1 The present situation of the Philippines 174

4.3.2 TB control in the Philippines 175

4.4 Need for relationships between stakeholders in the TB control

programs 180

4.4.1 The current of global TB control programs 180

4.4.2 Previous study 184

4.5 Case study of TB control in the Philippines 187

4.5.1 Study outline 187

4.5.2 Case study 192

4.5.3 Consideration 202

4.6 Conclusion 207

References 211

Analysis and Conclusion 213

Analysis 215

Stakeholder cooperation 215

Education 217

Conclusions 220

ix
 References 225

Appendixes 227

Schedule for Field Survey in the Philippines in 2011 HAYASHI Seminar, Chuo

University, Tokyo, Japan 229

Visiting List 233

Maternal and child Team 233

Water and Sanitation Team 236

Food and Nutrition Team 239

Infection disease Team 242

Postscript 245

x
List of Table

Table 1-1 History of the Philippines 31

Table 1-2 Summary of Interview Research 40

Table 1-3 Attribution 43

Table 1-4 Questions and answers about sex knowledge 45

Table 1-5 improvement in knowledge 60

Table 2-1 Estimated economic gains from improved sanitation (million US$) 95

Table 3-1 Percentage of women taking weekly Iron-Folic acid Supplementation by

pregnancy status and survey period 140

Table 3-2 Targets of PPAN for 2008-2010 148

Table 4-1 The Millennium Development Goals 6: HIV/AIDS, Malaria, and other

disease 170

Table 4-2 Major 22 high-burden country in the world 175

Table 4-3 Transition of TB control in the Philippine 179

Table 4-4 Goals of Stop TB Partnership 184

Table 4-5 Questionnaire to the organizations 189

Table 4-6 Questionnaire to the inhabitants 190

Table 4-7 Answer from WHO, DOH, RJPI and CANOSSA 195

Table 4-8 Answer from ICAN 200

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 List of Figure

Figure 1-1 Maternal mortality ratio 16

Figure 1-2 Fertility differences between the rich and the poor Average number of

children by region and quintiles of household wealth 21

Figure 1-3 Adolescent fertility rates 35

Figure 1-4 Gender 44

Figure 1-5 Frequency 44

Figure 1-6 Job 44

Figure 1-7 Partner 44

Figure 1-8 Sex experience 44

Figure 1-9 Questions and answers about sex knowledge 45

Figure 1-10 Having sex on safe day would perfectly prevent girls from getting

pregnant 56

Figure 1-11 You will get pregnant by having sex even once 56

Figure 1-12 You will not get infected with STD by having sex with a particular

partner 56

Figure 1-13 Use of condoms is effective to prevent girls from being infected with

sexually transmitted disease 56

Figure 1-14 You will become susceptible to HIV/AIDS once you get infected with

STD 57

Figure 1-15 Use of condoms would perfectly prevent girls from getting pregnant 57

Figure 1-16 You may get infected with sexually transmitted diseases by having oral

sex 57

Figure 1-17 You will be difficult to get pregnant once you get infected with STD 57
xii
Figure 1-18 Enjoy peer education 58

Figure 1-19 Peer educator was friendly 59

Figure 1-20 Want to spread peer education to friends 59

Figure 2-1 The economic loss per year by the defect of sanitation facilities and The

economic effect by introduction of health facilities in 2005 (dollars in

millions) Economic losses and gains (dollars in millions) 84

Figure 2-2 Social environmental issue relating to water supply and sanitation 88

Figure 2-3 Economic losses due to poor sanitation, by impact type (million US$) 95

Figure 2-4 These posters painted by pupils as school curriculum for sanitation

education 99

Figure 2-5 Rainwater harvesting tank 100

Figure 2-6 Sanitation facilities of Bagong Ilog elementary school where the project

of Fit for School is ongoing. 102

Figure 2-7 The toilet in the urban poor area 104

Figure 3-1 Rate of extreme hunger in the world by region 127

Figure 3-2 Rate of stunted, underweight, thinness, overweight of 0-5 children in the

Philippines (1990-2008) 143

Figure 3-3 Structure of NNC 147

Figure 4-1 TB and poverty linked in vicious cycle 173

xiii
Summary of the Study

In chapter 1, we have researched about the effectiveness of peer education as an approach

to improve access to the reproductive health in the Philippines. In the Philippines,

adolescent fertility ratio remains high and has not made a considerable improvement

since 1970s. On the back ground, there is an insufficient access to the information

concerned with reproductive health, poor access to contraceptives, fact that the sexual

issues are remarkably sensitive in the Philippines. 83% of the Filipinos believe in

Catholic, and division of the politics and religion has not been achieved in the Philippines.

Hence, there is no national framework of the reproductive health. In addition, there are

fundamental issues of poverty and it is true that pregnancies and birth deliveries in

adolescent are common in the poor adolescents who could not receive education. To

improve access to the information, this research has focused on peer education. Peer

education is an approach or strategy that involves the use of people in similar age group or

upbringings, and it is recently receiving plenty of attention in the field of reproductive

health. This research has set up the hypothesis “peer education improves the adolescent’s

knowledge of reproductive health” To verify this hypothesis, we have set up the

following four research questions. “How is the present situation of the access to RH in the

Philippines?” “How does the religion affect RH?” “What are the needs of RH among

people in the Philippines?” “What kind of effect was provided by peer education?”

Moreover, we have conducted questionnaires to students who receive peer education in

order to measure accurate improvement in their knowledge. Peer education improved

youth’s knowledge of STD, correct contraception, and reproductive function etc. This

research reveals that peer education leads to not only improvement of the knowledge, but

also actually doing these. In addition, these effects are found in not only peer students but
xiv
also peer educator, so peer education is of mutual benefit to students and educator. On the

pretext of conducting research and studies, our hypotheses was proved. However, it is

apparent that the main target of peer education is not only adolescent whom this research

focused on, but also people of all ages, mainly 20s youth. Furthermore, this research

focused on only improving on knowledge, but actually, peer students and educator

become take action based on knowledge gained in peer education.The separation of

politics and religion is not done in the Philippines, and national framework of sexual

education is not defined, too. Moreover, there are many out-of school-youth because of

poverty and some of them get unwanted pregnancy because of lack of knowledge. To

improve this present situation, peer education is one of the effective approaches to

provide youth with knowledge about RH.

Chapter 2 is a research about the effect of awareness program as the approach of

expanding sanitation coverage and its customary usage. In developing countries, it is

considered that defect of sanitation facilities is a big problem. Although access of safe

drinking water tackles preferentially, supply of sanitation facilities is far late. Defect of

sanitation facilities will also be connected with water pollution because polluted water

flows into a river and also causes soil pollution by being forced to excrete in the field.

Such an insanitary situation becomes a cause which causes water borne disease and leads

also to an economical loss of a country. In the Philippines, the sanitation facilities such as

drainage and toilets were improved only to a limited extent because of the delay in

construction causing some serious problems. However, the residents in poverty area have

still no access to safe water. The number of toilets in school is also lacking. It is difficult

to use these facilities even if there are sanitation facilities in school because they have

become old. To assist in this situation, the government of Philippines has been conducting

xv
activities. However, the government has not adopted definite policies and the lack of

adequate funds has been the biggest barrier against improving the sanitation facilities.

This research believes that the importance of sanitation facilities has to be spread through

the sanitation education or media. As a result, we expect the students and the inhabitants

to get accustomed to sanitation facilities and use them properly and spread the knowledge

about sanitation to a wider sphere of people. Our study was setup under the theme

'Importance of awareness program to spread awareness about sanitation facilities and get

the people accustomed to use properly". We investigate and examine 2 case studies

conducted in Philippines. In this thesis, we focus on spreading knowledge about

sanitation facilities to schools/communities through awareness program. We will express

on what we can do in order to spread the awareness about sanitation effectively and to use

improved sanitation facilities for the community's sustainability.This thesis deal with

WASH project which conduct the spread of water and sanitation facilities and awareness

program for school and habitants living in poverty area, and Fit for School which is aim at

accustom hygienic habit with supported goods for students in the school. Researching the

project, we found 3 common points. They are (1) Low cost, (2) Community participation

and (3) The collaboration of the stakeholders. These 3 points must be the effect of

awareness program and they advance prevailing the facilities and making people adjust

using them properly. Thus the importance of awareness program is proved. Moreover, it

seldom be seen that the participation of the company through CSR activities and BOP

business. Therefore it may be possible to speed up to solve the problem about sanitation

in the Philippines through the cooperation of the companies by CSR and BOP.

The third chapter researched into “The possibility and limitation of public-private

partnership in nutritional improvement”. Solving nutrition problems is important because

xvi
they are related to the whole field of health and sanitation. Nutritional improvement

contributes to cure and prevent every disease. It is also important to maintain and recover

the energy of each person for the development of a country. Based on this opinion, this

chapter focuses on the various methods of nutritional improvement, especially

public-private partnership (PPP). Nutritional problems are divided broadly into two

categories: hunger and hidden hunger. “Hidden hunger” is an undernourished condition

caused by lack of micronutrient such as vitamins and mineral, which are indispensable for

maintaining health. It causes incomplete development, anemia, loss of eyesight, and other

problems. In many of the developing countries, these nutrition problems influence the

next generation, so various approaches have been developed all over the world. Mainly,

developing fortification technologies, spreading supplementation, feeding and education

can be picked up as examples. This research pays attention to PPP along with those types

of nutritional improvement. The origin of PPP is the movement of privatization in 1980’s.

After that, this movement gradually spreads to different fields and the steps and contents

of cooperation changed. This research focuses on PPP, because PPP should be effective

for improving nutrition through complementing the weakness and utilizing the strength of

each actor. At first, PPP is clearly defined and the forms of approaches are classified.

There are various forms of PPP such as funding support, technology transfer and

education. The preceding studies insist that PPP projects are important. Furthermore, in

order to have better results, PPP should include education and improvement of

recognition. In the Philippines, the economic disparity between rich and poor is serious.

The wide disparity makes the wealthy class to have lifestyle-related diseases and the poor

to suffer from hunger and malnutrition. This research focuses on the problems of the poor

people in the Philippines because the nutritional improvement of the poor is important for

xvii
the development the country. According to the national nutrition survey carried out in

2008, while the situation has improved, the nutrition problems of infants somewhat

increased. Therefore, better approaches for nutritional improvement should be

investigated.

Tuberculosis（TB） is one of the world’s three major infection diseases. The epidemic

of that is serious problem in the world. Especially, the epidemic is profound in developing

countries. WHO put 22 countries on the list of high burden TB countries of the world,

but most of these are concentrated in the developing countries, which is Asia and Africa

TB is called “social disease”. Social issues, which are poverty and social structure, are

concerned deeply with the epidemic. In developing countries, poor living conditions,

revenue instability, lack of knowledge, bias are involved in that deeply. The Philippines,

which is candidate for research, is one of the high burden TB countries. As for the

estimated number of TB patient per year, the Philippines is the 9th country in the world.

In the Philippines, tuberculosis is the sixth cause of death. There are regional differences

of the condition of the epidemic. TB spreads prominently in urban poor areas. Urban poor

areas had higher prevalence rate of TB than the other areas. The epidemic in urban poor

areas is serious.The history of the TB control programs is following. In 1993, WHO

declared a state of emergency of TB in the world. The next year, the DOTS strategy,

which is the base of today’s TB control programs, was recommended by WHO. But, the

effect of that program was insufficient especially in the 22 high burden countries. It is

because the problem which cannot be solved by the DOTS strategy, for example lack of

knowledge, bias, access to medical services and so on. Therefore, in 2005, Stop TB

Strategy based on DOTS strategy comes out, which is added 6 components that DOTS

strategy lacked. National TB control program in the Philippines introduced DOTS

xviii
strategy and Stop TB Strategy, too.This study, we got interviews to the organizations that

implement TB control and analyze the data of projects, and we clarify the impact of the

difference of the network on the TB control programs. Our study takes up “ ‘The

Tuberculosis Control Project in Socio-Economically Underprivileged Urban Area in

Metro Manila, The Philippines. “Stop TB para sa lahat” PhaseⅢ’ ”conducted by Japan

anti tuberculosis association and “Community-based Rehabilitation Project on Health

and Livelihood” conducted by ICAN as study objects. Filed survey conducted interview

and questionnaire to the 5 related organizations, WHO, RJPI, DOH, CANOSSA, ICAN

and some inhabitants. This study is explored with three research questions as follows:

Who are involved in the programs and how are they involved? What relationships

between stakeholders exist in the programs? What effect do such relationships between

stakeholders have in the outcome of the programs? According to the answer to these

research questions, cooperation between stakeholders has a positive impact for the TB

control programs. But, in the Philippines, private organizations don’t really involve in the

TB control programs, although many patients use private organizations. And, in this field

survey, we got answer that the future challenges of the TB control programs are the

progress of the case detection rate. Many patients go to the private organizations initially,

so it would appear that the entry of private organizations to the TB control programs

contribute to the progress of the case detection rate. As explained above, the network

between stakeholders is important to the TB control programs, and in the Philippines, the

challenge would be to involve private organizations.

xix
Introduction to the Study as a Whole:

Background, Fields and Focal points

Seoungho Kim, Shokei Yunoshita

 Background of the study

On the planet earth, more than 1.8 billion people are mired in extreme poverty and

making precarious living on less than one dollar a day. Income of 2.5 billion people

living on less than two dollars a day accounts for 5% of the world income. The top 10%

of the richest in global society are mostly living in developed countries and their income

account for 54% of the world income (Ogawa, 2010). In order to redress the gap in the

global society, multilateral and comprehensive approach is indispensable. This is

reflected in the wide vision the eight Millennium Development Goals (MDGs) – which

range from halving extreme poverty to promoting gender equality and providing

universal primary education and health care, all by the target date of 2015 – has implied.

This study has focused on health and sanitation issues to which three out of the eight

MDGs are related. Health and sanitation issues make significant influence on

developing countries economically and socially. Hence development in the field of

health and sanitation is indispensable to reduce poverty.

This study has conducted an investigation under the theme of “Health and Sanitation

Development ”in the Philippines, an island nation located in South East Asia. Filipino

society has been influenced by two-layer structure consisted of the elite and the masses

(Ohno, 2011). Traditional ruling class based on large landholding was formed during the

latter period of Spanish rule (1529-1898). Thereafter, they have grown to family-run

conglomerate under economic system during the period of American rule (1898-1946).

After the independence, they have taken real power even in politics and reinforced their

economic bases. Their existence exaggerated the Philippines’ economic development

and produced an impression of “The top runner of South East Asia” both politically and

3
economically from 50s to 60s. However, immense poverty of the masses emerges at the

rear of this overstated prosperity. Even today, obvious gap remains in the country and it

induces inequality of access to health services and education. This situation is causing

adverse effect on health of the poor and generating additional poverty. Therefore,

development in the field of health and sanitation is deemed as an urgent challenge to

suppress the rapid increase of poverty. We will write up the specific problems in latter

chapters.

This study has taken up four topics (“maternal and child health”, “water and

sanitation”, “food and nutrition”, and “infectious disease”) within the health and

sanitation issues which are considered as major problems in the Philippines. In each

topic, teams in charge focused on “peer education”, “enlightenment activities”,

“nutritious improvement and public-private partnership”, and “countermeasures for

tuberculosis”, and set hypothesis or research questions. Based on that acknowledgement,

we observe efforts of international institutions, governmental institutions, NGOs, and

companies concerned with the four topics to clarify their attempts and cooperativeness.

4
 Previous study of the studies

Setting 4 fields in order to proceed our study

Nilufar Ahmad, who investigated the health policy of South Asia, discuss about

improvement in health problem through voices of stakeholders which engage in

Bangladesh’s health sector. He divides the needs into following groups which are

necessary to improve the health problems and all stakeholders consent them. These are

mentioned in his “Priority Services within the Essential Services Package”.

・ Child health: EPI1, diarrhea control; and treatment fotacute respiratory

infections, malnutrition, vitamin A deficiency, and iodine deficiency
・ Reproductive health; Maternal health (nutrition awareness and
counseling); prenatal care (tetanus vaccinations and regular checks of
blood pressure); safe delivery (trained midwife or traditional birth
attendant); menstrual regulation and postabortion and miscarriage-related
complications (referral and treatment); family planning (raising awareness
among men and in-laws, distributing methods, and managing side effects);
adolescent health (especially education on reproductive health and
complications related to menstruation); and the management, prevention,
and control of reproductive tract infection (RTI), sexually transmitted
diseases (STDs), and HIV/AIDS
・ Communicable disease control: Tuberculosis control, elimination of leprosy,
malaria control, and intestinal parasite disease control
From above, you can see that chid health, reproductive health and communicable

disease control are big problems. Sanitation problems related to diarrheal diseases and

intestinal parasites, nutrition problems related to malnutrition and vitamin/iodine

deficiency, reproductive health problems related to maternal health, prenatal care, safe

1
The program of WHO to create vaccine that every children could use

5
delivery, menstrual and family planning, and communicable disease problem related to

tuberculosis and malaria are thought to be the four problems which causes the three

important problems above. Therefore, by focusing on these four fields, we will discuss

what is necessary to improve health problems in this study, especially through case

studies of the Philippines.

6
 Focal point 1: Relationship between stakeholders

Public and private sector roles

Ferranti (2004) mention about public and private sector roles and relationship in health

fields by giving examples of health problems and discussing the solution of it.

He mentions; people who are infected by infection diseases (especially tuberculosis)

can’t understand the effectiveness of the medicine even they recognize the attack.

Moreover, due to the price of medicines, they couldn’t take them continually and reach

complete therapy. Io provide medicines and treatment, the involvement of public sector is

important because it is difficult to do them only by private markets.

Furthermore, because sanitation systems are public goods, there are limitations to

diffuse techniques like refining water by private sector alone. Therefore, it is necessary to

emphasize the adequate systems, for example, cost-effectiveness and cost-benefit.

The relationship between government and NGO

“Voices of Stakeholders in the Health Sector Reform in Bangladesh” emphasis that the

relationship between government and NGO. NGO have close relationship with

communities and produce great performance in health and nutrition recognition

through effective communication with inhabitants. Although, the people that NGO could

provide services are limited. This is because the ranges of NGO’s activities are focused on

urban areas, not enough in rural areas. The cost of facilities and programs are high than

local government is the reason, the head of NGO says.

From such reasons, author protest that relationship between government and NGO is

necessary in improving the situation of people by setting up the effective communication

channel.

7
 In our study, we will analyze the relationship between stakeholders in health problems

through maternal and child health, infection disease, sanitation and nutrition which are

the four fields mentioned in previous studies.

Focal point 2 Education

The World Bank (2005) analyze the role of government, action of various sectors,

effective systems to breakdown the role of itself in improving health, nutrition,

population problems. According to the forth paragraph of it , ”Education and school

health are important inputs to better health and nutrition and reduced fertility” in

“Multisector Action to Improve Health, Nutrition, and Population outcomes”, education

is important in improving health problems. In this part, in-school children are typically

the most health age group among demography. At the same time, they are the age group

who are easy to become habitual in bad customs. It is mentioned that by doing health

education, we can prevent diseases, reduce child mortality rate and nutritional

modification. To improve these situations, the following four components have been

identified as operationally feasible in both, hard-to-reach rural areas and in accessible

urban areas;

・ Adopting health-related school policies, such as those that provide incenti

ves for girls to avoid pregnancy or to discourage smoking

・ Providing safe water and sanitation and a healthy learning environment

that reinforces hygienic behaviors and provides privacy

・ Promoting a skills-based approach to health, hygiene, and nutrition educa

tion that establishes lifelong healthy practices and reduces the vulnerabili
ty of adolescents and teachers to HIV/AIDS

・ Having teachers deliver school-based health and nutrition services that ar

8
 e simple, safe, and familiar, and that address those health problems reco
gnized as important in the community, including counseling to cope with
HIV/AIDS

From these previous studies, we can recognize that education could be one of the

method to improve the situation in maternal and child health, sanitation, nutrition and

infection diseases problems. In our study, we will verificate the importance of the

education in health through above four sections

9
 References
Ahmad, N. (2003). Voices of Stakeholders in the Health Sector Reform in

Bangladesh : Building Capacity for Reform. In A. S. Yazbeck, & D. H. Peters

(Eds.), Health Policy Research in South Asia (pp. 369-400). Washington,

D.C.: World Bank.

Atsunobu, T. (2010). The Health and Sanitation Field. In M. Ogawa, Theory of

International Cooperation. Kokin Shoin.

Ferranti, D. (2004). Public and Private Roles in Health: Theory and financing

patterns. In P. Musgrove (Ed.), Health Economics in Development (pp.

35-76). Washington, D.C.: World Bank.

Ohno, T. (2011). The 61 Chapters to Learn about the Modern Philippine (2 ed.). Akashi

Shoten.

The World Bank. (2005). Improving health, nutrition, and population outcomes in

Sub-Saharan Africa : the role of The World Bank. Washington, D.C.: World

Bank.

10
Chapter 1

Improving Adolescent’s Knowledge

on Reproductive Health:

Effectiveness and Challenge of Peer Education

Moe Sasaki

Kimihiro Kato, Moe Suzuki

Shokei Yunosita, Ayako Shukuya

Introduction

Background of our study

This thesis is a summary of the result of our research. This study set up the theme that

“Improvement in the Knowledge on RH through peer education for adolescents” on the

basis of the main theme “Health and sanitation development in the Philippines -

Potential for education and stakeholder cooperation-”

The Millennium Development Goals (MDGs)which started as a global development

framework in 2000, While the target about community systems development is

achieving fixed success towards the goal achievement term in 2015, the MDGs target 5

"An improve maternal health" is most behind in the progress, and it is doubtful of the

achievement in many developing countries. This study paid attention to the access

improvement to RH, in the target 5, and to find the solution in the long term, also

biologically, we focused on the adolescents in which reproductive behavior is possible.

As the educational method, we focused on Peer education which attracts attention as the

main approach method of the access improvement to RH in recent years.

In the Philippines, it is hard to say that access to RH is enough, and There is a big

problem that the unwanted pregnancy in the younger age group. The Philippines

government signed the U.N. population declaration in 1967, the Ramos administration

13
and Aquino administration has promoted the policy of population control based on long

economic growth. However, with local autonomy transfer of 1991, there is the present

condition that the difference of the action in each local government occurs, and the rate

of the birth at the institution of health was 44%. Moreover, contraceptive prevalence

rate was 51% [UNICEF, 2009], and those are the low rate in comparison with other

developing countries. About field of health, Philippine is the Asian greatest Catholic

possession country, and the construction of the cooperation system with the religion

becomes the important problem in the Philippines where separation of church and state

is not legislated. However, The RH bill are going to be approved, and a big change is

going to be accomplished in the field of maternal and child health in the Philippine.

This study set up three research questions that (1)How is the present situation of the

access to RH in the Philippines? (2)How does the religion affect RH? (3)What are the

needs of RH among people in the Philippines? (4)What kind of effect was provided by

peer education? , on the basis of the hypothesis “Peer education for adolescents

improves the knowledge on RH.” This study analyzed the result of the questionnaire

and an interview.

14
1.1 Importance of RH

1.1.1 Maternal mortality ratio

Since 1990, the estimate of the global annual number of maternal deaths has exceeded

500,000. 99% of the maternal deaths have occurred in developing countries. Although

the number of under-five deaths worldwide has fallen consistently – from around 13

million in 1990 to 9.2 million in 2007 – maternal deaths have remained stubbornly

intractable. Limited gains have been made worldwide towards the first target of

Millennium Development Goal (MDG) 5, which aims to reduce the 1990 maternal

mortality ratio by three quarters by 2015; and progress on diminishing maternal

mortality ratios has been virtually non-existent in sub-Saharan Africa.1

1
Sub-Saharan Africa includes Eastern, Southern, Western, and Middle Africa.

15
 Figure 1-1Maternal mortality ratio

Source: This was made by author from THE STATE OF THE WORLD'S

CHILDREN,2009,UNICEF

Maternal mortality ratio presents the number of deaths to women per 100,000 live

births which result from conditions related to pregnancy, delivery and related

complications [Universal Journal company, 2004]. Direct causes of the maternal deaths

include atonic bleeding after delivery, uterine rupture, infections due to unclean delivery,

unsafe abortion. However, on the background of these incidents, there are insufficient

knowledge of human sexuality, inappropriate or low-quality information and service on

RH, the spread of high-risk sexual behavior, discriminative social customs, negative

attitudes toward women and girls, and the limited empowerment of women and girls in

relation to sex and reproduction, etc.

16
 Moreover, the maternal mortality ratio strongly reflects the efficiency of the whole

health system in a country. In most of the least developing countries, there are lack of

skilled health care professionals due to vulnerable government or insufficient financial

investment to health services and facilities. Facing these circumstances, effective

assistance measures could be for example, implementing HIV examination prior to

delivery, increasing the number of births attended by skilled health attendants2, making

urgent obstetric care accessible when necessary, offering post-delivery care, etc.

Expanding the scale of these measures would sharply reduce the number of maternal

and under-five death in the world. In addition, if women are able to acquire knowledge

of family planning and access to basic health care at the reasonable cost, the maternal

mortality ratio would decrease even more. These measures are definitely not impossible

and unrealistic.

1.1.2 Universal access to RH

Firstly, the concept of RH was globally agreed at the Cairo International Conference in

1994. At the Cairo International Conference, realizing RH is recognized as a

prerequisite to sustainable development centering on human and stability of population

(Taguchi, 2004). According to Population and Development Program of Action (ICPD

2
The term ‘skilled attendant’ refers exclusively to people with midwifery skills (for example, doctors, midwives, and
nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose,
manage, or refer obstetric complications.
17
Program of Action) adopted at the Cairo International Conference in 1994, RH is a state

of complete physical, mental and social well-being and not merely the absence of

disease or infirmity, in all matters relating to the reproductive system and to its

functions and processes.

Ever since the Cairo Conference in 1994, many UN organizations and countries

started to reflect the concept of RH in their existing family planning programs and to

modify their policies. In addition, the approach to the population problem has shifted its

emphasis to gender equality, women’s empowerment (improvement of their status and

capacity), and the promotion of RH. However, due to the insufficient fund and gap

between the services provided to people in the least developing countries, there are

numerous problems being unsolved including the spreading HIV/AIDS and unmet

needs of family planning especially of youth, high fertility ratio and maternal mortality

ratio in the least developing countries.

Having many unplanned children would be a big burden for the poor. As an example,

for mothers, giving birth to many children would lead to the maternal death and high

risk of acquiring disease. The whole family would be pushed into poverty if the mother

dies or gets infected to disease. It affects adversely to economic opportunity and

education for girls. In big families, it is likely to make their daughters leave school to

18
take care of their younger siblings. If a girl could not take the sufficient education, she

cannot learn how to do family planning. Due to this kind of vicious circle, the poverty

of family would continue from generation to generation. Hence, improving the access to

RH would contribute to reduction of poverty.

1.1.3 Adolescent RH

According to UNFPA, the number of youth in the world surviving on less than a dollar a

day in 2000 was an estimated 238 million, almost a quarter (22.5 per cent) of the

world’s total youth population [UNFPA, 2003]. Education is a key for breaking the

transmission of poverty from one generation to the next. Yet studies show that the poor

are more likely to not complete schooling. [Deon Filmer, 1999]Consequently, they are

deprived of the education on RH and sexuality that is provided at higher grade levels

and do not know how to find health information.

Therefore, diffusion of modern contraceptive methods would contribute to

improving the access to RH. According to the United Nations Population Division,

contraceptive methods can be divided into two big groups, modern and traditional.

Traditional methods of contraception include rhythm (periodic abstinence), withdrawal,

breastfeeding, douching, etc. These methods are so called natural birth control which

does not accompany contraceptive device or medicine. So they are not grounded on

19
scientific evidence. On the other hand, modern methods of contraception include female

and male sterilization, oral hormonal pills, the intra-uterine device (IUD), the male

condom, injectables, the implant (including Norplant), vaginal barrier methods. Modern

contraceptive use among adolescents is generally low, but increases with economic

status. Fewer than 5 per cent of the poorest young use modern contraception. Inequities

in access to family planning increase the likelihood of unwanted or ill-timed births.

In the world, there are enormous amount of young women dropping out from school

because of pregnancies. Due to limited knowledge and guidance, adolescents are less

likely to practice safer sex or to use contraception. Contraceptive use is still infrequent

in most early sexual experiences. Young women consistently report lower usage rates

than men, evidence of their unequal power in negotiating use of family planning with

their partner or restrictions on their access to services (due to lack of information, shame,

laws, health provider attitudes and practices or social mores) [UNFPA, 2003]. Fertility

differences between the poorest and richest strata in many countries are among the

largest of any health indicator. Early childbearing in poor families perpetuates an

intergenerational cycle of poverty.

20
Figure 1-2 Fertility differences between the rich and the poor
Average number of children by region and quintiles of household
wealth

Sub-Sahara Africa
(29countries)

Asia/North Africa Lowest quintile

(18 countries)
Highest quintile

Latin America and the Caribbean

(9 countries)

0 1 2 3 4 5 6 7

Source: This was made by author from The World Bank

Based on such situation and needs of adolescents, it is important that their health

and rights for decision-making be assured and that the risks of unwanted pregnancy and

sexually transmitted infections including HIV/AIDS be reduced by providing

appropriate education, information, service and care in relation to RH. Providing the

same level of information/services to young people as those for married couples

indicates public acknowledgement that unmarried young people are already sexually

active, and there may be social resistance to this, although the degree of resistance may

vary. This is a major difficulty in providing RH/services to young people.

Poorer young women are less likely to have their births attended by a skilled health

21
worker. Skilled attendance is important for the health of the mother and the child,

particularly when there are delivery complications. The younger the mother is, the

greater the chance that she will face complications during pregnancy and childbirth.

Also, those who are poor have the least access to health care services to deal with

increased pregnancy and delivery risks.

As mentioned above, there is a situation that the poorer the adolescent is,

the more insufficient the access to RH.

1.2 Peer education

1.2.1 What peer education is

Recently, peer education has become one of the most common approaches in

addressing adolescent RH. Peer education is an approach or strategy that the members

of a given group affect other members of the same group in behavior and knowledge

[UNFPA, 2003].It is commonly-used in informal situations, such as out-of-school

activities, and often used as a part of programs which aim for the improvement of

adolescent RH. The names used to describe teachers differ in each programs: “peer

educator”, “peer counselor”, “peer helper”, “peer promoter” and “peer distributor”.

Moreover, peer programs provide not only education, but also counseling and distribute

contraceptives to improve RH (Senderowitz, 2000). The best point of peer education

22
is that it is a kind of education which is place taken by the peers. People who give

adolescent peer educations tend to be in similar situations to their students, for example,

in-school, out-of-school and having job.

According to the peer program in Zambia, which we will introduce it in section 2,

the effect of peer education that it change peer’s behavior and mind bases on “social

cognitive theory”. Social cognitive theory is one of the social psychology which

advocated by social psychologist, Bandura at 1963. It says that one can learn from

other’s behavior and emulation.

Through these circumstances, we decided to focus on diffusing knowledge of RH to

adolescent through peer education. The “grape bine activity” which spread among the

youth at England in 1972 is said to be the begging of the sexual peer education in the

world. After that, it diffused to the United States of America, and Milwaukee family

planning church havs practiced it on 1976. Thereafter, sexual peer education had spread

throughout the whole world beginning with the USA, Canada and Latin America [Saito

tadathu, 2002]. Even now, peer education is practiced in wherever feasible, for example,

schools, clinics and community health centers.

1.2.2 The possibility of peer education

Adolescent is an age group who develop from children to adults. Which is to say,

23
adolescent is the stage that achieve a rapid growth in both physically and mentally most

in one’s life. At the same time, it is an age group which increases attention to sex and

become sexually active. Furthermore, they are the age that is sensitive to sexual topics.

If adolescent boys and girls don’t have enough access to RH information and services,

it causes many troubles, for example, early pregnancies/childbearing and spread sexual

transmitted diseases which we mentioned in chapter 1.

Peer education has been one of the most famous approaches to improve adolescent

RH during recent years, which we have mentioned in the previous section, and peer

education programs are practiced in all over the world. We will introduce three of them

in this section.

First is the sexual health peer education project in Cameroon which is called “Entre

Nous Jeunes”. This project aims not only to increase contraceptive use but also to

reduce unintended pregnancies and sexual transmitted diseases, including HIV among

adolescents. The boys and girls who are chosen to be volunteer peer educators are the

youth recruited by program planners and passed the motivation and commitment test.

Every three months, peer educators received additional training to reinforce their skills

and knowledge. Peer educators arranged discussion groups and meet with their peers

one-on-one. They also distributed materials including calendars, comic strips with

24
information about contraception and sexual health, and posters. Increase use of

contraception/condoms and improvement of knowledge on sexual transmitted diseases

were seen as the positive outcome of the project, and the adolescent RH access has

improved. [Advocates for Youth, 2005]

Second is the sexual education program for adolescents in Scotland. While the

annual teenage pregnancy rate fell between 1987 and 1996, in the13-15 age range, the

rate has increased. The teaching style and of information about availability of services

were thought to be inadequate. Therefore, peer education was chosen as a method to

improve the situation. Medical university students provided sex education through 30-

40 minutes discussions as peer educators to 13-14 year old pupils. According to the

questionnaire and interviews, most pupils mentioned that they felt medical students

would be easier than teachers to communicate with. Moreover, many pupils recognized

that their knowledge was incomplete. [James Jobanputra, 1999]

And finally, third is the peer program in Zambia. Zambian adolescents don’t have

correct information about HIV, because the information they receive is often misleading.

At the same time, many of them oppose condom use. This is because, they associate

condoms with immorality. Therefore, safe sex isn’t practiced. 80% of the citizens in

Zambia are Christians, and the rest are Muslims, Hindus and traditional religion beliefs.

25
The wrong view “condoms are ineffective at preventing HIV” supported by many

church groups is also thought as one of the reason which diffused mistaken information

among adolescents and have prevented their access to RH. By considering these

circumstances seriously, in 1999, after receiving permission from the Ministry of

Education to conduct sexual health interventions in schools, Society for Family Health

(SFH) started a peer sexual health intervention aimed at school-based adolescents. The

peer sexual health intervention is an important component of SFH’s social marketing

AIDS prevention activities. Peer educators, consisting of male and females aged

between 18 and 22 years, discussed sexual health issues, for example, abstinence,

condom use, and the risk of acquiring sexually transmitted infections with secondary

school students. In addition, they used drama skits to present scenarios that reflected

actual experiences of many adolescents. The result was that peer education diffused not

only the information about HIV/AIDS itself and how it does infects, but also the

information that proper use of condoms can avoid sexual transmitted diseases have

diffused among students. Therefore, access to adolescent RH improved. [Agha, 2002]

As seen above, improvement of adolescent RH through peer education is attracting

attention in recent years. Moreover, you can understand that peer education could

spread information about RH among adolescents more effectively and more comfortably.

26
1.2.3 The challenges and limits of peer education

So far, we have mentioned that peer education is effective in improving adolescent RH

all over the world. Although, peer education have some challenges left which we can’t

take our eyes off. To begin with, time pressure and shortage is one of the challenges

which peer education faces. The relation-building between clients, providing continual

and high quality education for peer educators are also necessary points. Especially, the

RH education/counseling is a challenging area because it tends to be complicated.

(World Health Organization, 2001)

In the peer project in Zambia, which we have introduced in previous section, it is

said that because the study measured the impact of the peer sexual health intervention

soon after the intervention was implemented, it cannot assess whether those changes in

beliefs are likely to persist. Moreover, because it is not possible to tell whether the

specific peer project is effective in all schools, the method should be chosen if it

matches each school and target.

In Cambodia, Reproductive health Association of Cambodia (RHAC) done peer

program in 1999. It was implemented in three areas including capital city, Phnom Penh,

and high school students were trained to provide RH information to their peers, both in

and out of school. The project was concluded to be effective. However, some problems

27
were also noted in this evaluation too. For example, it was mentioned that because the

peers were still at the stage of learning in certain topics, they couldn’t provide enough

information. [United Nations Educational Scientific and Cultural Organization, 2003]

Thus, because peer education is an approach done by youth, it carries some

challenges too. Moreover, because peer education tend to be used as one of the

approaches in whole adolescent reproductive project, although the project ended

successfully, there is a limit that it is difficult to say whether peer education itself was

effective or not.

1.3 Adolescent RH in the Philippines

1.3.1 Politics and religion of the Philippines

Philippine is a country which is Asian’s largest Catholic country; 83% of population are

Catholic. Considering RH in the Philippines, it must be considered about religious

influence. Protestant church allows all methods of contraceptives and abortion. In

contrast, Catholic Church discourages modern method’s contraceptives and abortion,

whether people are before-marriage or not.

The most salient characteristic of Philippine’s politics, is “religitics”. In effect,

Philippine don’t separate religion from politics. How do they become the situation like

this?

28
 Philippine was a Spanish colony between 1565 and 1901. Spain in those days is

puritanical Catholic country [Hagino, 2002]. Before being Spanish colony, general

religion in Philippine is Islam. Christianity arrived in the Philippines with the landing of

Ferdinand Magellan in 1521. In the late 16 th century, soldiers and missionaries firmly

planted the seeds of conversion when they officially claimed the archipelago for Spain

and named it after their king. Spain transformed the Philippines into the first and then

one of the two predominantly Christian nations in East Asia. After American colonial

period and Japanese colonial period ended, Philippine have attained independence in

1946.

Philippine has no religious interference from colonial master than Spain.

Two points had made religion specially in the Philippines compared with other

Catholic countries. First, Philippine is the first country that Catholic became common in

Asia. Second, Philippine’s Catholic has been arranged uniquely by community people.

In addition, other two points made politics of Philippines religitics. First, Philippine was

in religious control by developed country. Second, Philippine had been colony for long

time, so Philippine had not experienced governing their own country. It is so hard that

Government which don’t have know-how of governing preside as many as 700 islands.

Over its long history, Philippine has become Catholic country and it don’t separate

29
church from politics.

These situation influences to RH problems. First, abortion is illegal in the

Philippines. Catholic Church doesn’t allow using modern contraceptive methods and

abortion because they think unborn baby as a person from the moment conception and it

is special gift from the god, so abortion is guilt for any reason. However, each year in

the Philippines, hundreds of thousands of women become pregnant without intending to,

and many women with unintended pregnancies decide to end them abortion. Unsafe

abortions can endanffer women’s RH and read seriously, often life-threatening

complications [DarrochJe, 2009] Also, it change depending on mayor that the rule as

to whether allows using modern contraceptive methods including condoms. For

example, mayor of Manila Atienza enjoin people from using modern contraceptive

methods, but Mayor Alfredo Lim allow it. In this way, policy about RH vary highly

among region. For instance, Mayor of Olongapo city James Gordon Jr. work on RH

problems all over the city and this activity has succeed. The detail will be described in

chapter 4.

30
 Table 1-1History of the Philippines
Before Spanish Control (Before 1521)
the late 14th century Introduced Islam into the southern islands and extended
Muslim immigrated to shouthern islands from Sumatra
early 15th century
Built sultanistic regime by in the middle of 15th century
in mid-15th century Expanded Islam to Maranao in Mindanao(～early 16th century)
Spanish Control Period (1521-1897)
1521 Ferdinand Magellan landed southern islands and introduced Christian religion
1565 Miguel de Legapsi landed in Cebu.
Firsit Philippine republic period (1898-1900)
1898 The Spanish-American War began
Constitution of the Philippine Republic was promulgated
1899
First Philippine republic established
U.S. Control Period (1901-34)
Japanese occupied period (1942-45)
1942 Manila was occupied by Japanese
Third Philippine republic period (1946-71)
1946 Philippines becomes independent nation
Martial rule period (1972-80)
1978 Metro Manila become capital city officialy
Forth Philippine republic period (1981-85)
Fifth Philippine republic period (After 1986)
1986 Corazon Aguino was elected president and Aquino forms new government
2010 Benigno S. Aquino III was elected president
Source: Yoshio Hagino, 2003, [Philippines no syakai rekishi seiziseido] ”The society,
history, and political institution” Akashishoten

1.3.2 The policy of the Philippines government

Now, the bill of RH is widely discussed in Philippine. This is formally called the RH

and Population Development Bill (House Bill No. 5043/Senate Bill no.3122) and

generally known as RH Bill [Snate Economic Planning Office, 2009]. This bill is

considered important for this country to make an RH policy because this is for aiming at

distributing contraceptives to poor families and giving sex education to students in

elementary schools and students in junior high schools. However, the Catholic Church

is now strongly against this bill.

31
 In 1990, it is the first time that the comprehensive package of the RH Bill was

submitted to the Congress, but the Catholic Church strongly resisted it. The president at

the time took care of it, and finally withdrew it. The Church continued to take tough

stance with the RH Bill, and in response, the presidents showed a conservative attitude

to it. In June 2010, when Benigno Aquino III became the president and tried to pass the

RH Bill, it came to attract much attention again, and the Church responded strongly

against that.

Now, what do people in Philippines think of this problem? In June 2011, Social

Weather Station (SWS), which is the social research institution in Philippines,

researched the public awareness on this problem. The research showed that 73% of the

people said “Yes” if they were asked, “If a couple wants to plan its family, it should be

able to get information from government on all legal method”. They are 6 times as

many as the people who said “No.” And 68% of the people answered “Yes” to the

question: “Should the government pay money for all such measurements, when they

have a baby naturally or artificially?” which is 4 times as many as the people who

answered “No.” This result indicates that people in Philippines consider RH a part of

human rights and different from their religion although most of them are Catholic.

If the RH Bill passed through the Diet, it will be considered important because

32
people can have free access to RH, which has been banned legally. It will be a great

progress if the national RH policy framework is established and there is no regional

difference on RH because of that.

1.3.3 Adolescent RH in the Philippines

According to World Bank, Philippine’s population is 93,260,798 and 35% of this is

under 14 years old. It is characterized by high population rate of young. Adolescent

fertility rate is 55/1000 lives. This rate is still high in compared to Cambodia’s 52 and

Vietnam’s 35. No significant change in the fertility of young women during recent years

[World Health Organization, 2010]. This is one of the problems in compared to other

neighbor countries. The numbers of HIV carriers are increasing in the Philippines, it is

rare compared with other Southeast Asia country. In 2010, 30.73% of new cases are

youth aged 15-24 [Department Of Health, 2011].

In the Philippines, it is so hard to speak about sexual topic from religious

background and it have huge effect on RH as previously mentioned. The lack of access

to information and services about RH causes many problems.

First, it is frequent cause of pregnancy in adolescence. Adolescent pregnancy is high

risk because adolescent’s body is developing. In addition, there are many adolescent

can’t help but drops out school because of pregnancy. Therefore, preventing adolescent

33
pregnancy connect to protect adolescent education chance.

Second, STD. If adolescent don’t have enough access to RH, they couldn’t know

how infect STD and how prevent from it and how cope with it. In the worst case, they

will die from HIV/AIDS. In addition, they can prevent from these STD by using

condoms but most of them don’t know how to use its. Also, there is a situation that it is

hard to buy condoms in the Philippines.

It leads to protect not only adolescent but also their partner that they gain knowledge

about RH and do family planning.

In the Philippines, condom use rate is less than 4%. It leads to not only adolescent

pregnancy but also rampancy HIV/AIDS [Population Concil, 2009] . It is one of the

important points that improving access to modern contraceptive methods.

Having sex education in schools is important chance to gain knowledge about RH

for adolescents. However, Philippine can’t make an RH policy framework. Therefore,

sex education has not done in the school, or even if it is practiced, it is lack coherence.

This is why push adolescent from access to correct information about RH. Boys are 2x

likely to repeat or drop out of school. Main reasons for high dropout rates among boys

are these three: They had to work, they don’t have enough money for school

requirement, and they had to take care of siblings. Even though the national framework

34
of sex education has made, if there is no follow-up for the poor, the full access to

information on RH doesn’t be achieved.

Figure 1-3Adolescent fertility rates

Source: This was made by author from World Development Indicators

1.4 Peer education in the Philippines

1.4.1 Research outline

In previous chapter we discussed relationship between government and religion in the

Philippines and present situation of RH revolving around Adolescents. In the

Philippines, there is a climate that sexual topic is taboo because of effect of religion. So,

it is difficult to talk about sexual topics to their parents or teachers. Therefore, education

from their peer could be effective to prove these problems because it could be easier for

them to talk to their peer and peer education also suits their other needs.

35
 In our study, we set up our hypothesis that “Peer Education for Adolescents can

improve the knowledge on RH (RH)”. To verify this hypothesis, we held field survey in

the Philippines.

In this chapter we introduce two case examples of peer education in the

Philippines held by UNFPA Philippines (UNFPA) and Family Planning

Organization of the Philippine (FPOP).

We set three research questions to verify our hypothesis, “How does the religion

affects RH?”, “What are the needs of RH among people in the Philippines?” and “What

kind of effect was provided by peer education?”.

We conducted interview to project performer, peer educators and peer students

based on these research questions. Furthermore, we carried out a questionnaire survey to

peer students as quantitative survey to measure the effect of peer education.

1.4.2 Case example

(1) UNFPA Philippines

UNFPA, the United Nations Population Fund, is an international development agency

that promotes the right of every woman, man and child to enjoy a life of health and

equal opportunity in the Philippines. Their main activities are improving maternal health

and access to RH. Peer education program on RH held by UNFPA was surveyed in our

36
study. This is core program of UNFPA Philippines.

Since 2009, UNFPA has started the program to achieve standardization of peer

education in the Philippines and they have been conducting with Y-PEER (Youth Peer

education Network).We inspected peer education program held by UNFPA Philippines

in Olongapo city.

As we discussed in chapter 4, Olongapo city supports RH activity as local

government. This case could be rare because there is serious problem between religion

and government in the Philippines. In Olongapo city there are about 200,000 people. It

could be large population comparing other cities. Increasing population is serious

problem in whole Philippines. Similarly, it is major problem in Olongapo city.

Olongapo city have started supporting RH because population became saturated and

personal income decreased. UNFPA conducts peer education at kalalake high school

and out-of-school in this city. At this school, students conduct peer education

themselves. They offer counseling to students who have problems about sex in “Teen

Wellness Center”. The good point of Teen Wellness Center is that it is located in an

obscure place. Therefore, students can visit there with less resistance to sex.

Furthermore, as you understand from that name “Teen Wellness Center”, there is no

sensitive word like “RH” or “Family Planning”. Therefore, it could be easy for students

37
to use this service.

(2)Family Planning Organization of the Philippines

FPOP in a NGO organization which provides clinic services including obstetric care

services and has many activities to improve access to RH in the Philippines. FPOP is a

member of International Planned Parenthood Federation (IPPF). IPPF is the world’s

biggest NGO in RH. FPOP is a Philippines section of IPPF. FPOP has 26 clinics in the

Philippines.

Since 2009, FPOP has started “YES4YES project (Youth Friendly Service for

Young People’s Sexuality in ASRH in the Philippines Project)”.In this project, FPOP

provides RH services including Peer education and health care service mainly for young

people. The feature of this project is that young people work as youth staff and they

decide contents of the project by themselves. Peer educators as youth staff also give a

lecture to other NGO on peer education and join the meeting with local government.

Then they become a leader of young people. Another feature is that FPOP provides not

only information through peer education but also they enriched health care services.

1.5 Analyzing case example

1.5.1 Analytical method

We set up the hypothesis, “Improvement in knowledge on RH through Peer Education

38
for Adolescents”. In order to prove our hypothesis, we have set three research questions

below, “How much does the religion effects RH?”, “What are the needs of RH among

people in the Philippines?” and “What kind of effect was provided by peer

education?”. Then, we have conducted on on-the-spot investigation in the Philippines

between 28 August 2011 to 9 September 2011.

By using the information we got through interviews/questionnaires for staff and who

participate in peer education in the project sites, which we introduced in Chapter 4, we

are going to prove our hypothesis from now. We will use the analysis software SPSS in

case to analyze the questionnaires.

The below are the limit of our study.

Firstly, the number of questionnaires which we were able to collect was only 20.

Secondly, either the interviews or questionnaires were done thorough staff who could

speak Tagalog. Thirdly, the investigation was done in such a limited time span.

Therefore, we would like you to pay attention that this study was done in such a limited

situation.

1.5.2 Conclusion of the interviews and questionnaires

The conclusions of the interviews and questionnaires are below. We did them by the

method which we mentioned in section 1.

39
 Table 1-2 Summary of Interview Research
Location: UNFPA Philippine

Date: 31rd August, 2011 (Wed)

Targets: 6 members of the project which aim to improve the adolescent’s

access to RH in the Philippines

RQ1：How does the religion affect RH?

Q1. How do people in the Philippines think about the relationship between

the government and religion?

A1：Because Catholic is there with us since we were born, I mean, most of

Filipinos were born as Catholic, it is difficult to think religion apart from

our thoughts. Although, there are many Catholics who can think rights

apart from religion too. However, we think that not only the religion

affects people but also the backgrounds they grew up and the schools

they graduated do a lot.

Q2：How is the relationship between religion and RH like?

A2：The Catholic church has big influence. In case of legalizing abortion, it is

thought to be difficult to achieve it. Present president is supportive to

RH. He said that he was amazed to see a 16 years old mother with 2

children, and felt it is important for youth to have needed information.

Although he is supportive, the past presidents were not. The law and

system depends on the leader of the government. Moreover, proceed of

decentralization is making local governments and mayors authorized. By

using their power, they can make rules of their own in their community,

and this make unifying whole nation difficult. For example, condoms

40
 must be prescribed by doctors in some areas while in other areas they

oppose it.

Q3：What are the specific characteristic of the RH/Peer education in the

Philippines compared to other countries?

A3：In the Philippines, there is a kind of Catholic churchism and sexual

topics are considered to be taboo. There is no difference seen further than

that. In terms of Muslims, it is also difficult to talk about sex, condoms

and contraception.

RQ2：What are the needs of RH among people in the Philippines?

Q1.：Do people have the needs of RH knowledge?

A1.：They do have the needs, although the point is that whether they

empowered enough to talk about it or not. People who have access to RH

could talk, but who don’t may not even recognize it as problem. In

addition, there are people who do not practice it though they have the

knowledge. Therefore, it is important to change their behavior through

peer education and advocacy. Peer educators are not only diffusing the

knowledge and skills, but also behavior change educations too. Peer

education is also important in the case of the difficulty in talking about

sex with family.

Q2：Are condoms sold in convenience stores?

41
A2：It is sold in convenience stores and super markets. Though, it is difficult

to buy them because of a sense of shame and fear to be stigmatized.

Sometimes, it is displayed at the back of the counter which people can’t

reach it. Furthermore, also there are people who cannot afford for it.

Location：kalalake high school, FPOP’s clinic

Date：September 3rd,4th,5th,2011

Targets：peer educator(15 people)、sex worker（peer student）5people、

Client(student）15people

RQ3：What kind of effect was provided by peer education?

Q1：what kind of effect did you get from peer education?

A1：【peer educators】

・we could become get confident by watching peer students grow up.

・we recognized strongly how important RH issue is in the Philippines.

・we could get many valuable skills and it leaded to educate ourselves.

【peer students】

・we could get confident in our choices.

・we could get correct information about contraceptive method and how to get

infected with STD.

・Taking peer education made us conducting Family planning.

・Taking peer education made it easy to talk about sex.

・we could get many friends who have similar consciousness.

・we could solve personal problems about sex.

・we could abolish prejudice to condom.

42
Q2：Did you have any wrong information about sex before you take peer

education?

A2：we thought that we don’t get infected with STD expect having sex, and

pill is for abortion before we took peer education.

Table 1-3 Attribution

（ ）:％
Age 17 18 19 20 21 23 24 27 32 34
Number 3(15) 3(15) 4(20) 2(10) 1(5) 2(10) 2(10) 1(5) 1(5) 1(5)
Family old young old young
father mother childlen
structure sister sister brother brother
I have 8(40) 8(40) 8(40) 5(25) 5(25) 9(45) 6(30)
I don't
12(60) 12(60) 12(60) 15(75) 15(75) 11(55) 14(70)
have

43
Figure 1-4 Gender Figure 1-5 Frequency

Figure 1-6 Job Figure 1-7 Partner

Figure 1-8 Sex experience

Source: Figure1-4 to 1-9: These

were made by author
from questionnaire.

44
 Table 1-4 Questions and answers about sex knowledge

N=20

TRUE Yes No

You will get pregnant by havin sex even once Yes 11 (55%) 9 (45%)

Having sex on safe day would perfectly prevent

No 17 (85%) 3 (15%)
from getting pregnant
Use of condoms would perfectly prevent girls
Yes 15 (75%) 5 (25%)
from getting pregnant
Use of condoms is effective to prevent girls
from being infected with Sexually Transmitted Yes 16 (80%) 4 (20%)
Diseases
You may get infected with Sexually Transmitted
Yes 17 (85%) 3 (15%)
Diseases by having oral sex
You will not get infected with STD by havint sex
No 9 (45%) 11 (55%)
with a particular partner
You will become susceptible to HIV/AIDS once you
Yes 13 (65%) 7 (35%)
get infected with STD
You will difficult to get pregnant once you get
Yes 10 (50%) 10 (50%)
infected with STD

Figure 1-9 Questions and answers about sex knowledge

45
 (1) How is the present situation of the access to RH in the Philippines?

First of all, we will summarize our first Research Question, “How is the present

situation of the access to RH in the Philippines?” by comparing the information from

the literature and on-the-spot investigation.

In 1.3.3., we mentioned about the dangerousness of early pregnancy/birthing.

During the visit and interview at Cervical Cancer Caravan of FPOP, we had a chance to

talk with few women who experienced early pregnancy. What we heard from a woman,

who experienced pregnancy and birthing when 16, was that not only her but also there

are some people experienced early childbearing around her. From this, we were able to

determine that early pregnancy/birthing remains to be a problem.

The low rate of contraceptive use is also one of the problems in the Philippines.

According to the interview at FPOP’s clinic, the present situation of the Philippines

revealed. It was that pills and injections are more commonly used than condoms. The

correct use of condoms could prevent pregnancy. Moreover, it is also effective to

prevent sexually transmitted diseases. Although, the convenience is the adverse effect in

the Philippines, because controlling the birthing easily is causing the feeling of guilt.

Furthermore, due to the appearance of using condom is very like contraception than pill

or injection that some Catholics in the Philippines refuse to use condoms. Surely, pills

46
and injections are effective in contraceptive but they don’t prevent people from being

affected with sexually transmitted diseases. The situation above seems to be the

influential factor in increase of infected people with HIV/AIDS.

Finally, we will introduce the current situation of sex education. As we mentioned in

1.3.3., the content of sex education differ in each communities and schools. However, in

Olongapo city, which aim to improve their resident’s access to RH, schools and

barangays3 were doing education program for youth who cannot go to school because

of their economic conditions or early pregnancies. If this kind of project is done at a

universal level in the Philippines, the knowledge of RH will definitely improve.

We were also able to hear about the misconception about sex in the Philippines

when we done questionnaires and interviews in teen wellness center. For example, a

woman said that before getting an education, she believed the rumor which said that

pills are effective in abortion. We cannot say it for sure that this rumor is diffused all

over the country, but we can certainly say that sex education is necessary to correct this

kind of misunderstanding.

(2) How does the religion affect RH?

Firstly, we refer to responses we have obtained to the research question “How does

3
Administrative class structure of the Philippine is these three: (1) province and highly Urbanized city (2) city
and town (3) Barangay; the smallest administrative division in the Philippines
47
religion affect RH”. Through on-the-spot investigation, we have recognized that the

custom based on religion is strongly-rooted in the Philippines. In the Philippines, a

country which decentralized government and influence of catholic churches

interdependently lack coherence of sexual education within its nation, there is a custom

which consider sexual issues as taboo. Moreover, even in regions where many Muslims

inhabit, similar custom could be seen and the access to RH is limited. From the

interviews at UNFPA, we obtained the following response, “Religion is innate and it is

difficult to distinct religious belief and our thought. Most of the Filipinos were born as

Catholic.” This custom was appeared in environment which makes people difficult to

discuss sexual issues in homes and schools and also in regulation of the access to

contraceptives. We have recognized the fact that many people are not able to discuss

sexual issues with their family through interviews at FPOP clinics. Since there are many

adults who feel repulsive of adolescent’s early sexual debut, adolescent hesitates to

consult adults. In addition, as for the access to contraceptives, although it differs in

regions, there are regions where contraceptives are completely unavailable or require

prescription of doctors due to restrictive policy of its regional government. As it was

mentioned in chapter 3, Catholic belief prohibits artificial birth control, and this custom

was remained in the Philippines. For example, in Manila, when Lito Atienza took up a

48
post of mayor in 1998, citizen became unable to access to artificial contraceptives

including condoms, pills, intrauterine devices, etc. Atienza was a Catholic, and from his

strong religious belief, he put emphasis on parental responsibility and adhered to natural

family planning. Currently, condoms are available at convenience stores in urban city.

However, since they were disposed behind the cashier and make customers feel sense of

shame or threat of scornful look from salesperson, it’s hard for people to purchase them.

Especially for adolescents, repulse from the society is strongly-rooted and virtually no

one buys condoms at convenience stores. As it was mentioned in Chapter 1, even

though contraceptives are available, custom in society becomes one factor of hindering

its prevalence.

As mentioned above, the Philippines have an environment which limits the access to

knowledge about sexual issues and health care services. As a false rumor about

HIV/AIDS is spread in Zambia, which we have taken up as a case study in chapter 2,

prejudice and false recognition are spread in the Philippines. This is one factor strongly

affecting the existence of unwanted pregnancies and sexually transmitted diseases. In

this regard however, there are some exceptions we would like to mention. First, religion

is not the only factor which discourages people from the access to reproductive health.

There are many people who cannot access to knowledge about sexual issues and health

49
care services due to their economic context. Secondly, although custom which makes

people consider sexual issues as taboo is still remaining in the Philippines, there are

people who deem the access to RH as human rights. Through on-the-spot investigation,

we have met people who pray at church every week but pay attention to sexual issues at

the same time. They were staffs of organizations which aim to improve the access to RH

in the Philippines or peer educators. Moreover, recently, there is a heated debate about

RH bill in the Philippines, and 73% of the citizens agree that "if a couple wants to plan

its family, it should be able to get information from government on all legal methods."

From these factors, we have found a glimmer of hope that the access to RH would be

improved in the future Philippines.

(3) What are the needs of RH among people in the Philippines?

Next, we will analyze the second research question, “How are the needs of reproductive

health among people in the Philippines?”

(i) Analyzing from Questionnaires

In our study, we have done questionnaires to 20 peer students in the project sites of

UNFPA and FPOP. We measured the needs of peer students about reproductive health

by the two questions below, “Do you want to have a conversation with peer educator

about sex?” and “Do you want to take peer education continuously?”. As a result, for

50
the first question, 13 students (65%) answered that they completely agree/agree and 7

students (35%) answered agree a little/don’t agree at all. And for the second question,

while 14 students (70%) answered that they completely agree/agree, 6 students (30%)

answered they agree a little/don’t agree at all. From here onwards, we have found out

that peer students actually have the needs for reproductive health.

(ii) Analyzing from interviews

We have done interviews at UNFPA.

First, on 31st August, when we visited the office in the Philippines, we asked “Do

peer students really have the needs to know about reproductive health, or does the

religion prevents adolescents from telling the needs of reproductive health?” to the 5

staff who engage in the project. We received some replies that “They do have needs.

The problem is whether they are empowered enough to talk about it or not.” “Moreover,

while the people who have the access to reproductive health could tell the needs, the

people who don’t have the access don’t even think it to be a problem.” Thus, we

discovered that while there are people who want to know about reproductive health, also

there are people who don’t even know that they are unaware about reproductive health.

Therefore, UNFPA are teaching about the reproductive rights to both, the people who

cannot tell the needs and the people who don’t even know that they are unaware of it.

Next, on 5th September, we visited the UNFPA’s project site, “teen wellness center”.

51
This is a center which is located in Olongapo city and doing community-based peer

education. Here, we asked “What kind of knowledge do you want to know?” to more

than 10 peer students. “We are joining this peer education to learn about prevention of

sexual transmitted diseases, the effects of early pregnancy and family planning”,

answered the peer students. From above, it became clear that there are peer students

who want to know about reproductive health through peer education, in short, they

surely have the needs. Moreover, according to some peer students, peer education has

corrected their misunderstandings, for example, knowledge about pills and infection

route of sexual transmitted diseases.

(iii) Analyzing from literatures

According to the previous study of peer education program in Scotland, which we have

introduced in chapter 2, peer students felt that they would like to know more about

emergency contraception, correct condom use, teenage pregnancy, communication skills,

homosexuality and local services, although the teachers were feeling that they had

covered many of these subjects in detail already. Moreover, 43% of pupils were feeling

that the amount of sex information given was insufficient. Therefore, you can see that

adolescents do have the needs to know about reproductive health worldwide too.

In addition, according to the reports of YES4YES peer education project and other

materials, which mention about the details of the activities and the problems that

52
Philippine adolescents face, we can say that they certainly carry the needs to know

about reproductive health information from 3 points below. (The reports and materials

we used is the one which FPOP have handed down for us when we visited the Manila

office in 3rd September.)

First, most of women who used the FPOP services were pregnant or married in the

past, but now, many types of youth uses the services. For example, junior high school

student who wanted to know about adolescent reproductive health (ARH) information

came to the clinic. Moreover, prostitute women, who are under the risk of sexual

transmitted diseases, came to get condoms. From above, there are many youths who

potentially have the needs to know about reproductive health.

Second, FPOP extended the opening hours in response to requests from youths. By

extending the opening hours, FPOP made students who are on their way from schools,

youths before heading off to work could use the clinics. In addition, they made the

clinics open on Saturdays too so that more people could use them. From this, you could

see that there are youths who didn’t have enough access while they had the needs to

reproductive health.

Finally for the third, in the Philippines, 73% of the population is thinking that the

government must provide the reproductive health services to the youth. Therefore,

53
including the RH bill discussion, which we introduced in chapter 2, there are

compelling needs for reproductive health information in the Philippines.

(4) What kind of effect was provided by peer education?

(i) Analyzing from Questionnaires

This analysis focuses on two points. First, we focus on a correlation between predicable

and improving knowledge. Second, we try to show a correlation between other

questions.

As we mentioned before, number of questionnaire is few that we could not do

grouping like we have planned, so we manage to demonstrate a correlation between

frequency of taken the peer education and question about improving knowledge. We ask

these 8 questions to measure knowledge of peer students and students answered ○ or ×.

(1)You will get pregnant by having sex even once (2)Having sex on safe day would

perfectly prevent girls from getting pregnant (3)Use of condoms would perfectly

prevent girls from getting pregnant (4)Use of condoms is effective to prevent girls

from being infected with STD (5)You may get infected with STD by having oral

sex (6)You will not get infected with STD by having sex with a particular partner.

(7)You will become susceptible to HIV/AIDS once you get infected with STD

(8)You will be difficult to get pregnant once you get infected with STD.

54
 Considering simply percentage of questions answered correctly, it is very widely.

From figure 1-10 to figure 1-17 shows correlation with student’s predicable and class

period. It shows the percentage of questions answered correctly of the “over fifth” group

develop rapidly. However, even though “over fifth”, there are some question which is

low percentage of questions answered correctly, or “first time” is more high percentage

of questions answered correctly than “more than 2 and less than 5”.This showed 1 or 2

times class was not effective and it is important to get an education no single moment

but sustainably. We would like to know why differences occur in percentage of

questions answered correctly during same group but we couldn’t know about it because

of time pressure.

Next, we try to observe correlation between other questions. We focus on these three

questions. “I want to take peer education continuously” ”I want to have a conversation

with peer educator about sex” “I enjoyed participating in peer education”. Please look at

chart from figure 1-18 to 1-20.

Students who agreed “I enjoyed participating in peer education” are more likely to

continue peer education. We would like to define approachability of peer education but

unfortunately, we could not show conclusive correlation. Students who enjoyed peer

education are more likely to want to spread the information of peer education to friends.

55
 Figure 1-10 (1) Figure 1-11 (2)

Figure 1-12 (3) Figure 1-13 (4)

56
 Figure 1-14 (6) Figure 1-15 (7)

Figure 1-16 (8) Figure 1-17 (9)

57
 Figure 1-18 enjoy peer education

Not agree: consolidate “not agree” and “agree a little”

Agree: consolidate “agree” and “completely agree”

58
 Figure 1-19 peer educator was friendly
er

Figure 1-20 want to spread peer education to friends

Source: Fgure1-10 to 1-20: These

were made by author from
questionnaire.

59
Table 1-5 improvement in knowledge
Peer educators Peer students

Improvement in ・Sexually transmitted ・Sexually transmitted

knowledge diseases diseases

・Correct contraceptive ・Correct contraceptive

method method

・Biological mechanism ・Biological mechanism

・Right to access to RH

Changes in awareness ・Seriousness of RH issues ・Practice of correct

and action contraceptive method

・Practice of family

planning

・Correct recognition

Expansion of network ・Interaction at the PE ・Interaction at PE classes

seminar

・Interaction at PE classes

Others ・Self-development ・Elimination of one’s

worries

Source: This was made by author from questionnaire.

60
(ii) Analyzing from interviews and literatures

We have got interview to find answer for research question “What kind of effect was

provided by peer education?”.

We frame all responses of peer educator and students, and we could categorize the

type of responses. There seem to be three prominent types of these responses. First, it is

improving knowledge. On the peer students’ side, they could take knowledge about

contraceptive and how infect HIV/AIDS. The response for “Did you have wrong

knowledge before taken peer education?” is, for example, according to peer educator in

Kalalake high school, there is student who think pill as medicine to abortion. Even

students like this could improve their knowledge.

Second, it is behavior and mind change. On the peer educator side, they were able to

recognize significances of current RH problems. On the peer students side, actually they

were able to execute contraceptive methods which is knowledge from peer education. In

addition, they said that they were able to have an open discussion about sexual topic,

and some of them said that they could eliminate bias to condoms.

These responses of peer students and educator have 1 feature in common. It is that

they could become get confident through peer education. Peer educator built confidence

by seeing growth of students. On the student’s side, also they built confidence about

their choices.

61
 Finally, it is growth of network. For both students and educator, there are many

people who have same distress about RH in the peer education class, and they are

understood by contact with them.

Additionally, there are many positive responses for peer students and educator; they

could do personal development, they could eliminate their worries, and so on. Personal

development means that they learned their skill which is essential for living. For

example, they were able to choose correctly less emotionally.

As the results showed, peer education is effective as many ways for both students

and educator. Peer education is especially effective in improving knowledge, changing

behavior, and growing network. The results showed approachability of peer education

supported by social cognition. The situation where it is hard to talk about sexual topic

like Philippines, peer education is effective. Rather, for situation like this, we can expect

possibility of peer education.

1.6 Conclusion

1.6.1 Summary and conclusion

In this chapter, we summarize past chapters and describe the conclusion.

Since 1990, world’s annual maternal mortality is more than 500,000. The most part

of that have occurred in developing country. Though Millennium Development Goal

62
was declare and “Improve maternal health” was set in goal5, it is difficult to say that

there is a great improvement of maternal mortality on present showing. Maternal

mortality is caused by social and economic problem and other complicated problems.

Moreover, it reflects efficiency of health system strongly. In 1994, concept of RH was

agreed worldwide, and some policies reflected this concept. However, unmet need of

STD or Family Planning remains serious issue. Low access to RH causes the vicious

cycle of poverty. Therefore, “Education “makes a great contribution to break out this

vicious cycle of poverty. Education to the adolescent who is an age group which they

start reproductive activity is necessary to challenge these problems in the long term.

Also, RH Bill has a big effect on access of people in the Philippines. Therefore, in our

study, we focus on Peer Education which is common approaches in addressing

Adolescent RH worldwide.

Peer education is an approach or strategy to promote changing one’s consciousness

and behavior.

We focused on the Philippines where the maternal mortality ratio remains high in

Asia and the number of Adolescent fertility and unwanted pregnant is still large. In the

Philippines, it is difficult to access to sexual information because of strong effect by

religion. And sexual education isn’t enough. The usage of condom is very low and

63
people need to improve access to modern method of contraception. It is difficult for

Adolescent in the Philippines to talk sexual topics with elders or parents at public place

or home. So they don’t have enough opportunity to get knowledge on RH. Furthermore,

RH bill has a huge effect on access to RH strongly.

Therefore, Peer education is efficient approach to work on this problem. The

reason why we focus on peer education is that Peer education could provide

comfortable and friendly circumstance to adolescent. Moreover, as we mentioned in

1.3.2 and 1.3.3, peer education has great effects and possibilities.

In this chapter, we also summarize responses of our research questions and our

consideration.

(1) How is the present situation of the access to RH in the Philippines?

First of all, we learned through field survey that early pregnancy/birthing is still serious

problem as reflect our literature survey. And about contraceptive method, taking pill or

using injection is common method. It could be said that there isn’t great improve of

usage rate of condom. And we thought that sexual education is important to improve the

present situation. Especially, about the misrecognition is spreading out. About sexual

education, not only people don’t get an enough education but also there are many

different situations and qualities of education. But still the active action like Olongapo

64
city is necessary.

(2) How does the religion affect RH?

In the Philippines, there is a custom which consider sexual issues as taboo. This custom

was appeared strongly in which makes people difficult to discuss sexual issues in homes

and schools, and also in regulation of the access to contraceptive. Moreover, this custom

affect to policy sometime. So it could be said that this custom has a great effect to social

in the Philippines.

However, there are many Catholics who deem the access to RH as human rights and

pay attention to sexual issues. Moreover, recently, there is a heated debate about RH bill

in the Philippines, and 73% of the citizens agree that "if a couple wants to plan its

family, it should be able to get information from government on all legal methods." It

shows that there are some possibilities of improving access to RH in the future.

(3) What are the needs of RH among people in the Philippines?

As can be seen from result of interview, there are needs on RH in the Philippines.

Expanding the age group of the clients in FPOP shows that there are needs of adolescent

especially. But it could be another problem if there are people who become empowered

to talk about their needs on RH. There are people who don’t even know that they are

65
unaware about reproductive health. Therefore, UNFPA are teaching about the

reproductive rights to both, the people who cannot tell the needs and the people who

don’t even know that they are unaware of it.

(4) What kind of effect was provided by peer education?

As we mentioned before, number of questionnaire is so few that we could not do

grouping what have planned. But we could see that there are some relationships

between frequency and fixing of knowledge, also conscious/interest to peer education

and continuousness.

Moreover, from interview, we found that both peer educator and peer student have

effects through peer education. Peer education has wide range of effects, for example,

they can improve their knowledge on RH, change their consciousness and behavior,

enlighten themselves, and expand their network. In addition, we also found that not only

adolescent but also whole young people including adolescent have effect of improving

their knowledge through peer education.

In this field survey, place or organizations we had visited are very limited, and there

are more than 7,000 islands in the Philippines. Furthermore, there is a quite difference

of living environment between urban and rural. Thus, it’s hard to say that survey

findings in this study reflect whole situations completely. But, from our consideration,

66
we could verify our hypothesis “Peer Education for Adolescents can improve the

knowledge on Reproductive Health (RH)” almost.

1.6.2 Issues and foresight

This study attempted to analyze peer education for improving knowledge on RH.

However, we found that education, of course, is very important,but it is urgent to

enhance access to health care service. We have to accept that as a given when we are

addressing RH issue in the Philippines. Because of lack of medical facility, people can’t

satisfy their needs. And, when people conduct peer education, they might face a lot of

challenges. For example, peer education isn’t really popular in the Philippines, lack of

facility or infrastructures like space or textbook to their needs, and it require long time

to train peer educator. Especially, people who have experienced pregnant in adolescent

or out-of-school don’t have enough time to get peer education because they have to bear

children or they already have job. But it is true that they are target of peer education. So,

we found that it is difficult for them to get peer education continuously. In addition, peer

education doesn’t have standardized curriculum and teaching methods. So, the quality

of education is not same in each project. It is because dimension and definition of

“peer” have not defined yet.

However, as we mentioned in 1.2.2, peer education have a great effect in many case

67
examples worldwide. And we found that it has many effects by analyzing our findings

of field survey in the Philippines. In the future, we hope strongly that UNFPA

(international organization) and FPOP (NGO) keep on addressing to diffuse and

promote peer education in the Philippines, and we hope that visibility of peer education

will be increased and government will address RH more active Moreover, also in Japan

(HIV/AIDS patient are increasing rapidly and there are a lot of misunderstands about

sex), we desire that peer education will be more popular and be a great part of health

education.

68
Appendix

Questionnaire for peer students

Date Location

I.

・Age ( )years old

・Gender □Male □Female

・Family structure Fill in the parenthesis with the number if you have any.

□Mother □Father □Older sister( ) □Younger sister( )

□Older brother( ) □Younger brother( ) □Children( )

・Frequency (How many times have you taken the peer education?)

□0(Today is for the first time) □1 □2 □3 □4 □More than 5

・Job (What do you do? Where do you work at?)

( )

・Partner (Do you currently have a partner to have sex with?)

□Yes □No

・Sex experience (Have you ever had sex experience?)

□Yes □No

II. True or False

1. You will get pregnant by having sex even once

□T □F

2. Having sex on safe day would perfectly prevent girls from getting pregnant

□T □F
 3. Use of condoms would perfectly prevent girls from getting pregnant

□T □F

4. Use of condoms is effective to prevent girls from being infected with

Sexually Transmitted Diseases.

□T □F

III. True or False

1. You may get infected with Sexually Transmitted Diseases by having oral sex.

□T □F

2. You will not get infected with STD by having sex with a particular partner.

□T □F

3. You will become susceptible to HIV/AIDS once you get infected with STD.□T

□F

4. You will be difficult to get pregnant once you get infected with STD.

□T □F

IV. Check in a box

1. I enjoyed participating in peer education

□Completely agree □Agree □Agree a little □Don’t agree at all

2. The lesson was easy to understand

□Completely agree □Agree □Agree a little □Don’t agree at all

3. The peer educator was friendly and easy to talk with

□Completely agree □Agree □Agree a little □Don’t agree at all

4. I want to have a conversation with peer educator about sex

 □Completely agree □Agree □Agree a little □Don’t agree at all

5. I want to take peer education continuously

□Completely agree □Agree □Agree a little □Don’t agree at all

6. I want to spread the information of this project to my friends

□Completely agree □Agree □Agree a little □Don’t agree at all

V. Check in a box

1. I can have a talk with my partner about prevention of pregnancy

□Completely agree □Agree □Agree a little □Don’t agree at all

2. I can directly ask my partner whether he has condom or not

□Completely agree □Agree □Agree a little □Don’t agree at all

3. If my partner doesn’t have condom, I can refuse to have sex.

□Completely agree □Agree □Agree a little □Don’t agree at all

Reference

Advocates for Youth. (2005). Science&Success in Developing Countries: Holistic Programs

that Work to Prevent Teen Pregnancy, HIV& Sexually Transmitted Infections.

Adovocates for Youth.

AghaSohail. (2002). AN EVALUATION OF THE EFFECTIVENESS OF A PEER SEXUAL

HEALTH INTERVENTION AMONG SECONDARY- SCHOOL STUDENTS IN

ZAMVIA. AIDS Education and Prevention, 14(4), 261-281.

DarrochJe. (2009). Meeting women's contraceptive needs in the Philippines,in Brief.

Guttmacher INstitute(No.1).

Deon FilmerH. PritchttLant. (1999). Estimating Wealth effects without Expendiure Data-Or

Tears: An application to Educational Enrollments in States of India.

Department Of Health. (2011). National Epidemiology Center HIV Registry. Department Of

Health.

Family Plannning Organization of the Philippines. (n.d.). FPOP HP. Retrieved 11 24, 2011,

from htttp://www.fpop1969.org/

HaginoYoshio. (2002). Philippinenosyakai, rekishi, seiziseido(Society, history, and political

institution). AkashiShoten.

James JobanputraR. Clark, Giles J. Cheeseman, Annna Glasier, Simon C. RieyAlice. (1999).

A feasibility study of adolescent sex education:medical students as peer educators in

Edinburgh schools. British Journal of Obstetrics and Gynaecology.

Population Concil. (2009). The Adolescent Experience In-Depth:Using Data to Identify and

Reach the Most Vulnerable Young People:Philippines 2003. New York: Population

Concil.
72
Saito tadathuHIroe, Rie Ikeda, Aiko TakenagaThushima. (2002). Peer counseling wo motiita

sisyunkiseikyouiku to sono zissen(Adolescent sexual education through peer

counseling and practice). The Journal of the Kawasaki medical welfare, Vol.12(No.2),

259-279.

Senderowitz, J. (2000). A Review of Program Approaches to Adolescent Reproductive Health.

Poptech Assignment Number 2000.176.

Snate Economic Planning Office. (2009). Promoting reproductive health: A unified strategy

to achieve the MDGs. POlicy Brief, 1-14.

Social Weather Stations. (n.d.). Social Weather Stations HP. Retrieved 11 24, 2011, from

http://www.sws.org.ph/

Taguchi, T. (2004). Kaihathukadainitaisurukoukatekiapproach~Reproductive health~(The

effective approach to development subject~Reproductive health~). Retrieved 11 23,

2011, from JICA research station: http://www.jica.go.jp/jica-

ri/publication/archives/jica/field/pdf/200408_02_01.pdf

UNFPA. (2003). state of world population "Investing in adolescents' health and rights".

UNFPA.

UNFPA Philippines. (n.d.). UNFPA Philippines HP. Retrieved 11 24, 2011, from

http://philippines.unfpa.org/

UNICEF. (2009). THE STATE OF THE WORLD'S CHILDREN "Maternal and Newborn

Health". UNICEF.

United Nations Educational Scientific and Cultural Organization. (2003). Peer Approach in

Adolescent Reproductive Health Education:Some Lessons Learned. UNESCO.

Universal Journal company. (2004). Kokusai Kyoryoku Yougo syu (International cooperation

glossary version 3). Universal Journal company.

73
World Health Organization. (2001). INFORMATION, EDUCATION AND

COMMUNICATION-LESSONS FROM THE PAST: PERSPECTIVES FOR THE

FUTURE-. WHO.

World Health Organization. (2010). World Health Statistics 2010. WHO.

World Health Organization. (2011). National Epidemiology Center HIV Registry. Department

Of Health.

74
Chapter 2

Direction of Expanding Sanitation

Coverage and Its Customary Usage:

Considering the Effect of Awareness Program

Momoe Kinebuchi

Naoki Ikeda, Azusa Ochi

Fumie Nakajima, Yuya Hayashi

Introduction

The biggest problem developing countries are facing is the lack of sanitation facilities and

access to safe water. Access to safe water has been addressed by many developing countries

and has been given the preference. According to Human Development Report 2006, about 2.6

billion people around the world lack proper sanitation facility. People who are lacking the

sanitation facility are almost 2.5 times more than the people lacking access to safe water.

Wastes from household are directly released into river without prior treatment because of

poor sanitation facility. This intern pollutes the river water causing water pollution. Moreover,

soil is contaminated because the lead waste is discharged directly into land people living in

unsanitary conditions use the water from contaminated source for drinking and washing

purpose. The soil is polluted because of excretion of waste outdoors due to lack of sanitation

facilities. Conditions like these will induce and spread diarrhea, and other water borne

diseases1. To be infected with diarrhea has brought a big impact for less than 5 child mortality

rate and health hazards, economic losses to people living in developing countries

According to “Economic Impact of Sanitation in Southeast Asia Summery”, The

Philippines, where our study was primarily focused on, has had considerable economic losses

due to lack of sanitation facilities, about 1.4 billion dollars per year. The economic losses can

be cut down by 45 %, the mortality rate can be brought down by 32 % and the health impacts

can be reduced by 32% by improving the sanitation facilities and the condition. In the

Philippines, the Manila water supply and sewerage supply corporation (MWSS 2 ) was

privatized. The water supply was improved significantly over the years but the sanitation

facilities were improved only to a limited extent because of the delay in construction causing

1
Waterborne diseases are kind of infection disease acquired by water. For example: trachoma and diarrhea
and so on.
2
In 1997, Metropolitan Waterworks Sewage System is become private. So Manila Water took over the East
Zone and Manilad took over the West Zone.
77
some serious problems. It is said that after the improvement in water supply facilities, many

people have got access to safe water, but actually the people living in poverty and inferior

living conditions have never been able to access the safe water. The sanitation and water

facilities although present in elementary school, the children face difficulties in using them as

they have become old and the facility provided is small when compared to the strength of the

students. To assist in this situation, the government of Philippines has been conducting

activities; Waterborne diseases are kind of infection disease acquired by water. For example:

trachoma and diarrhea and so on.

In 1997, Metropolitan Waterworks Sewage System is become private. So Manila Water

took over the East Zone and Manilad took over the West Zone. Several laws have been

passed to control water pollution and improve standards of hygiene, a national hygiene

summit was held to spread awareness. Although several activities being conducted, the

government has not adopted definite policies. To improve the sanitation, the government of

Philippines has to spend 600 billion pesos per year but presently the government has been

investing only 15 billion pesos per year. The lack of adequate funds has been the biggest

barrier against improving the sanitation facilities.

In our studies on sanitation facilities, we included toilet and hand washing stand. We

believe that the importance of sanitation facilities has to be spread through the sanitation

education or media. As a result, we expect the students and the inhabitants to get accustomed

to sanitation facilities and use them properly and spread the knowledge about sanitation to a

wider sphere of people Our study was setup under the theme 'Importance of awareness

program to spread awareness about sanitation facilities and get the people accustomed to use

properly". We investigate and examine 2 case studies conducted in Philippines. In this thesis,

we focus on spreading knowledge about sanitation facilities to schools/communities through

78
awareness program. We will express on what we can do in order to spread the awareness

about sanitation effectively and to use improved sanitation facilities for the community's

sustainability.

In 2.1, we comment about the spread of sanitation facilities in the world. In chapter 2.2,

we analyze the present situation of sanitation in Philippines. In chapter 2.3 and 2.4, we have

summarized our study by including the details of case studies, content verification and

definition of terms. In chapter 2.5, we examine the interview conducted with the inhabitants.

The reference and links related to the contents are included along with the conclusion in

chapter 2.6.

2.1 State of the world

2.1.1 Rate of achievement of the MDGs

As the international community's goal in the 21st century Millennium Development Goals

was adopted in the UN Millennium Summit in the year 2000. The target 7.C in seven of the

goals of MDGs set a target of halving the proportion of people without access by sustainable

to safe drinking water and sanitation facilities by 2015. The desired value of the population

which can access safe water and sanitation facilities by 2015 in a developing country is 89%

in safe water supply and 71% in sanitation facilities. About sanitation facilities, people who

cannot use the improved sanitation facilities amount to 2.6 billion people all over the world

and people who cannot use fundamental sanitation facilities in a developing country reach to

48% as of 2008 (The Millennium Developing Goals Report 2010,2010,P61). The global

effort of MDGs relating to drinking water is progressing and now more than one billion

people worldwide have been accessible to safe drinking water. If current efforts continue, it is

possible to use safe drinking water than before for the people of the world population more

79
than 90% by 2015 (The Millennium Developing Goals Report 2010,2010,P58)

However, even in comparison to the problem of improving access to safe drinking water,

progress of sanitation facilities is too slow in a developing country. Unless sanitation facilities

are immediately improved, they will not be able to achieve even half of the target by 2015;

sanitation facilities coverage goals will remain difficult. According to Human Development

Report 2006 (2006,P136), “About 2.6 billion people cannot still use improved sanitation

facilities and its population is 2.5 times that of people without available safe water” is said.

As the reason sanitation facilities do not spread rather than safe drinking water, it is

considered that the lack of safe water is a threat pressing for the life rather than sanitation

facilities, such as a toilet and the profits by the improved sanitation facilities are not more

widely understood than the profits by use of safe water. Moreover, a political leader in and

outside the country is negative for excrement and its safe processing are set on the subject of

international development cooperation and compared with water supply, the insufficient

national strategy, insufficient fund supply and the lack of ability of local governments are the

factor from which spread is prevented because it is thought that the improvement of

sanitation facilities is a result of economic growth, and is not a factor which determines

economic growth (Human Development Report 2006,2006,P143).

But the defect of sanitation facilities causes many illnesses and is leading the younger age

group, especially a child to die in fact. According to Human Development Report 2006(2006,

P23), “It becomes obvious from investigation among many countries that the disposal method

of excrement is one of the greatest factors that influence infants' survival situation. The

improvement of sanitation is decreasing all the mortality rate of infants by a third, and also

brings a merit to public health, a life, and dignity, and the profits spread from the home to the

whole community” is said. In fact, it can be said that improving sanitation facilities may

80
become a driving force which significantly enhance economic efficiency for a long time. It

can be said that the offer both of continuous accesses to safe drinking water and sanitation

facilities becomes an aid which saves poor people from poverty, and it is one of the most

important development support.

2.1.2 Relation between defect of sanitation facilities and water-borne disease

As Passage1also described, the defect of sanitation facilities causes many illnesses and is

making the younger age group, especially little children to die. According to The Millennium

Developing Goals Report 2010 (2010, P61), “About 1.1 billion people are defecating outside

by the defect of sanitation facilities. Open defecation is not only the insult to man's dignity

but also fundamental cause by which illness is infected from a mouth and brings about fatal

result to little resistless children” is said. About 1.4 million infants die every year owing to

the diarrheal illness which can be prevented. Infants who die owing to the usual diarrhea also

among the illness related water supply, sanitary facilities and health are 43％ and it’s the

most common cause of death (The United Nations World Water Development Report

3,2009,P8). Moreover, 300 million tons of excrement are not processed by defect of

sanitation facilities every year and pollute the riverhead. This is the biggest causes of

diffusion of more than 20 kinds of infection disease. About 50% of the number of sickbeds of

the hospital in a developing country is formed by the patient of water-borne disease through

water (Joint G8+ science academies’ statement on Water & Health, 2011).

Unless sanitation facilities are improved, the effect of the expensive vaccine for

controlling water-borne disease or a chemotherapy is spoiled remarkably. Improving

sanitation facilities becomes a role which saves a life for disease such as diarrhea. Suppose

the use of improved sanitation facilities that a child's mortality rate in Cameroon and Uganda

is decreased by not less than 20%. Moreover, the flush lavatory in a home supposes that the

81
risk of the infant death in Egypt and Peru will be decreased by not less than 30 % (Human

Development Report 2006, 2006, P4). If the decline of open defecation rate continues, it

mainly becomes preventive against of diarrhea and the growth inhibition and malnutrition

following it and it can be said that it may be able to have big influence on an infantile

mortality rate reduction.

2.1.3 Economical loss which defect of sanitation brings about

According to the investigation report of World Bank East Asia and the Pacific Ocean office

(2007, P6)“it was investigated that the defect of the sanitation facilities in Cambodia,

Indonesia, the Philippines, and Vietnam affects health, water, environment, the tourist

industry, everyday life, etc. The defect of sanitation facilities suffer the about 9 billion dollar

(2005) loss per year only in four countries. (Refer to Figure 2-1) This deserves about 2% of

GDP in four countries” is said. However, it is considered that the improving of the whole

sanitation facilities and sanitary conditions reduce the losses resulting from it by 45% (except

for the health effect). Moreover it is estimated that the economic effect will bring in 6.3

billion dollars a year to countries (World Bank East Asia and the Pacific Ocean office, 2007,

P6). As health impairment the defect of sanitation facilities makes caused the symptoms of

many illnesses, such as diarrhea. Also, as almost all homes are pouring drainage from the

household and solid waste to a river or the sea, it is the cause of serious water pollution or

environmental pollution. According to those causes, expenditure, productivity, governmental

annual revenue, and the income of the household/company were affected, and it has led to the

economic loss. Also in the tourist industry, tourism is an important industry to accrue income,

employment and foreign currency for these four countries and it is considered that the

economic loss is induced owing to insufficient sanitation facilities because the travelers set

one of the factors whether to be able to use sanitary and suitable toilet with guaranteed

82
privacy and perform use of water service and soap in order to determine the destination of a

vacation (World Bank East Asia and the Pacific Ocean office, 2007, P6).

Moreover, the economic loss of everyday life influences the quality of life greatly

because the existence of the toilet of the single room where water service equipment has for a

woman is especially important. The long distance toilet and outside use has a high physical

danger in especially the night. At the home without a toilet, or the home in which only the

below standard toilet is established, as they go to the place of public toilet and open

defecation, or as they have to wait in an insufficient public toilet on a population basis and, it

takes time. For this reason, the economic loss of the spent time reaches also in 1.3 billion

dollars per year as the whole country. In the case of the female who makes account of

especially privacy, the loss of time is larger than a male. Moreover, the state of a toilet and

the existence of a toilet in an institution influence the capability in order to go to work or

school. In many offices, suitable water and sanitation facilities run short and it has especially

had influences of many on a female use, productivity, and employment determination.

83
 Figure 2-1 The economic loss per year by the defect of sanitation facilities
and The economic effect by introduction of health facilities in
2005 (dollars in millions) Economic losses and gains (dollars in
millions)

Source: World Bank East Asia and the Pacific Ocean office, 2007, P6

Additionally, there is an economical loss in a school. When a child is suffered from water-

borne disease, there is the present condition of suffering many disadvantages as an

educational beneficiary in many cases. If health condition is bad, intellectual and mental

development will be inhibited directly and long absence and early dropout of school will be

caused indirectly. According to Human Development Report 2006(2006,P49), “days for 443

million days of school attendance are lost with the illness relevant to water every year and the

days of school attendance which are lost by the influence of the parasite which is infectious

through water and feces are nearly half. More than 150 million who reached school age are

severely troubled by the parasite of the intestines through water. In the rate which is absent

from a school, the child infected with the parasite doubles rather than the child who has not

been infected. Even if the infected child attends a lesson, he is worse off academically than
84
the child who has not been infected. It is shown clearly by the test result that infection with

parasites exerts a bad influence on power of memory, the capability to solve a problem, and

duration of concentration” is said. Thus, disease transmission is expanded by the defect of the

sanitation facilities in a school, and as a result absence is increasing. The illness of infancy

and the loss of an educational opportunity are being connected to the poverty of adulthood

and falling into spiral of poverty.

2.1.4 A spread of the concept of WASH

Nowadays, the concept of WASH is quickly spreading all over the world by making a project

called WASH in schools of UNICEF into a subject. WASH is Water and Sanitation Hygiene

and refers to safe water supply and sanitation facilities. In this project, it aims at healthy

promotion of children or those homes, surrounding people, and the next generation by

improving sanitation facilities and supplying safe water for school. While safe water supply

has spread preferentially as Passage1 may show, the view through at both of them must be

circulated is going to spread through the concept of WASH, as neither safe water nor

sanitation facilities can be separated. Although Section 2 described the influence which the

shortage of sanitation facilities brings about, without a supply of safe water even if only

sanitation facilities spread, water and a health problem will not be solved. According to

Human Development Report 2006(2007, P140), “when a certain investigation for two or

more villages in Kyrgyzstan is conducted, it turns out that there are few people who wash

hands and about a half of homes are throwing away their excrement on the yard or street” is

said. The problem was not the ignorance on hygiene but rare opportunity to wash hands at

home because water was not supplied and it was difficult to purchase soap. At the home in

which water service passes and which has a washstand, the frequency of hand washing was

going up by 3 times. As it may understand from here, it becomes an effective measure to

85
solve problem only after there are elements of both safe water supply and suitable sanitation

facilities.

Moreover, call to action is in one of the big measures of WASH in schools. This measure

increases mainly the stakeholder in connection with WASH in schools by the appeal from

media or stakeholders, and spread the measure of WASH in schools. By increasing

stakeholders, various stakeholders, such as not only the national organization and

international organization but the local government, NGO, are concerned and they are

working on a project together. Thus, WASH in schools increases many stakeholder and is

extending the concept of WASH further now by introducing the data of the effect of a project

and activity with using various media.

2.1.5 Previous study

On this section, we will introduce to corroborating previous study. First, we take up “The

Intermediate Technology to Cope with Sanitation Relating Issues in Bangladesh” as relating

awareness campaign. This thesis shows the problems of environmental and sustainability of

toilets. Moreover, it mentions how to solve those problems.

In the Bangladesh pit latrine toilets are spread, but these are not maintaining properly.

This thing connects to water pollution or worsening of toilet’s sanitation situation. There are

2 reasons of impediment. One is not having properly technologies, second is lacking of

citizen’s awareness to activities for implement sanitation situation.

This thesis conducted questionnaires in 2 areas of Manikganj province. In one area, more

than half habitants don’t have toilets. On the other hand, in the other area, relatively rich

people live. They ask 2 questions. One is “Do you keep on now using toilet?” Against the

question, only 30%~40% people answered “No. We would like to improve our toilet”. The

other is “In order to prevent disease from unsanitary, do you want to implement your toilet?”

86
They answered “Yes, we want.” These result shows citizen feel alarmed by effect for health

from unsanitary, but people who have awareness be willing to implement toilets

preferentially are not so many.

This thesis describes that introduction of intermediate technology is a must to two

subjects. Intermediate technology means “Technology corresponding to the local

characteristic which contains various constraints and the local needs using the funds which

can supply and human resource”. We use the word, Appropriate technology , to enphasize the

nuance that it is appropriate to the community because Intermediate technology is relative

concept. This technology realizes that mitigation of an environmental impact or sustainability

of using sanitation facilities. In order to introduce this intermediate technology, “the approach

1) Institution of the problem from local residents, 2) Selection of the solution by local

residents, 3) The integration with training and the service offering from the local government

or NGO, 4)Self-supporting management by local residents” are effective.

It is important for conducting these approaches to build their consciousness in order to

recognize the problem of sanitation situation. By making consciousness formation, residents'

ownership is raised and they improve their sanitation situation by themselves. Hence their

own management system is built by themselves. Residents' positive participation makes it

easy to collaborate with external organization or people such as the government and NGO.

Communication between the external organizations and residents leads to exact technical

propagation. Moreover, they recognize the needs of sanitation facilities. After all, it leads also

to the sustainability of use and the suitable maintenance management. Therefore, it can be

said from the above that intermediate technology is required for improvement of the

sanitation situation in the Bangladesh. Besides, residents' consciousness formation is a

success function to improve sanitation situation. Since awareness program are needed for

87
consciousness formation, awareness program are important for improving a sanitation

situation effectively.

Figure 2-2 Social environmental issue relating to water supply and

sanitation

Source: This made by author from Akira Sakai, 2005, “Mizu to eisei ni kakawaru kaihatuenjo no houkousei”
(Directionally of development assistance relating to water and sanitation), Japan Water Forum,
Figure- 10

2.1.6 Overseas previous research

This section introduces the project a company currently undertakes as part of CSR activity

which is the philanthropy of a company or BOP business BOP business aiming at the

business for a low income group from the problem by the delay in progress of global

sanitation facilities spread. Consideration of Chapter 2.5 describes the possibility of the CSR

activity or BOP business in the Philippines.

First, there is NEPIA’s 1000 toilet project which OUJI NEPIA, Inc. has been undertaking

as part of CSR activity since 2008. "The support activity about water and sanitation" in East

Timor of UNICEF is supported with some sales of the NEPIA goods. UNICEF is carrying out

construction of the home toilet of 1000 households and construction or reparation of school

the toilet of 15 schools (The project in 2008) in East Timor and also is supporting activity for
88
the spread of sanitary practice and fixing. NEPIA is supporting those activities. In

implementation of a project including construction of a toilet, construction work and

awareness program are carried out chiefly by residents under the instruction and the

education of UNICEF or local NGO. According to investigation of UNICEF in 2006, in East

Timor, it turns out that 77% of the population of farm village part has an environment that

cannot use a toilet and that 61% of schools need the improvement of a toilet and a water

supply system. One per six persons of less than 5-year-old children has suffered from

diarrhea owing to the defect of polluted water and a toilet and especially the toilet and the

environmental improvement of water in a rural area have been an urgent subject. In building

a toilet first, it starts with achieving the understanding of importance of a toilet to the

residents. It is because residents do not have the custom of excreting in a toilet, so they don’t

feel the necessity for a toilet the project starts from that problem and builds a toilet together

with local NGO and residents, and advises on the way of repairs. Although the form and the

system of a toilet to be built are simple, residents can build by themselves and its

maintenance is also easy. Of course, not only a toilet but simple hand washing place to wash

hands and a cistern to keep with the water to stream after excreting are built. Moreover, as

activity for the spread of sanitation customs, the education can be sociable and get interesting

to children when an external person performs sanitation education to school with using

teaching materials, a picture-card show. The educational campaign of the sanitation education

using media is performed, under the lead of UNICEF, the radio program about water and

health and the comic books about parasitic prevention are produced, and also it is offering

technical support for the radio programs and magazines for children. Thus, this project carries

out not only installation of toilets and water supply system by resident himself but also the

spread of the various required knowledge in order to reduce the illness about sanitation and

89
sanitation consciousness and still awareness program.

Second, Hindustan Unilever Limited (HLL), the subsidiary company in India of

multinational Unilever, is a company which deals in various housewares and foodstuffs such

as soap and detergent. HLL has run BOP business named “Project Shakti” for the residents

living in rural area. It has employed the women living there as salesperson in order to make

them independent and providing them income. The basic work of the salespeople is to

promote of soaps and shampoo in the market. Moreover, it aims to prevent the people from

various water borne diseases by giving them sanitation education and accustoming them to

wash their hands with soaps.

In India, a total of nearly 18 million children are killed by diarrhea owing to lack of

sanitary practices and unsanitary environment conditions annually. Although many

households have soaps, the poor does not regard washing hands with soaps as a precautionary

measure. The HLL came up with the business model which can sell product in low price for

rural areas. The company has also introduced antiseptic elements to its products in order to

make an appeal regarding health and aroma chemicals to them for women and kids. Moreover,

it has incorporated newer technology in order to make soaps more durable. Besides, it also

empowers women living there by employing them as salesperson called “Shakti Ammas”.

In order to be “Shakti Ammas”, they must understand the products they sell and also know

the information of effect for health and sanitation by using products during cohabitation in 6

weeks.

It can be said that “Project Shakti” is managed by many stakeholders because it makes

use of “Global Public-Private Partnership for Hand washing with Soap” for sanitation

education and awareness program. It means that government and HLL works side by side by

getting manpower and money resources from USAID, World Bank and UNICEF.

90
Furthermore, more than 400 NGOs have been involved in the awareness program in schools

with HLL.

According to Japan Water forum (2008), attention should also be paid to “new idea such

as toilet business” as well as “awareness-raising” as the key for widely installing sanitation

facilities. These 2 items are important when thinking about the ways to widely installing

sanitation facilities and accustom people to use them properly in the Philippines; therefore

they are abstracted and quoted here.

<Who should work for realizing “Toilet as business” and what should be done? >

*Through public activities, media, NGO and donor should work together to create

demand for toilet from the local people.

*The stakeholders such as NGO should create a system which relates the ideas on new

type of public toilet or innovation toilet developed to creating an opportunity for business.

*Supporting institution should contribute technological support for efficient excretion

usage.

*NGO should make the measure and construct a system in each community, which

provides toilets incentive such as using excretion as fertilizer and fuel to possess.

*Government should encourage NGO to widely install toilet through subsidy, and

company should do so as CSR (corporate social responsibility) activities.

<Who should work for realizing “awareness-raising” and what should be done?>

*Donor, local government and NGO should help to adopt sanitary education as one of

local education programs.

*Designers should design the toilet which everyone wants to use.

*To involve leaders into the action is important to encourage participation in the political

level.

91
 * School builders should add installing toilet and sanitation education into the project.

*Local people, NGO, and local government should find and solve problems through

conversation, coalition and role division.

*Communities should conduct awareness-raising for children.

*Toilet manufacturer should implement awareness-raising which appeals visually, as CSR

activities in cooperate with the communities.

*NGO should provide (portable) tools of awareness-raising about toilet.

Source: Japan Water forum, (2008), Pages 4-1 and 4-2

2.2 Condition in the Philippines

2.2.1 The sanitation condition

The privatization of the waterworks in Manila, capital of the Philippines, has been passed for

14years.As a result , Asia Development Bank reports that the coverage rate of water supply

has been boosted from 60 % in 1997 to 87% in 2011.On the other hand, the coverage rate of

drainage is still low to 7% in Manila. There is a condition that the residents living in urban

poverty area let raw sewage and drainage flow into a river. As for the coverage rate of

improving sanitation, according to World Bank, East Asia and the Pacific Region (2007), it

came to 80% in Manila but to 56% in rural area in 2004. However, UNDP (2006) points there

exists a possibility that these figures do not include the residents in poverty area and useless

infrastructures because of overage. Hence, World Bank, East Asia and the Pacific Region

(2007) mentions that the total number of 13,000,000 people in the Philippines does not have

access to safe water and 27,500,000 people do not have access to improving sanitation.

Moreover, improving sanitation includes also the toilet style of pit-latrine which is simple and

basic. The usage of pit-latrine is that vacuum car takes raw sewage which is collected into the

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tank. However, pit-latrine which is not set up correctly at times causes the water

contamination because the human waste leaking to soil from tank reaches water resources.

As a result, according to UNDP (2006), most of the rivers in the Philippines have been

contaminated. The Pasig-river in Manila which is one of the most polluted rivers in the world

is piled up with drainage and excrement from the residents living around the river coming up

to 35 tons. A total number of 10million inhabitants live around there. Hence the 4.4million

people living along the river are always confronted with acute problems such as water-borne

and infection diseases, especially during the rainy season in the June to October.

As mentioned above, in the poverty ridden areas in the Philippines, water contamination

in the river occurs because they do not have enough water supply, drainage and improved

sanitation .These conditions contribute to increasing the number of people suffering from

water-borne diseases. According to Department of Health, the third highest cause of infant

mortality rate is diarrhea. The number of deaths came up to 1,038 people per year and the

cause of infant mortality rate comes up to nearly 12%. Moreover, the rate of people suffering

from other water-borne diseases such as trachoma and malaria is high.

2.2.2 The sanitation condition at the school

Schools in Philippines have still been short of access to water supply and drainage. Moreover,

most of the schools still lack sanitation facilities. Therefore some pupils are forced to

discharge outside. Even with toilets present, problems still do exist. Such as, Common toilets,

unclean and unsanitary facilities, lack of enough toilets and toilets being too distant from

classrooms. According to the Department of Education of the Philippines, low number of

toilets is the biggest problem currently. Their aim is to provide at least one toilet for 50 pupils.

PCWS announces that sanitation facilities are short in schools with a deficit of 26,736 toilets,

composed of 12,796 urinals for males and some 13,940 for females. A number of 1,000

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pupils cannot possibly help using the same sanitation facilities. In fact, some pupils tend to be

absent from school because of these problems.

2.2.3 The facing problem of sanitation

The Philippine government also recognizes such problems and they are conducting some

projects to make sanitation facilities using low cost and proper technology in schools and

public places with NGOs and international organizations. Besides, there are some laws in the

Philippines such as the Sanitation Code of the Philippines, Clean Water Act and so on.

Moreover, PCWS says that the local governments are responsible for providing sanitation

facilities and services to their residents as mandated by the Local Government Code of 1991

and section 15 of the Philippine Constitution mentions that “The state shall protect and

promote the right to health of the people instill health consciousness among them.”.

Additionally, they have held Philippine National Sanitation Summit with local governments,

journalists, NGOs and so on. They have made a framework of measure of sanitation in the

Philippines by holding discussions, etc. Furthermore, Department of Education of the

Philippines, Department of Health and Department of the interior and local government have

also dealt with sanitation problems.

3
Poor sanitation causes an amount of economic loss of about PhP77.8 billion per year.

Department of Health says that it is same as 1.5% GDP of the Philippines. Although a total of

PhP60 billion per year is needed to provide water supply and sanitation facilities for all

Filipinos, the annual budget amounts to only PhP1.5billion per year. However, they can get

much economic profits by solving the problem of sanitation (Table.2-1). Besides,

enforcement of various rules has also been weak owing to the weakness and limitations of the

3
The details of an account(US$923 billion for health impacts, US$323 billion for water impacts,US$40 billion for
tourism impacts, US38 billion for other welfare impacts)

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many institutions expected to enforce them. Moreover, awareness for sanitation of the poor in

the Philippines has been low as mentioned in the example of "Pasig" river. Hence it is

difficult to solve these problems in the Philippines.

Table 2-1 Estimated economic gains from improved sanitation (million

US$)
Latrine Improved
Hygiene Treatment or
Physical toilet Reuse
Practice disposal
Access system
Health 455.0 - 323.6 - -
Water - - - - 323.4
Other
- 37.5 - - -
welfare
Tourism - - - - 40.1
Sanitation
- - - 1,500.2 -
Markets
Total 455.0 37.5 323.6 1,500.2 363.5
Source: World Bank, East Asia and the Pacific Region (2007)

Figure 2-3 Economic losses due to poor sanitation, by impact type (million
US$)

Economic losses due to poor sanitation

(millionUS$)
1,412
1,500

1,011
1,000

Economic losses
500 323

38 40
0
Health Water Other Tourism Total
welfare

Source: World Bank, East Asia and the Pacific Region (2007)

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2.3 Outline of the Case Study in the Philippines

2.3.1 Research Outline

This research was focused in schools and communities for “Awareness programs for

spreading sanitation facilities effectively and sustainably”. In order to prove three research

questions―“The problem of installing sanitation facilities” “How can the awareness

programs be effective” and “The necessities for installing sanitation facilities and to

accustoming themselves to use them properly in the future”, this research shows two

organizations which realize of spreading sanitation facilities in schools and communities

which do not have effective and sustainable access to them. This research gives an answer by

analyzing three views. Finally, we suggest a solution of which two project problems are

found by examining three points of view by comparing them to overseas cases.

In this research, two organizations for spreading sanitation facilities have been

considered: (1) PCWS (Philippines Center for Water and Sanitation) (2) Fit for School Inc.

The entire research was conducted in Manila. The name of this project was "Fit for school".

We conducted two interviews for the persons concerned in PCWS and for the persons,

students and teachers related to the project "Fit for school". Moreover, we visited Bagong

Ilog elementary school, in order to inspect the sanitation facilities which were made by the

students’ parents. Inspections were conducted in various places. PCWS had conducted them

in communities and in the school. On the other hand, Fit for School had conducted in the

school only. Discussed below are the details about definition and merit of the awareness

program when providing sanitation facilities.

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2.3.2 The definition of awareness program and accustoming themselves to use

facilities

The measures for improving sanitation in the Philippines have not advanced not only because

of limited of budget of the government, but also because of the low awareness of sanitation

facilities and its access. They do not consider sanitation facilities as Basic Human Needs

which is minimum necessity stuffs on living with dignity such as education,

food/clothing/shelter, and health care. In order to boost recognition, and create awareness, it

is necessary to give lectures to the bodies regarding the bad effects of unhygienic sanitation.

Such as, lack of sanitation facilities makes the environment unsanitary, and unhygienic usage

of water may lead to contamination and various water-borne diseases. In order to prevent

such events, they have to accustom themselves to use facilities correctly after setting it up,

which is why awareness programs are necessary. Generally, these awareness programs

promote proper behavior by spreading knowledge or information through lectures in schools

and communities or through publicity works. This research defines the awareness program as

sanitation education, training and publicity work in order to learn and follow appropriate and

hygienic rules of sanitation and to be able to make sanitation facilities by themselves. We

judge whether the people have achieved the appropriate level of behavior by using our

research readings in the Philippines with the transtheoretical model of health behavior change
4
and KAP model5.

4
It theorizes about behavior change by dividing it into 5 steps. It can be said that their behavior have changed when to

reach final step. First step is called “Precontemplation”( People have no intention to take action in 6-months future). Second

one is called “Contemplation”(People have an intention to take action in 6-months future ).Third is called

“Preparation”(People have an intention to take action in one month)Fourth is called “Action”(People have taken action for

less than 6-months)Final step is called “Maintenance”(People have taken action for more than 6-months and they can do

without intention.)

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 As stated above, the awareness program has a lot of aspects such as publicity work through

mass media, training and sanitation education for the schools and communities. The goal is to

increase the number of stakeholders who are involved with the project, to make their

behavior accurate and to make them join the project for sustainable development. We have

basically focused on three activities―sanitation education for school, sanitation training for

community and publicity work by mass media.

First, in the awareness program for the communities, one of the relief organizations and a

leader from the community conduct conference several times, causing a gradual increase in

the number of attendees. At first, they are given the importance of living in a hygienic place.

After which, information on the ways to construct and manage facilities are told. Finally, they

are to decide whether to construct the facilities by themselves. The sequence of these

activities is most general approach in communities. However the way is depending on various

different factors present in each of the communities.

Secondly, sanitation education in school can be classified into two types. First, it is

practical education which teaches how to use sanitation facilities to the pupils. For instance,

the usage of soaps correctly and the way to use the toilet without making it dirty. Pupils can

get the habit of behaving correctly by learning the exact use of sanitation facilities and the

proper way of hand washing. The other one, it is being theoretical education providing the

reasons why sanitation is as important as the school curriculum itself. For example, the need

for washing hands, the reason why diarrhea occur, how good sanitation contributes to a clean

environment and so on. A student’s awareness of sanitation can also be boosted by providing

the basic knowledge of sanitation. Two sanitation educations cause the multiplier effect for

5
The installation of knowledge is eventually connected to desirable habit through to let them think the problem and to make

their attitude desirable.

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behavior change of children.
Figure 2-4 These posters painted by
Finally, programs through mass media such as TV, radio, as
pupils newspapers
school and posters can
curriculum
for sanitation education
induce a lot of awareness on the

importance and the basics of

sanitation within the general public.

Mass media being popular amongst

the general public obviously makes it

a very efficient way to spread

awareness. However, the choice of

the medium depends on the

popularity of the medium. For Source: This taken by author in Bagong Ilog elementary school

example, if most of residents possess a television, then, broadcasting the program on the

television would provide the best results.

'Bandwagon effect' is generated by conducting three awareness programs effectively.

The 'bandwagon effect' is a general rule which basically means that conduct or beliefs spread

among people, as fads and trends clearly do, with "the probability of any individual adopting

it increasing with the proportion who have already done so". It can be said that the speed of

accustoming themselves to use it correctly has been faster because many people recognize the

importance of sanitation.

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2.4 Research cases in the Philippines

2.4.1 Case study WASH

The Wash project aims to spread knowledge of

Figure 2-5 Rainwater
sanitation and provide safe water supply facilities to
harvesting
tank
schools and inhabitants living in poverty ridden areas

in the Philippines. This project works with various

stakeholders, mainly WASH Philippines Coalition. The

WASH Philippines Coalition is supported by WCCSS

and PCWS. They have two main activities. One is to

spread of various water supply and sanitation facilities.

Second is awareness program aiming to make a

Source: PCWS HP
(http://www.itnphil.org.ph/
combination of policy making, to increase the Access 2011/12/1）

number of people who are aware and to build their capacities.

The WASH project has utilized various facilities such as sewage, septic tank, rainwater

harvesting tank and water supply facilities and so on. One of the main features of this project

being the use of low-cost technologies for the construction some facilities. Most of the

facilities have been made from Ferro-cement 10 which is comparatively reasonable and

durable. The community, NGO and local government are taught the methods of construction

and management of low-cost technology facilities. Hence it is possible to reduce the costs

needed to build facilities with the help of NGOs and habitants.

Awareness programs in WASH aim to spread such facilities over wider area by spreading

more knowledge of their stakeholders and encouraging their initiative. The awareness

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campaigns are held for various masses such as, for policy makers, for communities and for

students in the school.

Awareness programs for policy makers have been conducted in order to get financial

support from them. Various project proposals have been submitted to international institutions

and NGOs for their support and resources. Actually, project proposals, in this case were

approved by four institutions, including WHO and DAR. As a result, they could construct

water supply facilities for household in communities affected by flood in the Philippines.

In awareness programs for the inhabitants, building low-cost facilities highlight the fact

that sanitation facilities are not expensive and are easy to construct, use, and maintain and the

sanitary conditions of household and the communities also get a drastic improvement.

Another prevalent program is the awareness program using radio. Not only hope of access to

sanitation facilities, but also various WASH messages are broadcast on the radio from

Monday to Friday from 6 to 8 in the morning by collaboration of the WASH coalition and the

local University. These messages are intended to raise attention, intent and awareness.

Awareness programs for children in the schools are called ‘School Toilet Campaign’

whose purpose is to raise awareness about sanitation. As mentioned in chapter 2.2, water-

borne diseases are easy to spread in the schools of the Philippines because of inadequate

sanitation facilities. Hence various rainwater harvesting tanks have been installed and

education about the way to reuse water and its management is being taught. Additionally,

workshops about sanitation are conducted in summer vacations. Where they discuss about

sanitation facilities and draw posters including messages about environmental sanitation

facilities. Moreover, children write about their experiences in order to use them for the

activity next year.

As described above, in the WASH project, inhabitants get to know the importance of

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sanitation and can familiarize themselves with sanitation facilities by the spread of facilities

using low-cost technology and awareness program. These methods make the effective spread

of facilities possible.

2.4.2 Case study Fit for school

As a part of education activities, Fit for

Figure 2-6 Sanitation facilities of
School advanced focusing on Fit for Bagong Ilog
elementary school
School Inc. of the NGO in the where the project of Fit
for School is ongoing.
Philippines carries out the project to

educate and routinize daily hand washing

at school, brushing-teeth and parasitic

extermination (take the medicine which

exterminates the parasite included in an

abdomen twice per year),and still to make

children perform these acts spontaneously

in order to solve infection or the problem

of many cavities especially in the

Source: This taken by the author at Bagong Ilog
Philippines, in the view of construction of elementary school

children's sanitation custom. Three measures, such a hand washing, brushing-teeth, and

parasitic extermination, are called EHCP (Essential Health Care Program), those right

methods are taught to children by teachers and health workers with the manual which Fit for

School Inc. created and are made to practice with using actual facilities and goods. Therefore,

the local government and others is to provide all goods, such as soap, brushing- teeth powder,

and medicine not so that it may become a burden of children or a community. The manual for

teachers and health workers describes clearly the contents of sanitation education by each
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field, such as how to wash hands rightly with using soap, the reason to take the medicine for

parasitic extermination, and how to brush teeth, and also it shows how to make sanitation

facilities and their designs, such as simple hand washing stand. They educate the children in

this way, monitoring about whether it was actually routinized by children is also performed

by the check point with the manual and sanitation education is thoroughly performed. In Fit

for school, sanitation education is performed to children in this way, and it aims at making

change of behavior so that finally hand-wash can be spontaneously performed. Teaching

children sanitation education repeatedly such as hand-wash, brushing-teeth, and parasitic

extermination as a part of school education from the elementary school stage where a

fundamental lifestyle is formed leads to effect of routine behavior and a healthy life.

Moreover, it has participated in various meetings, a workshop, an event and others as

enlightenment activity. In order to strengthen the partnership of rural areas and a center, it

will hold the 2nd National School Health Summit and participated in Global Handwashing

Day in the sponsor's position and has told importance of a hand-wash at least in fiscal 2010.

In addition, in eight workshops including SEAMEO INNOTECH, Closing Ceremony of the

Governing Board Meeting, or University of Handwashing share experience of them to other

persons, and it is also performing positively activity for spreading EHCP (Essential Health

Care Programme) in order to increase a partner also internationally

2.5 Consideration from cases focusing on the awareness programs

Our research in the Philippines revealed that the sanitation situation which is showed at

chapter 2.2 was much more serious than we expected. According to the report of WSP-EAP

(2007), the sanitation coverage in urban areas is 80%. However, most of the poor citizen in

the urban area cannot have access to the sanitation facilities such as toilet. In poor urban areas

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near the Smokey Mountain, open-defecation is still popular. There, people cover their feces

with newspapers and throw them away, or they excrete them into the river nearby their living

area. Such actions make people live under insanitary environment and cause serious water

pollution in the rivers. Also, the coverage of the water supply system is low, so people depend

on expensive selling water in order to gain drinkable water. Except for drinking water and

cooking water, they use rain water without any treatment. When there is no rain, they use

water from polluted rivers. Nevertheless, the poor living in the slum often has recreation

facilities such as TV and DVD player.

Figure 2-7 The toilet in the urban
poor area
Even though, it should not be thought

that their awareness of the sanitation is

low. It is said that people living in the

poor area also prefer to use the toilet if

possible. The problem is that they feel

they must pay immeasurable costs to get

sanitation facilities, and the system of the

facilities is too complicated to

Source: This taken by the author in the urban poor area
understand. The agent of DepED (Department of the Education) says “Although there is no

water, no facilities to utilize, no soap for washing or cleaning, soon they get used to it,

unaware that it may cause them to be unhealthy, sick or even worse, lead them to death”.

Hence it is necessary for people to re-realize the relation between water-borne diseases and

insanitary life, and accustom themselves to sanitary behavior like hand washing as well as

installing sanitation facilities. At the same time, they should be informed that sanitation

facilities are not something given by someone but something they get by themselves, by

awareness program and introduction of low-cost technology. That is why awareness program
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is the considerable process for solving the sanitation problem.

Looking on the statements reported by the Japan Water Forum (2008), most of them have

already been worked on in the Philippines. The fact may be obvious from PCWS’s project

and Fit for School. Moreover, the NGO named CAPS (the Center for Advanced Philippine

Studies) has implemented the project introduced above. Besides offering technological

support and awareness program, they are deeply engaged in widely installing Ecosan toilet in

the poor areas and communities in rural districts. Ecosan toilet which they promote is urine-

diverting dehydration toilets that use ash to cover and dehydrate the feces. Using this

technology, urine and feces can be converted into soil conditioner or fertilizer and useful for

agriculture. In fact, Ecosan toilet is eco-friendly. By having and using Ecosan toilet, people

can get soil conditioner or fertilizer easily. Thus it is very effective to generate incentive of

inhabitants. Additionally, some of the institutions which are challenging to solve water and

sanitation problem are holding a meeting once every few months at the DepED. When we

participated in the meeting in September, they were discussing about the child-friendly

designed toilet ―a toilet that can be used by any child easily― at that time.

Thus the fact that words like ‘awareness program’ and ‘public activities’ are used often in

the list indicates the importance of awareness program. In chapter 2.4, we picked up the

projects focusing on awareness program for widely installing sanitation facilities and forming

the habit of using them properly, and we found 3 things in common. These are (1)

Community participation, (2) The collaboration of the stakeholders and (3).Low cost. In this

part, we would like to go through these 3 points.

(1) Community participation

The important point of this project is that the resident themselves are related to this project

directly. Mr. Masatsugu Simokawa (n.d.) says “Mr. Amartya Sen claims that the poor should

105
be seen as the agent of the development, not as objects. In fact, the poor acts with their will

only in the individual project brought from outside. I do not think that the poor acts with their

will in terms of the process of development.” As he claims, the poor is often an outsider of

the project in the actual work for development.

PCWS, however, actively carry out the projects which grows the self-direction of the

residents. In one of the projects called LOCAL WATCH, all facilities set up with low cost

technology are made not only by engineers but also by the residents. The engineers of PCWS

actively go to the poor regions to advertise low cost technology and create the demands. Then,

they teach how to make the facilities using low cost technology to the members of the

communities. Also, all the washstands in the elementary schools under Fit for School project

are made by parents of the students. The design is created by Fit For School Inc, but they will

take good care of washstands or fix them when they are broken because they know how to

make washstands. These two projects start with training the residents and teaching that they

have to make everything by themselves, therefore, the facilities will be used with good care

and be used by whole community.

When the residents try to solve the problems by themselves, we may get better results

than we expected. In Orangi Pilot Project carried out in Pakistan, the residents set up the

drain pipes underground with the help of NGO called OPP to solve drainage problem. Once

the projects went well, the residents changed their way of thought eventually, though they

would only make a request and wait until the government would start to work before the

project started. Finally, the residents started to work on the business territory which the

government should be responsible for; therefore, the government which had done nothing

before had to start working. As a result, the system of drainage spread rapidly. We can learn

many things from this example. The most importantly, if we keep working on enlightening

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movement based on the facilities spreading and encouraging the habit of using the facilities,

the resident will realize that they have to work on the projects themselves and try to solve

their problems such as drainage problem which are not worked on in the Philippines where

the coverage of the urban sewage connection treated is still 7%.

(2) The collaboration of the stakeholders

Various stakeholders take part in the project carried out by PCWS. They lead not a formal,

legal and flexible entity called WASH Philippines Coalition and work with people who

decide the policy of the country or the regions for improving the saturation level of water and

hygienic facility in the poor region. And WASH Task Force, organized by PCWS and WASH

Philippines Coalition, conducts the advocacy action. WASH Task Force is composed by

teacher, parents of students, government employees, members of the community and NGO.

Moreover, WSSCC which endeavors to solve international water and hygienic problem gives

financial aid. Because of cost effectiveness of EHCP, Fit for school project is carried by

Philippines NGO called Fit for school Inc. Various stake holders are involved in it too, such

as, Philippines office of education which hastens to achieve, the local government which

offer supplies. In addition to it, the program gets the international cooperation from German

NGO called GTZ (the Deutsche Gesellschaft für Technische Zusammenarbeit), CIM (Centre

for International Migration and Development) and Inwert.

Through an observation of the elementary school in the project, we found that a part of

supplies like soaps are donated by the companies. At the school, they are cooperating with

health workers and teachers who coach students. Like this example, thanks to help or

cooperation from many stakeholders or the community, this project is carried out in 23

regions in Philippine and more than 900,000 children have got the benefit of EHCP. We

expect that if many stake holders are involved, they can take advantage of a strong point of

107
every sector. Also, if many groups cooperate together and residents do what they can do, they

will be able to overcome the biggest problem that they have a limited budget of water and

hygiene section. In addition, through teaching people who decide policy the importance of

water and hygiene facility, the speed of spreading them will get much faster.

(3) Low cost

On the project implemented by PCWS, people in the community have built rainwater

harvesting tanks which collect rain water effectively to use it for daily life, and biogas

digester septic tanks which converts biogas ― it is generated during treating excretion － to

methane gas used for cooking, with the help of technologists. These facilities can be made of

relatively cheap and durable material called ferro-cement which is thin cement. Installing the

biogas digester costs only 8000 peso (about 184 dollars) except the wage of the engineers.

Compared to the price of smallest shared septic tank system － it costs from 7,000,000 to

8,000,000 yen －, that of PCW’s septic tank is much cheaper, though the way of treatment is

different and it is difficult to compare. The facilities using low cost technology with

sustainability is appropriate than the one using high cost and high quality technology, because

government in the Philippines is worried about the lack of the budget for sanitation.

On Fit for school, people adopt the low cost technology to build facilities for daily hand

washing and tooth brushing. For example, they adopt a simple design for washstands with

water pipe connected to stands made from wood or iron, not expensive steel. The price for

one washstand which 21 students can use at the same time is less than 500 peso6 (about 11

dollars) so it is relatively cheap. Simpler facilities such as PET bottles with some holes

6
Average monthly wage of a family in the Philippines is 6000 pesos (about 138 dollars). Legal minimum wage is 280
pesos (about 6 dollars) per day in Metro Manila. (The Fukuoka Asia Urban Research Center,(2007), Research on the water
supply for the urban poor in the reign of Asia)

108
suspended from a long stick are built. This is much cheaper than the one which we introduced

above. The ingredients of soaps and tooth pastes supplied for the project are eco-friendly.

Hence the water is collected in a bucket after using and it can be given to plants near the

washstand. Like this, they use resources effectively and cut waste. More surprisingly, it costs

only 25 peso (about 0.58 dollars) for a student per year to conduct provision like hand

washing, tooth brushing and deworming using EHCP (The Essential health Care Package)

designed by the NGO called Fit for School Inc. Even so, forming hygienic habits using EHCP

has contributed greatly to improving child health. Though this project launched in 2008, it

was announced that there was 40% reduction in dental caries, 42-47% reduction of diarrheal

incidence and 30% reduction of respiratory infections.

While the government in developing countries still tends to prefer high quality and high

cost technology, usage of Appropriate technology is becoming important in the field of

development assistance. Though there are many definitions for Appropriate technology, we

use the definition of APEX focusing on the Appropriate technology in this thesis. The

definition is that: “the technology appropriate to the social, economic and cultural conditions.

It can be used by many people, meets the needs adequately and eco-friendly.” The

appropriate technology has an advantage that it is not harmful to both human bodies and

environment. Also, since it matches the needs of the residents, it has better chance to be used

preferably.

Moreover, Appropriate technology is sustainable socially, economically and

environmentally because of using sustainable resources and capitals. Therefore, residents can

use the technology by themselves even after the project is finished. If the sanitation facilities

are widely installed but people don’t use them every day at their own initiative, they may not

get their benefit enough. Hence it is important to teach Appropriate technology suiting the

109
residents’ needs to solve the sanitation problems.

It can be said that these three factors were gained as a result of an awareness program.

Inhabitants recognize their sanitation problems by conducting awareness program. It means

that they take part in the project independently. Moreover, they keep holding ownership for

such facilities. In other words, they continue to maintain the facilities correctly. In two

Philippines’ cases, it is true that awareness programs which involve residents have been

conducting and inhabitants last to use the facilities. Besides, various stakeholders take part in

the project by awareness program. Moreover, it is also considered that communication

between inhabitants who have already recognized their sanitation problem and external

organization becomes better. It is really important for them to complain what is needed for

them and to work side by side together thinking how they should do because external is able

to know their needs easily. It is connected to spread appropriate technologies which are really

needed for them because they can use and maintain easily. In the case of Philippines, since

the lack of budget is subject, low-cost technology spread out as appropriate technology. It can

be said that negative chain which this research shows in overseas previous research can be

resolved by conducting awareness program.

We consider whether awareness programs contribute to promotion of widely installing

sanitation facilities and accustoming themselves to use these facilities properly by analyzing

the result of the projects. We could go to the Bagong Ilog elementary school where Fit for

School project had been implemented to research our study in the Philippines. In front of the

class rooms, a lot of washstands which the parents had built were installed and they worked

well. Of course, the number of the washstands was enough for the students. Also, awareness

program including sanitation education in the school caused behavior change of the students.

110
The students washed their hands before eating and brushed their teeth with their own tooth

brush put their name on it after eating using the facilities. According to the interview to the

students and teachers, the students had not washed their hands and brushed their tooth.

However, we found they always washed their hands and brushed tooth using the facilities

properly after students had been had the awareness program and the washstands had been

installed by the project. The report of Fit For school Inc. said the hand washing caused about

40% reduction of diarrheal incidence. Considered from these facts, it is appropriate that

project focusing on the awareness program contributes to accustom the students use the

facilities properly. Thus awareness contributed not only to widely install the facilities but

only to accustom them use the facilities properly.

However, the Filipino awareness programs still have some challenges. It can be said the

citizens may not carry on doing awareness programs because NGO has become the key sector

who conducts them now. It is important to train the residents who is illuminated to conduct

the awareness programs for the other people. The approach like this makes the effect of

programs spill over. Especially, the awareness programs conducted mainly by children are

important to spread their effect. In the project of Malawi, Safe Water Clubs was established at

the school of Neno area in 2007. 5500 people learned the importance of clean water, adequate

sanitary practice and improved sanitation and they produce songs, dramas and simple games

by themselves to tell the other people. It was reported that 90% reduction of school absence

by diarrheal incidence was achieved through this activity. Children also appealed to their

parents and members in the community. As a result of it, the diarrhea patients decreased by

35% in the hospital of the community. Thus, it is effective that the residents including

children are proactive in conducting the awareness program.

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 While in study of two projects, we found that there is few companies’ entry into hygiene

area through CSR movement or Bop business in Philippine. On Fit for School, we found that

the companies contributed some goods to the school as charity. One-sided assistance like this

is not sustainable. If this assistance is stopped suddenly, the well-established sanitary practice

might fade out. For this reason, the participation through CSR activities and BOP business is

preferable.

As we mentioned before, in the report of the Japan Water Forum (2008), “New idea

related to toilet business” is introduced as a key to spread hygiene as well as “consciousness

revolution”. Also, companies encourage NGO to set up toilet through CRS”, “Toilet makers

make visual enlightenment movement in CSR in cooperate with the community” are

proposed. In Philippine, few companies work on it. In other countries, some companies are

starting to work for solving hygiene problems of field in CRS or BOP business. As we

claimed in an earlier research, Ojinepia co. is trying to spread toilet and enlightenment

movement in east Timor as a part of CSR activities in ‘1000 toilets project’ carried. In ‘Shakti

project’, a multinational corporation, Unilever, conduct BOP business. It is for residents in

farming areas in India. Like this, they contribute to widely install the sanitation facilities and

accustom them use the facilities properly. After referring to these examples, we think that if

they take part in the projects carried out in Philippine with different point of views from these

companies; they can enlarge the project and fasten the spread of facilities and forming the

habit.

Some companies entry into this field for business. In fact, an example of public sanitation

business in Nairobi7 was tried at individual level. As mentioned before, hygiene facilities,

7
In 2008, the company called Ecotact Limited has been implemented the project of Ikotoilet in the Nairobi, the capital
city of Kenya. The most of the poor in Kenya do not have the basic sanitation facilities. They excrete into the plastic bag and
throw it away outside. (This action is called ‘flying toilet’.) To improve this situation, they provide the high quality sanitation

112
such as toilet, are not spread enough in slam in urban areas of Philippine. If many of residents

in slam open-defecation, hygiene level in the community would not change dramatically even

if somebody paid a lot to set up sanitation in one’s house. Then, one woman in slam set up

public sanitation and started business that charged 10 peso (about 0.23 dollars) for one person

to use sanitation for one time. This is all for the community. She used to be an owner of a

groceries store so she had some income. This is why she could start this business. According

to her, she has just started this business; people in slam take positive attitude toward using the

public sanitation. Philippine in slam have some knowledge of hygiene therefore they have a

will to pay money for the sanitation.

If the companies support the approach and make it effective, the project like this would be

more sustainable than the one conducted by the individual. Therefore, the status of sanitation

in the poor area would be dramatically improved. Moreover, the famous companies’

participating in the project would inform the residents the sanitary problem, collect the funds

easier and expand the scale of the project. What is most important for letting businesses to be

involved in the solution of sanitation problems is that they get incentives to make profits from

projects in the field of sanitation. To construct the win-win relationship between company

and other stakeholders through CSR activity or BOP business such as case studies of overseas

is more sustainable than one-sided support. In any case, it is true that companies should

struggle for solving social issues such as water and sanitation because CSR activity is

watched all over the world. In any case, nowadays CSR activities and BOP business are paid

attention to, so the companies should take responsibility for solving the social problem like

water and sanitation.

facilities and shower for everyone. If they want to use them, they have to pay 5 schilling a time.

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2.6 Conclusion

Before this chapter, we considered an awareness program and accustom them to use properly

by comparing two cases in Philippines. On a basis of these examinations, this chapter is to

provide the way to popularize sanitation facilities effectively and to let people keep using

them from three points of view: the problem of the spread of sanitation facilities, the effect of

awareness program, and what kind of institutions collaborates and how they do.

Three common things have been found by comparing two cases in Philippines on chapter

2.5. The first point is the low cost providing, the second one is citizens’ participation and the

last is various stakeholders’ collaborations. A low cost providing of facilities which is using

relatively cheap materials enables people to realize a sustainable spread of them. Additionally

citizens’ ownership is enhanced by an activity with their participations and it can help

accustoming them to use these facilities. 2 case studies compared each are concerned with

NGOs, government of the Philippines, a local government, communities of habitants and so

on. Cutting cost, the sustainable spread of sanitation facilities, and more wide speedy spread

can be expected by involving various stakeholders. We think these 3 methods are results of

awareness programs from various public relations with using education, workshop and media

for citizens. When citizens and policy makers understand the importance of sanitation

facilities and the merit of low cost technology, they will try actively to spread of sanitation

facilities. Moreover they can work on that effectively even at lower cost if they can involve

various stakeholders.

As stated above, we will show answers for research questions. First, the answer to the

problem point with spread of sanitation facilities is serious lack of fund. Moreover there is the

problem on recognition of Philippines. They have an image that sanitation facilities are

expensive and complicated, so they can’t spread of sanitation facilities willingly. Second,
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awareness campaign helps people who have to do with spread of sanitation facilities like

inhabitants and policy-makers to understand importance of sanitation facilities. Furthermore,

understanding of that importance connects to get accustomed to use sanitation facilities

properly and to involve various stakeholders. Involving stakeholders enables them to spread

of sanitation facilities and take awareness program in a wide sphere. This thing makes spread

of sanitation facilities sustainable and cut funding. Therefore it can be said that the awareness

campaign is very effective. Last on collaborates with stakeholders, we found that each case is

concerned with government of the Philippines, local government, NGOs and inhabitants.

These stakeholders like NGO or government support them in funding, materials and

technique, so citizens join up actively to build facilities or awareness campaign. It makes a

lot of fruits. Many stakeholders’ support connects with cost cut and the spread of sanitation

facilities in wider sphere, so such support is important for the spread of sanitation facilities.

However, we couldn’t find the cooperation with companies on BOP business or CSR in

this study. In other country, some companies conduct BOP business or CSR, for example

“Project of thousand toilets” by Oji Nepia Corporation or “Project Shakti” by Unilever. They

achieved good results. In addition, there is business that toilets are lent people by 10 pesos

per once in Philippines. If companies participate in developing support with different

perspective like this, new advantage will be born and the people will be able to spread of

facilities more effectively.

On this paper, we come to a conclusion as follow about the way to be able to spread of

sanitation facilities effectively and the way to make people use them habitually, from above 3

research questions. Awareness campaign is effective in spread sanitation, and it is important

for making people use them habitually to encourage people to get accustomed to use them

properly through awareness programs. With conducting awareness programs and spreading of

115
facilities at the same time, to get accustomed to use properly can be took root in citizens.

Moreover, understanding of sanitation facilities from using them habitually raises demand of

sanitation facilities. Therefore making accustom of using sanitation facilities properly and

awareness program are essential elements for the spread of sanitation facilities in Philippines.

As future prospects, we think the cooperation between firms with aim of BOP business or

CSR and various stakeholders expands possibilities for the spread of sanitation facilities in

Philippines. Although there are some differences on purposes or opinions between

development side and business side, we can expect more speedy spread in the future.

116
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Chapter 3

The Possibility and Limitation of

Public-Private Partnership in

Nutritional Improvement

Seoungho Kim,

Keisuke Tagawa, Kana Togo,

Manabu Ito, Miyuki Ito, Mizuki Hayashida

Introduction

These days, the alleviation of global hunger has been attracting attention and GOAL 1

of the Millennium Development Goals (MDGs) sets the target of halving “between

1990 and 2015, the proportion of people who suffer from hunger”. However, the

number of people suffering from hunger, which was as high as 925 million in 2010, had

only decreased by 16%. Moreover, nutrition problems lead to other serious problems as

well as poverty. Addressing nutrition issues is a necessary part of solving health and

sanitation problems such as high infant mortality rate and maternity rate, and diffusion

of infectious diseases. In GOAL 8 of the MDGs (“develop a global partnership for

development”) cooperation between private and public sectors is stressed. The

Philippines, which is the target country of this research, is one of the countries which

focuses on the cooperation between different sectors. Therefore, this research pays

attention to public private partnership (PPP) between various approaches to solve and

improve nutrition problems and we take the Philippines as the focus of our analysis.

As it is explained in the preceding studies of the whole research, since the roles of

public and private sectors are different, the cooperation between them is necessary for

eliminating world poverty. Although NGOs have networks in local communities, they

don’t have enough funds or a wide range of activities, so the need for the cooperation

between governments and NGOs is emphasized. In this way, PPP is essential because

each actor has its own role. Furthermore, the preceding study shows the importance of

nutrition education in combating nutrition problems and how each actor is expected to

include nutrition education in their future activities. Considering these studies, this

research develops the theme, “The possibility and limitation of public-private

partnership in nutritional improvement”, and is organised around an on-the-spot

123
investigation based on the following research questions:

1. What approaches are used to improve nutritional problems?

2. Which stakeholders are involved? How do they cooperate?
3. What are the objectives of such cooperation?
4. What are the difficulties of such cooperation?
Based on these research questions, this thesis discusses and examines the state of

nutritional improvement projects in the Philippines and tries to uncover the problems in

order to build better partnerships in the future.

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3.1 Nutrition problems and the state of nutritional improvement

activities

3.1.1 The relationship between nutrition problems and poverty

As mentioned above, nutrition problems and poverty are closely related. Nutrition

problems are caused by inadequate access to food for some reasons, which leads to a

lack of nutrition for keeping a person healthy, and life-threatening conditions such as

chronic hunger or malnutrition. Nutrition problems bring about further poverty. For

example, health impairment in pregnant women affects not only women’s bodies but

also fetuses. Undernourished mothers tend to give birth to underweight babies. More

than 20 million low birth-weight infants are born in developing countries every year.

Low birth weight infants have the risk of dying in growth and are likely to face physical

and mental difficulties. Also, mental retardation causes lack of sufficient education and

decreases the rate of school attendance. Insufficient education deprives opportunities of

stable accession and lowers one’s income, and results in further poverty. If the low birth

weight infant is a girl, she also has the high risk of giving birth to an underweight child.

As stated above, nutrient deficiencies continuously have effects on the next generation.

Nutrient deficiencies also lead to the decrease in immune strength against infectious

diseases. Over 75% of the causes of death are disorders of newborn and possibly

curative infectious diseases like diarrhea, malaria, pneumonia and measles. These

deaths are due to nutrient deficiencies. As mentioned above, the decrease in immune

strength resulting from nutrient deficiencies damages the health of people and deprives

people of opportunities to work. As a consequence, labor productivity decreases. In this

way, nutrition problems have negative effects on countries and promote further poverty.

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Therefore, nutrition problems are related to MDGs – GOAL 1: Eradicate extreme

poverty and hunger, GOAL 4: Reduce child mortality, GOAL 5: Improve maternal

health, and GOAL 6: Combat HIV/AIDS, malaria and other diseases. In other words,

solving nutrition problems not only improves the nutritional status of people, but it is a

key to achieving these goals.

3.1.2 The nutritional condition in the world

Basically, there are two types of malnutrition. Limited access to food leads to

malnutrition, which is caused by lack of basic energy such as fat, protein and

carbohydrates. On the other hand, another type of malnutrition is caused by lack of

micronutrients such as vitamins and minerals due to lack of economic strength in

households or nutritional knowledge although they have access to sufficient amounts of

food.

First, it will look at the nutritional problem caused by lack of energy. According to

the World Food Programme (WFP), there are approximately 925 million people who

suffer from hunger in the world. Seen by region, there are about 578 million people in

Asia-Pacific, 239 million in sub-Saharan Africa, 53 million in Central and South

America and 37 million in the Middle East and North Africa. It turns out that more than

half are in the Asia-Pacific region. In addition, the number of people who die from

hunger a day is about 25,000. The background of the increasing number of people who

suffer from hunger is related to the unfair system of food distribution, rising food prices,

increasing world population, war, global warming and so on. Nutrition problems caused

by these matters raise the child mortality rate, spread infectious diseases such as

HIV/AIDS or malaria, and damage maternal health.

While there are a lot of people who suffer from hunger, a lot of people suffer from

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Figure 3-1 Rate of extreme hunger in the world by region

Source: United Nations Food and Agriculture Organization statistics retrieved 30th Nov,
2011

“hidden hunger”, which we can define as micronutrient deficiency. “Hidden hunger” is

an undernourished condition caused by lack of micronutrients such as vitamins or

mineral. Malnutrition caused by lack of main energy can be easily recognized visually,

but malnutrition caused by lack of micronutrients is difficult to identify. That is why it is

called “hidden hunger”. Today, it is said there are about 200 million people who suffer

from hidden hunger. A sufficient intake of micronutrients is essential for maintaining

good health. Lack of micronutrients causes incomplete development, intelligence

impairment and decay of immune strength against infectious diseases. In these ways,

lack of micronutrients becomes the cause of death for many people all over the world.

According to the World Health Organization (WHO), lack of iron, vitamin A and zinc

are to be included in the 10 major causes of death by diseases. In fact, the deaths due to

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pneumonia, diarrhea, malaria and other infectious diseases are caused by decay of

immune strength from lack of micronutrients.

As stated above, nutrition problems in developing countries ruin health, reduce labor

productivity and encourage further poverty. For these reasons, the issue of nutritional

improvement for poor people should be prioritized.

3.1.3 The symptoms resulting from malnutrition

This section describes the symptoms of diseases caused by lack of essential nutrients

and the outline of nutrients because nutritional knowledge is central to a discussion of

this topic.

3.1.3.1 Essential nutrients

Essential nutrients can be classified into carbohydrates, protein, fat, vitamin and mineral.

These are called the five major nutrients. Among them, carbohydrates, protein and fat

are called macronutrients. These are the most necessary for a human body in quantity.

Macronutrients are the source of essential energy (calorie) for vital activity. This energy

is necessary for not only daily activities like walking and working, but also physiology

activity like maintaining organ functions, breathing and so on. Macronutrients are

essential for composing the body and maintaining health.

Vitamins and minerals are called micronutrients because the small amounts of these

nutrients play very important roles for health. Micronutrients must be taken from food

or supplements because they are not made in the body. Many kinds of vitamin are

essential for keeping body functions. Minerals compose the body, and maintain function

of the body as well as vitamin. Though micronutrients can’t be made in the body like

macronutrients, they support the function of macronutrients. Micronutrients play an

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important role in maintaining or controlling the body, so they are essential for human

health.

3.1.3.2 Malnutrition

In this section, diseases caused by nutrition deficiency, especially Protein Energy

Malnutrition (PEM), Vitamin A Deficiency (VAD), Iron Deficiency Anemia (IDA),

Iodine Deficiency Disorders (IDD), are explained. These four diseases are often

common in developing countries. These diseases are harmful for human health and can

be potentially deadly at worst.

PEM is the condition where the amount of protein doesn’t reach the required

amount. PEM is often seen in the poor, especially infants under 5 years of age. In

general, people suffering from PEM also lack micronutrients, accompanied by a decay

in immune strength and an increase in infectious diseases.

The livers of infants store some vitamin A, and the deficiency of vitamin A can

occur because of the diarrhea in early infancy. If the lack of vitamin A becomes serious,

it is likely that illnesses connected to the eyes such as night blindness will increase. In

addition, if such illnesses are untreated, loss of eyesight may follow, and this is a serious

problem in developing countries. Vitamin A plays important roles for the immunity

function, and the lack of vitamin A increases the risk of infectious diseases such as

malaria, measles and so on.

The lack of iron is also a serious problem in developing countries. The lack of iron

may lead to malaria, hookworm infection, and so on. Anemia by the lack of iron may

result in dizziness or palpitations. If pregnant women lack iron, they may die from a loss

of blood when they give birth. The lack of iron ranks higher on the causes of mortality

of pregnant women. In addition, iron deficiency is linked to a decrease in immunity,

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anorexia, weight loss and loss of learning ability.

Iodine has to be taken in constantly because a constant amount of iodine is

discharged from the body every day. A lack of iodine causes underproduction of thyroid

hormone. Since fish or seaweed includes iodine, deficiency symptoms are often seen in

areas where the soil doesn’t include iodine or inland areas where the custom of eating

seaweed does not exist.

Children born to mothers who lack the nutrition are malnourished or underweight

from when they are born, and it is difficult to improve the malnutrition of them. If they

can continue to live, they have difficulties in their health, mental and learning ability in

their lives.

3.1.4 The approaches for nutrition improvement in the world

As seen above, nutrition problems in the world are serious conditions, so it is need to

improve the present situation immediately. In this section, we describe different

approaches taken in the world to address serious nutrition problems. There are four

main methods: fortification, supplementation, feeding and education.

3.1.4.1 Fortification

This is the method of making up for lack of nutrition by fortifying nutrients in daily

food. The merit is that it is easy for poor people to get fortified foods because they are

cheap. Though it comparatively takes a long time to see effect, people can sustainably

take in some nutrients every day, for example, flour-fortified vitamin A, salt-fortified

iodine and rice-fortified iron.

3.1.4.2 Supplementation

This is the method of making up for lack of nutrition directly by taking in nutrient

supplements. It is possible to specify and take in necessary nutrients. Since supplements

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condense nutrient components, it is possible to take in necessary nutrients in a short

time. But it is difficult for the poor to get supplements because they are more expensive

than fortified foods and people have to take in supplements until the effect appears.

3.1.4.3 Feeding

This is an approach that provides food to the poor mainly by NGO/NPO or international

organizations. This is effective for the people who have difficulty in getting access to

enough food. It is part of the projects conducted by NGOs or international organizations,

but is not suitable for solving the lack of specified nutrients because it only focuses on

the balance of nutrients. There is also danger of lack of sustainable nutritional

improvement because feeding is usually conducted as one big project.

3.1.4.4 Education

Nutritional education aims to help to improve awareness of health care with the

knowledge of nutrients’ influence on the body. It is said that the lack of knowledge is

also one of the cause of malnutrition, so educational approach is important for

nutritional improvement. Educational activities are conducted in not only formal places

such as schools, but also in non-formal places such as communities for targeting broad

age groups.

These four approaches to nutritional improvement help us confirm what advantages

or disadvantages they have. It is important to choose the best approach which meets the

needs of local people.

3.2 Public-Private Partnerships

In establishing the theme, this research focuses on ‘Public-Private Partnership’ (PPP) as

the key to solving the nutritional problem. First it looks at why PPP became the main

131
current of approaches in the world and why PPP was chosen for this research. It then

considers in particular the definition and the grouping of PPP in this research. Finally,

the preceding study will be explained.

3.2.1 The background of Public-Private Partnerships

Public-Private Partnership (PPP) is a cooperation between public and private sector on

public services, which has been encouraged since early times. However, it was

implemented as a method in 1980’s, when the so-called ‘Limited government’ policy

spread and services provided by government were cut. In that trend, government made

use of the private power positively, that is, privatization was made popular. The trend to

deal with projects together grew strong all over the world.

First of all, Private Finance Initiative (PFI) became popular. It is an approach that

was promoted in Western countries such as England and the U.S.A. It was introduced

for the purpose of trying to make operations more efficient through sharing risks and

using private capital. In the Japanese case, after the law referring to PFI was established,

many local governments looked for the good effect and carried out PFI projects.

Through the join activities such as PFI, the central government as a big player got to

reduce its own role because local governments and companies were appearing on the

scene as new players that could shoulder public services and social capital. At the same

time, NGOs also got to be more and more important. PPP has a wider definition and

includes not only funding support but also the cooperation from planning the projects.

Thus, PPP includes PFI. However, Japan still has the strong idea of PFI while western

countries adopt various forms of PPP with different stakeholders. The conditions of PPP

are very different from each country.

After so-called “Market failure” and “Government failure”, PPP was formed as a

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concept in the flow of decentralization and privatization from the above. What is more,

this concept was regarded as important in terms of development and collaboration

between different countries. Donor countries try to conduct PPP activities because of

they can take advantage of private capital, management know-how, specialization and

dispersal of risks. In many Japanese reports, the word ‘PPP’ has often been taken up.

Besides the above stream, this research regards PPP as a very important approach

for dealing with nutritional problems in the context of international cooperation. In

particular, it focuses on the roles of each stakeholder.

The following are the characteristics of each actor:

・ Governments can design the policy and conduct projects or research on a large

scale. Moreover, they often are trusted by the citizens, so they can carry out

sustainable projects. However, it is demerit that the government spends time and

money uselessly because of complicated procedure. So its demerit is inefficiency.

・ Companies may have specialist knowledge and skills or great amount of capital

and also have management ability. But in most cases, they don’t build local

networks so they cannot respond to specific needs and it is hard for companies to

get a feeling of trust from the people. It is also likely that companies cannot

continue PPP because they are conducted as single projects as part of the

company’s strategy.

・ NGOs act in local areas, so they can conduct activities that reflect the local

minorities or specific needs. The weak point of NGOS is greater insufficiency of

funds than others, so they lack the ability to act according to the best plan

possible and to maintain continuous activity.

Thus there is a limit to how each actor can cope with problems by themselves. It is

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so important to tackle problems by making the most of PPP as an effective approach. Of

course, this could apply to nutritional improvement projects and plans.

3.2.2 The classification of the forms of PPP approaches

The classification of public and private sectors and the forms of cooperation will be

explained next. The public sector refers to government agencies and international

organizations. Government agencies are configured of government ministries and local

governments. International organizations cover the organizational framework of the

United Nations: World Bank, Asian Development Bank (ADB), World Health

Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations

World Food Programme (WFP), Food and Agriculture Organization of the United

Nations (FAO) (Apart from these, there are many other international organizations. The

above-mentioned international organizations are concerned in this research.) The private

sector covers companies, laboratories of companies, Non-Government Organizations

(NGOs) and Non-Profit Organizations (NPOs). Companies and NGOs are not just

domestic but also transnational. Therefore, PPP is the cooperation between different

actors from public sector and private sectors through various projects.

Next we describe PPP in more detail. At present, there is a wide range of types of

PPPs; this section describes the specific types of PPP that we focus on in this research.

The first aspect is funding. PPP has started to fund other sectors as described in the

origin of PPP approaches. Both sectors fund projects. Especially, the companies as a

part of a Corporate Social Responsibility (CSR) program fund government agencies of

developing countries, NGOs and NPOs. Ajinomoto is a Japanese food company, and it

strives to promote a healthy and vibrant society by pursuing global corporate citizenship

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activities focusing on nutrition and health. Ajinomoto is advertised programs from

NGOs and NPOs fund to them as a part of a CSR program whenever Ajinomoto assents

to the project content. The contents are various from supporting projects in local

communities to providing training of human resources, and facilitating the creation of

social networks and information sharing. These include, for example, nutrition

education, promotion of kitchen garden and providing school lunches. Ajinomoto makes

a point of the project’s sustainability as a criterion for supporting a project. This is

considered as the developmental potential of the project after the end of Ajinomoto’s

support. Ajinomoto International Corporation Network (AIN) program is evaluated the

result through about 176 million yen financial support from 1999 to June 2011. AIN

program is spreading not only financial support but offering experts’ advice and

personal support such as local staff training. This activity acquires great reputation as a

CSR activity.

The second aspect is supporting technology, information and knowledge. For

example, international organizations and government agencies research what kind of

nutrients are lacking in the world and in particular countries. The company produces

fortified products build on information from international organizations and government

agencies. Furthermore, the company supports their technology, know-how and the

information it gets from marketing. These supports will stimulate to improve nutrition

problems.

The third aspect is abolishing trade barriers and taxes. If the government abolishes

or sets low level trade barriers and taxes to fortified foods, the company can go into the

market and sell their fortified products more low price. So people at the base of the

pyramid can buy fortified products more easily.

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3.2.3 The previous studies

Here we focus on the preceding studies on PPP in nutritional improvement, finding the

point of view about the viewpoint of PPP for nutrition improvement and the role of the

public and private sectors in PPP projects.

3.2.3.1 Previous study 1 – viewpoint of PPP for nutrition improvement

In the Manila Forum 2000: Strategies to fortify essential foods in Asia and the

Pacific, Glen F. Maberly and Jack Bagriansky reviewed PPP in food fortification for the

eradication of micronutrient malnutrition from 2000 from three points of view:

1. While the rhetoric calling for collaboration with the private sector has been
consistent, but real partnerships have been rare.
2. Stakeholders related nutritional problems looked at the consumption of basic
staple foods such as wheat, maize, vegetable oils, and sugar in countries around
the world.
3. The barriers to food fortification and public-private sector collaboration were
known from some survey of some food companies and included lack of public
awareness of micronutrient malnutrition, ambiguity of health claims, lack of a
“level playing field” and no research consensus on the need for fortified products.
Glen and Jack said that the advancement of food fortification as a viable solution to

micronutrient malnutrition will require investment by both public and private sectors

and the complementary role each sector can take in supporting such projects. They

claimed that public sectors need to advocate, increase awareness of nutritional problems

for the people through public educations, and promote food fortification foods through

tax/tariff incentive to the companies related in food industry. And they also claimed that

private sectors need to recognize their own position as nutritional experts, develop and

assure the products, and promote nutritional foods through marketing and researching

about consumer. Thus, public and private sectors have different roles so each sectors

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need to make up for the weak points.

3.2.3.2 Previous study 2 – Viewpoint of PPP in nutrition improvement and the role

of public and private sectors

In a paper called “Role of public-private partnership in micronutrient food

1
fortification ”, Venkatesh and Ameringen insist that effective and sustainable

fortification will be possible when only the public sector, private sector, and social

sector collaborate to develop, produce, and promote micronutrient-fortified foods. And,

they also claim that there is a critical need to initiate national dialogues to form links at

the national level among government, industry, scientists, non-government

organizations, and international agencies such as: opening channels of communication,

creating public awareness, developing consumer demand, defining coverage and market

segments, identifying food vehicles, marketing campaigns, keeping products affordable,

and assuring quality (S152-153). And, Venkatesh and Ameringen claim there has been

progress in eliminating micronutrient malnutrition and they classify the role of public

and private sectors in the process of PPP project as the following:

Process

» Public sector performs initial educational efforts

» Private sector takes the lead in market research

» Public and private sectors collaborate in developing themes and messages

» Public and private sectors partner in dissemination campaign

» Private sector tracks and fine-tunes the campaign

» Public and private sectors collaborate to revise messages

» Public sector evaluates national impact

1
“Unlocking the Potential of the World’s Children through Sustainable Fortification and Public-Private Partnership”
Cincinnati, Ohio, USA, 10-11 October 2002
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 Public sector

Governments need to develop political contact at the highest level and set policy and a

program framework within which food fortification can be promoted. Government’s

primary role when they work the program is in education and awareness campaigns and

the necessary integration. In certain cases, fiscal incentives (tax/tariff exemptions) and

physical incentives (preferred access to public infrastructure) may be necessary to

catalyze the process. Government could also ensure quality by providing a seal of

approval to fortified foods that meet specified standards.

Private sector

The food and pharmaceutical industry could work with governments to assess mutual

needs. By being part of the process from the start, industry can ensure its needs and

concerns are considered. Industry has the primary responsibility of creating products

and technology and developing marketing and distribution mechanisms. Industry could

create “best practices” codes for production and marketing of fortified products, so that

all companies can compete with regard to quality and excellence.

As is pointed out by these two studies, public and private sectors have appropriate

roles in the PPP to improve the nutrition situation. Actors in the public sector have to

make efforts to make awareness of nutrition through education, make the system

through policy and law such as tax/tariff exemption. Actors in the private sector try to

make awareness of nutrition through marketing, keep products quality from quality

assurance and develop products/mechanism as demands’ needs. Collaboration between

the public and private sectors is needed to develop products and invest infrastructure.

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Certainly, there are several problems in PPP projects. Lack of awareness about the

importance of nutrition in government, problems of access from product price increases

for wanting too much profit in private sectors, and adjusting these differences of

purpose between public and private sectors are the main problems. Likewise, it is

important to adjust differences of purpose, increase awareness from education and

marketing, and supply products from clarifying effects of products.

3.2.3.3 Previous study 3 – The approach to improve the recognition of the

nutritional improvement project

The weekly iron-folic acid supplementation project studied by Paulino et al (2003) is a

good example of awareness of nutrients and the project through marketing. This project

was based on guidelines from Weekly Iron and Folic Acid Supplementation (WIFS) for

Preventing Anemia in Women of Reproductive Age from WHO. It had been

implemented from 1998 to 1999 in Pangasina in the Philippines. In this project,

International Nutritional Anemia Consultative Group (INACG)/World Health

Organization (WHO)/UNICEF worked as programme planner, and the Department of

Health(DOH) and United Laboratories of the Philippines (UNILAB), a local company,

worked together to improve the nutrition of the women in reproductive age through

social marketing. The social marketing strategy for this project was structured as “4Ps”

of social marketing:

 Product: the target audiences were made aware about the importance of iron and
its benefits to the body.
 Price: the target audience was informed of the cost of the iron tablets and their
willingness to buy the product was encouraged.

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  Place: the target audience was informed of the availability of the iron tablets at
all times in places such as drugstores, barangay health stations, rural health units,
and secondary schools.
 Promotion: efforts were made to tell the target audience about the product, price,
and place, including advertising, packaging, point-of sale displays, and special
events.

Table 3-1 Percentage of women taking weekly Iron-Folic acid Supplementation by

pregnancy status and survey period

Pregnancy Survey Period

Status １ ２ ３ ４
Pregnant 5.7% 63.3% 84.3% 95.2%
Not
6.1% 64.0% 88.5% 98.6%
pregnant
Total 5.9% 63.8% 87.8% 98.1%
Source: Paulino et al (2003)

This project surveyed the percentage of women taking weekly iron-folic acid

supplementation by pregnancy status over 4 periods, and the Table 3-1 shows that

percentage of women taking weekly iron-folic acid supplementation had been increased

5.9 percent (first period) to 98.1 percent (fourth period).

3.3 Nutrition problems in the Philippines

The previous chapters were about the background of the nutrition problems in the world.

This chapter explains about the background and condition of nutrition problems and the

nutritional status in the Philippines through the specific data.

3.3.1 The problems of the poor and the rich

The Philippines is considered as a developing country, but has recently accomplished

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swift growth. According to the Ministry of Foreign Affairs, the economic growth in

these five years, except for 2009 when the Lehman Shock influenced the economic, was

4.6% at lowest and 7.6% at highest. On the other hand, because many farmers in the

Philippines are still bounded to large-scale landowners from the colonial age, it is said

the economic gap between poor and rich is large. Even the urban areas face serious

employment issue with the increase in population, and there are street children or

beggars in the town while there are scavengers who earn a living by picking up garbage

on the smoky mountains in the suburbs.

Today in the Philippines, the unemployment rate tends to be lower than that of 2006

when it was 11%, but it is still higher than 7% and unstable. There are three methods for

measuring poverty in the Philippines: the measuring standard of the government based

on incomes, the World Bank standard based on expenditures, and the method by the

National Statistics Office (NSO) based on the access to essential infrastructures. The

poverty line has been slowly raised since 2000. It is because the domestic prices rise.

Poverty Ratio had been improved before 2000, but the incomes didn’t increase for the

price rise, consequently Poverty Ratio and the number of poor people based on the

poverty line increases. According to the investigation of household economy by the

NSO in 2009, the number of poor people increased by a million from 2006, and become

about 23 million. This means 30% of people in the Philippines are poor. Poverty Ratio

in Mindanao, south of the Philippines, is 61.8%in 2006 by region. The Gini Coefficient,

which shows a gap between the rich and poor, was also 0.46 in 2006 (generally if the

index is higher than 0.4, there is a large gap). The gap has become worse since 2003.

With such a gap, rich people live in comfort and have the same health problems as

people in the developed countries. Therefore, the main cause of their health problems is

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lifestyle-related diseases, which are caused by high calorie intake, high lipids and high

blood sugar. According to the Ministry of Foreign Affairs in Japan, the 10 main causes

of death in the Philippines are tuberculosis, pneumonia, cancer, diseases of circulation

organs and diabetes. Compared with fatalities in 2003, about 40,000 people died from

diseases of circulation organs, 33,000 from pneumonia, 32,000 from cancer, 28,000

from tuberculosis and 9,000 died from diabetes. A lot of poor people are farmers, so

they tend to have carbohydrates like rice or corn, and they lack micronutrients like

vitamins or minerals which are essential also for the health. The lack of micronutrients

is a serious problem in the Philippines. Thus, the nutrition problems in the Philippines

tend to be misinterpreted as hunger or diarrhea, but in fact, having both nutrition

problems in developed countries and developing countries is a feature. In this thesis, the

nutrition problems of poor people are focused on.

3.3.2 Nutritional problems in the Philippines

The government of the Philippines has been outsourcing the national nutrition survey to

the Food and Nutrition Research Institute and officially publishing a report on the

nutritional status of the Pilipino every three years. The present situation of nutrition in

the Philippines is going to be explained next based on the 2008 national nutrition survey.

The rates of stunted and wasted children are mainly used as the indicators for

nutritional status. The WHO states that it is difficult to continuously research the

nutritional status of adults compared to that of children, so children often become the

subjects of research and the data is used as the essential indicator. The statuses of

underweight, stunted, and wasted are defined by Standard Deviation, which is evaluated

by the gap from the average.

In 2008, 26.2% of the infants between the ages of 0-5 were underweight, 27.9%

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were stunted and 6.1% were wasted in the Philippines. All of these three nutritional

indicators have the highest rate of increase between the ages of 0-1. These are related to

the infant mortality rate, especially suggesting that improving the nutrition of infants

leads the improvement of the mortality rate and other physical status of children.

The Philippines has been successfully approaching MDGs Goal 1, “Halve, between

Figure 3-2 Rate of stunted, underweight, thinness, overweight of 0-5 children in the

Philippines (1990-2008)

Source: FNRI, 2008

1990 and 2015 the prevalence of underweight children under-five years of age” and

other nutritional goals. However, continued efforts should be made since the three rates

increased by about 1% compared to the 2005 national nutrition survey.

Moreover, different characteristics appear when the nutritional status is evaluated by

region. The rates of underweight children are considered “high” between 20-29% and

“very high” over 30%. 28 states marked very high and 38 states were considered to as

high. The result shows that there are many states with serious problem of underweight

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children. In Metro Manila, the rate is “average ~ low”, but most of the southern parts of

the main land have very high rates, which demonstrate the regional gap.

Almost the same result is shown between the ages of six to ten. Although there has

been some improvement, there is the gap between the urban and rural areas.

Additionally, the central islands have very high rates of underweight children but

Mindanao Island has a very high rate of stunted children.

The research also included pregnant women who are likely to have nutritional

problems. Since 2005, the number of pregnant women who are in “nutritionally high

risk” has decreased. Women who are under 20 are especially in severe nutritional status,

and more than 35% of them are at high risk.

Moreover, there are results on the nutritional status based on the status of iron and

iodine. Firstly, when the research result is classified by age, more than 55% of the

infants under one are suffering from serious anemia and 42.5% of the pregnant women

also have anemia. It means that there are two age groups with more than 40% of serious

rate, which is said to have great influence on Philippine economy. Although they are not

reaching 40%, the rates of lactating women and the elderly suffering from anemia are

also high. While the rate of children under twelve who have anemia is decreasing, the

high rate of anemia among infants is still a problem which should be continuously

coped with.

3.4 Approaches for improving nutrition situation in the Philippines

As mentioned earlier, the Philippine have both nutritional problems can be found on the

rich—lifestyle diseases—and can be found on the poor—hunger, micronutrient

malnutrition—. Philippines’ nutrition problem is not only nutritional problems but also

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problems that have impinged on economics and culture. So, government of the

Philippines composes council to make plans and collaborations to improve nutritional

problems.

This passage explains the National Nutrition Council and PPAN programed by the

National Nutrition Council, examining several approaches on public and private

collaboration in the Philippines.

3.4.1 Investigation

Visiting the organizations related to nutritional improvement in the Philippines, this

research analyzes the types and availability of approaches for improving nutrition. The

target places were the Department of Health and Food and Nutrition Research Institute

as a government organization, Asian Development Bank as an international agency, and

Ajinomoto Philippine Corporation as a private company. To analyze the theme that

“Possibility and Limitations of Public-Private Partnership in Improving Nutrition”, the

research investigated the following four research questions:

1. What are the approaches to improve nutrition problems?

2. Which stakeholders are involved? How do they cooperate?
3. What are the objectives of cooperation?
4. What are the difficulties of cooperation?
Through investigating these four research questions, we look at the present nutrition

situation, approaches to improving nutrition status, and collaborative relationships with

other sectors.

3.4.2 National Nutrition Council

The National Nutrition Council (NNC) is the council for making country’s highest

policy and coordinating body on nutrition since 1974. NNC is made from several

departments in need of collaboration for improving the nutrition situation because this
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cannot be achieved by a single sector. NNC works for improving nutrition situations

under the six following core functions:

1. Formulate national food and nutrition policies and strategies and serve as the
policy, coordinating and advisory body of food, nutrition and health concerns;
2. Coordinate planning, monitoring, and evaluation of the national nutrition
program;
3. Coordinate the hunger mitigation and malnutrition prevention program to
achieve relevant Millennium Development Goals;
4. Strengthen competencies and capabilities of stakeholders through public
education, capacity building and skills development;
5. Coordinate the release of funds, loans, and grants from government
organizations (GOs) and nongovernment organizations (NGOs); and
6. Call on any department, bureau, office, agency and other instrumentalities of
the government for assistance in the form of personnel, facilities and resources
as the need arises.

3.4.2.1 Structure of NNC

NNC is composed of 10 Departments. Under the chairperson, Department of Health,

Department of Agriculture and Department of the Interior and Local Government play a

role as vice-chair. And Department of Budget and Management, Department of

Education, Department of Labor and Employment, Department of Science and

Technology, Department of Social Welfare and Development, Department of Trade and

Industry, and National Economic and Development Authority participate in NNC.

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Figure 3-3 Structure of NNC

Source: http://www.nnc.gov.ph/

3.4.3 Philippine Plan of Action for Nutrition (PPAN)

The Philippine Plan of Action for Nutrition is a set of measures against malnutrition

as an integral component of the Medium-Term Philippine Development Plan 2004-2010.

PPAN provides the framework for improving nutritional situations and contributes to

the achievement of the UN Millennium Development Goals as well as poverty

reduction. Medium-Term Philippine Plan of Action for Nutrition (MTPPAN) in 2008-

2010 worked for improving nutritional situation under 3 main directions in following;

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 1. Reduce disparities by prioritizing population groups and geographic areas
2. Increase investments in interventions that could impact more significantly on
under-nutrition
3. Revival, identification, and adoption of good practices and models
4. Going to scale in the implementation of nutrition and related interventions to
have wider coverage
And, table 3-2 is some of targets of PPAN for 2008-2010.

Table 3-2 Targets of PPAN for 2008-2010

Baseline Target
Key performance indicator
(Year) 2005-2010

Reduce the proportion of households with 56.9% (2003)

intake below 100 percent dietary energy 44.0%
requirement 70.0% (1993)

Reduce the prevalence (in percent) of 24.6% (2005)

21.6%
Underweight children, 0-5 years old 34.5% (1989-90)

Reduce the prevalence (in percent) of

22.8% (2005) 22.6%
Underweight children, 6-10 years old

Stunting among children, 0-5 years old 26.3% (2005) 25.4%

Anemia among Infants 66.2% 41.7%

Anemia among Children, 1-5 years old 25.1% 15.1%

Source: http://www.nnc.gov.ph

3.4.3.1 Roles of stakeholders in the PPAN

NNC

NNC and its networks including local nutrition committee and community nutrition

volunteer provides structure and mechanism for coordinating and adjusting the plan.

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National Government Agencies

National Government Agencies examine various policies about nutrition and announce

that policies and guidelines. Also that advocates to various stakeholders, support to do

capacity building and provision of logistics support to improve nutrition.

Local Government Units

Local Government Units conduct situational analysis to determine appropriate

interventions and implement and fund interventions to be implemented at different

levels.

Other sectors

Various sectors and many stakeholders are involved in the PPAN. NGOs conduct and

continue implementing nutrition and related programs and projects. International

organizations continue to provide technical and financial support to the national

government and local governments. Business organizations consider the possibility of

including nutrition and related services in a package of non-wage benefits for their

employees, especially the poor and marginalized. Food industry continues to develop

and market food products that are nutritious and safe, accessible, and affordable to the

consumer. Rice, flour, sugar, cooking oil, and salt industries continue to exert efforts to

comply with the food fortification law and ensure the availability of fortified foods in

the market. Business corporations with their own social foundations encourage

corporations to shift their programs according to the priorities for nutrition action.

3.4.4 PPP for nutritional improvement

There are various forms of PPP in the improvement of nutrition in the Philippines:

Sangkap Pinoy Seal Program (SPS Program) conducted by DOH, the transfer of food

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fortification technology from Food and Nutrition Research Institute – Department of

Science and Technology (FNRI) to local companies, nutrition education provided by

Ajinomoto Philippines Corporation (APC), and Project Iron Deficiency Elimination

Action (Project IDEA) implemented by International Life Science Institute. This

chapter explains about the characteristics of each approach.

3.4.4.1 The activities of DOH and FNRI

DOH and FNRI, which are both parts of the public sector, understand the importance of

the approaches of PPP. They even believe that the cooperation with the private sector is

indispensable for improving nutrition. When they try to develop PPP, they first discuss

and share the objectives and work together in line with the discussions. If by any chance

the public sector doesn’t share the objectives with the private sector, which seek profit,

the project might be different from its original goal and might not succeed.

DOH conducts various PPP projects such as one-time and several-time cooperations.

Sometimes they ask the private sector to develop fortified food products and buy them.

What they are especially focusing on is called Sangkap Pinoy Seal Program. In this

program, they give certified seals to the local companies and allow them to put the seals

on their fortified food products that meet the standards and sell them in supermarkets

and convenience stores. In order to be certified, the fortified food product should

include more than two thirds of the standard daily intake of the nutrients such as

minerals and vitamins. It is difficult for the companies to get the trust of the people and

make them buy fortified food because fortified food is not well known especially in the

rural areas. Therefore, in order to expand the sales and use of fortified food, government

certification is essential. DOH believes that they should sustain their PPP projects and

other approaches, cover the whole country, and cooperate with other stakeholders in

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order to improve the nutrition of the Filipinos.

FNRI carries out the national nutrition survey and develops the food fortification

technology. They are concentrating on transferring the food fortification technology to

local companies. Since FNRI cannot produce and distribute fortified food products by

themselves, the roles of the companies are important. The companies utilize the

technology and consequently spread fortified food throughout the country. Before FNRI

transfers the technology, strict assessments and meetings are carried out in order to

examine the sustainability of the business and to share the objectives of the companies.

Moreover, the supporting and monitoring systems after the technology transfer are

created so that the companies can use the technology for the right purposes. Although

the system to distribute fortified food has been developed, there still is the problem of

low degree of recognition of fortified food itself. Less than 10% of the Filipinos know

what fortified food is and the percentage is even lower in the rural areas. Distributing

food fortification is necessary as well as improving the degree of recognition.

3.4.4.2 APC

Ajinomoto Group Philosophy is to “create better lives globally by contributing to

significant advances in Food and Health and by working for life”. They provide healthy

and nutritional food as well as deliciousness for the sustainable health and happiness of

the people. APC is providing funds and information and conducting joint projects with

other stakeholders and highly contributing to nutritional improvement of the Philipinos.

There are the three main forms of PPP between APC and FNRI: providing funding

support, providing information, and jointly implementing self-planned programs. Firstly,

APC is providing funding supports to FNRI. Although FNRI is one of the governmental

organizations, they don’t have limited funds to spend for nutritional improvement. Thus,

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the funding supports from APC and other cooperative companies is important. APC

helps FNRI to promote the nutrition development programs and to disseminate the

research results through supporting 1st Brown Rice Culinary Challenge and the poster

presentation exhibit.

Secondly, APC is providing information on nutrition to FNRI in order to educate

FNRI staff on new scientific information and to update with new knowledge. For

example, APC held Allergy Symposium in 2009 attended by FNRI heads and

researchers. Thirdly, APC and FNRI are jointly implementing self-planned programs for

more resources and better results. APC has been supporting FNRI’s activities in

Nutrition Month every July since 2000. In Nutrition Month, FNRI holds symposiums

and meetings so APC donates giveaways and materials in place of putting

advertisements on them. In the near future, APC is planning to carry out nutritional

improvement projects with DOH, NNC and Department of Education.

The challenge of APC for nutritional improvement through PPP is how they can

cooperate with as many stakeholders within the limited funds they have. Many of the

governmental organizations are expecting APC and other strong companies to support

their activities but APC cannot help all of them. The problems are how APC can

distribute the funds effectively to cover all the requests.

3.4.4.3 ILSI

ILSI is a nonprofit worldwide organization founded in 1978 with the global network of

more than 400 companies and 3000 researchers. Their mission is “to provide science

that improves public health and well-being by fostering collaboration among experts

from academia, government, and industry on conducting, gathering, summarizing and

disseminating science.” They especially focus on nutrition and health promotion, food

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safety, risk assessment, and the environment. Providing scientific data, they are closely

connected to the international organizations such as WHO, FAO, and UNICEF, and

gains reliability on policy decisions for international harmony. Furthermore, they build

relationships with NGOs for health and security of the people in the whole world.

In 1997, ILSI has started a campaign to eradicate iron deficiency anemia, which is

called Project IDEA. In Project IDEA, ILSI works together with the governments of the

developing countries and fortifies their principal food and seasonings with iron. As a

result, they make it possible for the people to take in iron through daily diet and prevent

anemia. This program was launched because there was no clear measure to eliminate

iron deficiency anemia while many programs for the reduction of vitamin A deficiency

and iodine deficiency have been successful.

ILSI pays attention to rice and works together with FNRI to develop iron fortified

rice. Through the research, they proved the effectiveness of iron fortified rice for the

reduction of anemia and carried out the market trial in Orion City, Bataan State to

introduce the new technology. As part of the project, education and advertising

campaigns on iron fortified rice were conducted and the effectiveness of the rice and the

behavior of the consumers were analyzed. Using the result from the trial, the market of

the rice will be expanded to the whole country. Project IDEA is carried out not only in

the Philippines but also in Cambodia, Vietnam and other developing countries. China

has its national policies to distribute iron fortified soy sauce and the research on iodine

and iron fortified salt is developed in India.

ILSI has been working on the dissemination of fortified food through Project IDEA.

They recognize the roles of the private and public sectors and actively build the

relationships with other stakeholders. ILSI also believes that the government should

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certify fortified food products to make them reliable, as in SPS Program, and increase

the demand. The seals also improve the quality of fortified food themselves by ensuring

that the products contain the nutrients written on the labels. ILSI suggests that other

Asian countries should use this system to expand fortified food market.

Many of the stakeholders believe that PPP, in which the public and private sectors

have their special roles, is important for nutritional improvement. There are some PPP

projects going on in the Philippines, such as SPS Program and Project IDEA, and they

are expected to be highly effective in the future.

3.4.5 Analysis

In this chapter, the PPP projects for nutritional improvement in the Philippines

described above is summarized along with our answers to these following research

questions:

1. What are the approaches to improve nutritional problems?

2. Which stakeholders are involved? How do they cooperate?
3. What are the objectives of cooperation?
4. What are the difficulties of cooperation?
Firstly, there are various types of nutritional improvement activities in the

Philippines: Sangkap Pinoy Seal Program by DOH, national nutrition surveys and

development of the food fortification technology by FNRI, funding support and

nutritional information distribution to by APC and eradication movement of iron

deficiency anemia called Project IDEA by ILSI. Additionally, as an international

organization, ADB is building the base for the stakeholders to cooperate with each other,

covering whole Asia. In these ways, there are many PPP projects for nutritional

improvement in the Philippines and many of them are actually producing good results.

About the second question, DOH cooperates with companies since they give

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certified seals to their fortified food products, FNRI also has partnerships with

companies for its transfer of food fortification technology to them, APC and FNRI are

working together and supporting each other, and ILSI, together with FNRI, is

developing iron fortified rice. Each of these cooperation involves both public and

private sectors. Therefore, although the projects vary from financial support to

cooperation in the planning stage, all of them are PPP projects.

Next is about the objectives of the cooperation. DOH wants to spread the fortified

food products, which meet the standards, and improve the reliability of the companies

through SPS program. FNRI’s purpose is to distribute fortified food products through

the whole country, while APC expects to advertise their food products. The cooperation

between ILSI and FNRI enabled them to conduct the research on iron-fortified rice and

the large-scale market trial.

For these projects, this research finds three problems in making the nutritional

improvement projects more effective. First, one of the challenges is that nutritional

improvement projects and fortified food themselves are not well known among

Filipinos. For example, SPS Program is highly reputed but only 11% of the Filipinos

know about fortified food and the percentage of those who actually know the definition

of fortified food is even lower and drops to 9.8%. Some people, especially in the rural

areas, misunderstand that fortified food is harmful for their health. The awareness

should be improved and their behavior should be changed to make the projects

successful and lead to nutritional improvement. Secondly, the difference in the

objectives between the public and private sectors sometimes becomes the problem.

While companies seek profits, governments seek improvement of nutrition. It is natural

for them to have different purposes of cooperation, but both of them should share and

155
adjust each of their objectives to make PPP projects succeed. Thirdly, it is a challenge

for some of the companies to utilize their limited funds to help many of their

governmental partners. APC wants to help all the governmental organizations and

provide them with plentiful funds, but they have limited funds to use for nutritional

improvement projects. The framework is needed to manage effective projects which

benefit all stakeholders.

3.4.5.1 Problem 1: Awareness

As mentioned above, although the reputation of SPS Program is high in and outside the

Philippines, it is not well known enough to directly contribute to nutritional

improvement of the Filipinos. Moreover, the misunderstanding towards fortified food

prevents it from dissemination. In order to improve the awareness of the people, as

stated in Chapter 2, the public sector should educate the people on nutrition and remove

their misunderstanding. Additionally, the private sector should make the people aware

of the safety of fortified food through marketing.

The factors of success in PPP projects are going to be analyzed and the possibility of

improving the awareness of the people will be considered.

According to Paulino et al (2003), “Weekly Iron and Folic Acid Supplementation”

succeeded to improve the awareness among the people in reproductive age of iron-folic

acid supplementation. In this project, the awareness rate was surveyed four times. The

rate was 5.9% at the start, but it increased to 98.1% and most of the women in the

region came to use the products.

It is assumed that the factors of success are improving the awareness rate and

providing the products at the appropriate price. PPP worked well to provide safe and

affordable products and constant education and advertisement campaigns.

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 This research pays attention to the improvement of the awareness rate through

community-based marketing. Improving the awareness of the people through marketing

is one of the effective approaches which can also be used for fortified food and other

projects.

3.4.5.2 Problem 2: Objectives

The difference in objectives between the public and private sectors can sometimes

become a problem. While the public sector is working to improve the nutrition of the

Filipinos, the private sector seeks profits so they should get benefits through nutritional

improvement projects. Therefore, it is essential for them to share and confirm their

primary objectives of the projects. In order to overcome the difference, FNRI sets

meetings and assessments to share the objectives when transferring the food

fortification technology so that the companies can use it for their profits and the

improvement of nutrition of the people. M.G. Venkatesh and Marc Can Amerigen

mentioned in “Role of public-private partnership in micronutrient food fortification” in

“Unlocking the Potential of the World’s children through Sustainable Fortification and

Public-Private Partnership” about the importance of comparing and adjusting the

purposes to carry out projects effectively.

3.4.5.3 Problem 3: Fund Management

The third challenge in the Philippines is to improve the fund management efficiency.

It is important for both the public and private sectors to decide which projects to

focus on and how to utilize their limited funds. The last chapter explains about the

problem of fund management mentioned by APC. DOH, FNRI and other governmental

organizations demand funds from APC to support their projects. APC has limited funds

to help them, even though APC wants to provide funds for as many partners. Thus, the

157
management of funds should be efficient. The standards and frameworks to benefit all

the stakeholders are needed to be created. Overcoming these three problems leads to the

effective nutritional improvement project in the Philippines.

3.5 Conclusion

This research focuses on “the possibility and limitation of public-private partnership in

nutritional improvement” and then arranges various aspects such as the backgrounds,

activities, classification, summarizing preceding studies. First of all, this research might

have a risk of not finding precedents in Philippines because there was not enough

Japanese date and documentation. However the more deeply research we did, the more

clear facts we found, that is, we could reach the opinion that it is important positioning

for PPP in the nutritional improvement programs.

We got various answers for research questions based on this research theme. First,

this question “What are the approaches to improve nutritional problems?”, gave the fact

that each group which could agree to an interview carried out their own various actions.

For example, there is one group that builds the network and advocacy to support the

whole activities and another one that analyzes researches about nutritional status, and on

the other hand there are also players that plan the national nutrition policy or try to

expand distribution channels of fortified foods. So they take positive actions for PPP to

bring out the best in their own strengths. As for the question, “what are the approaches

to improve nutritional problems?”, there are various relationships such as technology

transfer from research and development institution to small and medium businesses,

capital cooperation, and announcement of official report.

As for “what purpose do you have through PPP?” it is more effective and essential

158
that their group conduct with other group to carry out their mission related nutritional

improvement. The different thing is their background of their mission. One group thinks

improving nutritional problem is their duty as national government, and another group

thinks it is possible to make the most of this national experience to other regions in the

all world. Of course actors such as companies might have an incentive to make a profit.

Finally, each group thinks various things for the question “What are the difficulties of

cooperation?” according to their role and activity content. The group which takes

great interest in advocacy thinks more active relationship with other sectors for it, and

the group which is devoted to researching needs recognition of the product made by

developed technique. They think that it is important to promote the activity by public

announce. If one is good at capital support, they shape the strategy to make the most of

it for the better project management.

Through hearing such groups, the approaches of nutritional improvement and the

relationships between stakeholders became clear. It is natural to solve the problem with

more efficient result that all groups cooperate with others. So they didn’t explain the

signification. But this research shows the three common problems to investigate the

possibility and limitation: “improvement of recognition”, “the difference among

sectors”, and “improvement of fund management”. This research explores the

implication by comparing and analyzing the field studies and the precedence research.

However, since the researches, which overcome on the problem of the difference in

objectives among sectors and the improvement of fund management, were not available,

this research could not go further into those topics. There is a case in which the

recognition succeeded which proved that the strategies of advertisement and education

should be included in the projects. In conclusion, there still is a scope for further study

159
about these two problems and various solutions.

160
References

Ajinomoto Philippines Corporation. (n.d.). Retrieved 9 27, 2011, from Ajinomoto

Philippines Corporation: http://www.ajinomoto.com.ph/default.aspx

Asian Development Bank. (2001). Manila Forum 2000: Strategies to Fortify Essential

Foods in Asia and the Pacific. ADB publishing.

FAO. (2004). The State of Food Insecurity in the World. Rome: Food and Agriculture

Organization of the United Nations.

Ferranti, D. d. (2004). Public and Private Roles in Health: Theory and financing patterns.

In P. Musgrove (Ed.), Health Economics in Development (pp. 35-76).

Washington, D.C.: World Bank.

Food and Nutrition Research Institute. (n.d.). Retrieved 9 25, 2011, from Food and

Nutrition Research Institute: http://www.fnri.dost.gov.ph

ILSI. (n.d.). Retrieved 9 25, 2011, from ILSI: http://www.ilsi.org/Pages/HomePage.aspx

ILSI Japan. (n.d.). Retrieved 9 27, 2011, from ILSI Japan: http://www.ilsijapan.org

Japan Bank for International Cooperation(JBIC). (2008). The poor profile (hincon

profile). JBIC.

Kazuhiro, U. (2008). The newest guide of food hygiene; to be a nutrient expert

(Shokuhineiseisaisingaido Eiyousonotsuninaru). Kagawa Nutrition University

Publishing Division (jyoshieiyoudaigaku shuppanbu).

Paulino, L. S., Agdeppa, I. A., Etorma, M. M., Ramos, A. C., & Sforza, T. C. (2003).

Weekly Iron-Folic Acid Supplementation to Improve Iron Status and Preven

Pregnancy Anemia in Filipino Women of Reproductive Age: The Phlippine

Experience through Government and Private Partnership. International Life

Sciences Institute.

161
PPAN. (n.d.). Retrieved 9 30, 2011, from NNC: http://www.nnc.gov.ph/

Ritsuko AIKAWA, Masamine JIMBA, JICA. (2003). Iron Deficiency Anemia Control

in Developing Countries (Kaihatsutojyoukokuni okeru

tetsuketubouseihinketsushoutaisaku). The study of International Cooperation

(Kokusaikyouryokukenkyu), 39-48.

The World Bank. (2005). Improving health, nutrition, and population outcomes in Sub-

Saharan Africa : the role of The World Bank. Washington, D.C.: World Bank.

The World Bank. (2008). The Poor Profile.

Venkatesh, M. g., & Ameringen, M. v. (2003). Role of public-private partnership in

micronutrient food fortification. Food and Nutrition Bulletin, 24(4), pp. 151-

154.

162
Chapter 4

Potential of Relationships among

Stakeholders of the TB Control

Programs :

A Case Study Focused on the Difference of

Network

Yuji Tashiro, Sahori Takei,

Yukako Tomii, Megumi Hagiwara,

Miha Matsubayashi
4.1 Introduction

4.1.1 Background of our study

According to The World Health Organization (WHO), 8.8 million people come down

with TB each year, and 1.4 million people die from TB1. Among them, 95% of the

people who die from TB are in developing countries including the Asian region.

Infectious diseases including TB account for 50% of the cause of death in the

developing countries. The disease causes not only the patients pain and individual

economic burden but also economic losses. These losses impede the development of a

country. Abmad, N (2003) takes up the infectious diseases control as a high problem of

a priority.

According to WHO, the Philippines is one of the 22 high-burden countries of TB

with reference to prevalence rate. 80% of the world’s total TB patients are found in

these countries. In the Philippines, situations of the spread vary per region. TB spreads

prominently in urban poor areas.2 According to the national TB prevalence survey in

1997, urban poor had four times higher prevalence of TB than the other areas. In order

to solve the TB problem in the Philippines, we have to focus on this urban poor area.3

1
Stop TB partnership TB FACT sheet
2
Poor people live in slum
3
Manila, The Philippines Tropical Disease Foundation. Final Report.1997National Tuberculosis Prevalence
Survey.1997
165
DOTS is the most effective TB control program advocated by WHO. A detailed

explanation is presented in section4.3.1.1. The situation of TB in the world has

improved significantly thanks to DOTS. But TB still continues to spread in the world.

Similarly, in the Philippines, about 100 people per day die from TB. WPRO areas,4

including the Philippines, are the only one who succeeded in the goal. Despite this, the

case detection rate of patients has stopped growing from 2005. Poor patients cannot

afford to receive medical treatment, so they don’t go to hospitals. Therefore, it is

difficult to find the TB patients even if DOTS systems are organized in the present

situation.

Our study focuses on the network between stakeholders in the TB control programs

and presents three research questions. Two cases of effective TB control have various

stakeholders, and this study analysis with the object of how to give the effect for TB

control. With the study method, we gain knowledge about our study-related material

from literature and report about TB control programs of the Philippines or the world,

and we had preliminary survey in Japan Anti Tuberculosis Association. After that we

conducted field survey in the Philippines. In the Philippines, visit the spot of the

projects, and conduct interviews and questionnaire for project staff, inhabitants and so

on.

4
Western Pacific Regional Office members are 37 countries including Japan, China and so on
166
4.1.2 Limit of our Study

There were various limitations such as time and distance between transfers and so on

during the course of our study. At first, we could only find two cases for study objects.

Furthermore, just one part of these two cases could conduct on-the-spot investigation.

Therefore, this research is just one part of the TB control programs in the Philippines. In

addition, we cannot gather enough information because some of the groups could not be

reached for communication after got back to own country.

4.1.3 The organization of the paper

In the section4.2, we give an explanation about TB from medical findings and TB

control programs, refer to the relationship between poverty and the status of TB in the

world the section4.3 explains the current situation of TB in the Philippines, and the

national TB control Programs by the Filipino government. In the section4.4, we

express the importance of relationships between stakeholders in the TB control

programs from previous study and the history of TB control programs. In the section4.5

gives an overview of the survey and outcome of the study, and explain the observations.

And in the section4.6 gives our conclusion.

4.2 About TB

This section explains medical information about TB, which is its symptoms and
167
treatments, while also referring to the relationship between poverty and the situation of

TB in the world.

4.2.1 Basic knowledge of TB

TB bacterium was discovered by Robert Koch in Germany in 1882. TB is infectious

disease which gets infected from person to person through the air. For example, coughing

or sneezing by people with TB causes the bacteria to be scattered in the air, causing others

to breathe air that people infected with TB. The symptoms of TB are about two weeks to

prolonged coughing, sputum, hematemesis, fever and others. There are individual

differences in the onset. In general, a person got infected with TB who has a strong

immunity will suppress the bacteria in the body for decades. The bacteria enter into a

dormant state, and it is prevented from developing further into the disease. On the other

hand, people with a weakened immune system are more likely to develop the disease.

Leptosome people, smokers, the like contained in the socially disadvantaged elderly,

homeless, and children are also likely to develop TB. TB bacteria are bred mainly in the

lungs, but may develop and spread to the spinal cord, the brain and others parts of the

body. Infections that occur outside the lungs are called extra-pulmonary TB. Also, there

are infant TB that infects children, HIV/AIDS complication of TB, and Multi

Drug-Resistance Tuberculosis (MDR-TB) that is caused by drug-resistance incomplete or

168
interrupted therapy cause. In this study, we focus on lung TB accounting for 80% of all

TB cases. There is sputum test to examine TB, which can be divided into smear test and

culture test. Smear test is the way to place sputum on a slide glass and stain it, for

detecting TB bacteria. The way of culture test is raising the bacteria in the sputum to

examine it. Sputum smear-positive patient who has positive reaction for TB bacteria can

be pointed out by sputum smear test.

4.2.2 TB and poverty

4.2.2.1 Status of TB in the world

The 6th goal of the Millennium Development Goals includes preventing the spread of TB,

as shown in Table4-1. It has improved compared to the 1990s, but the target value is still

far from what has been stated. DOTS in 6.10 of Table4-1 are an effective TB control

program recommended by WHO. The details about this are given in section4.4 TB is a

serious issue as it is included in the three major infectious diseases, along with malaria

and HIV/AIDS. According to WHO (2011), currently there are 128 people with TB per

100,000 people, and 15 people per 100,000 die from the TB in the world in 2010. The 22

high-burden countries that have been determined based on the height of TB prevalence

rate by WHO has been focused on developing countries of Asia and Africa. One of the

major causes of the spread is due to HIV / AIDS. HIV / AIDS patients are susceptible to

169
TB. These people have a weak immune system. At this point, we would like to present the

situation of TB in Japan. Japan is unique among developed countries about middle

epidemic country of TB where patients are increasing year by year. According to (WHO,

2011), the numbers of infected people are 27 per 100,000; out of which 1.5 people die per

year in 2010. Some of the factors are increase in the number of the elderly and the

socially vulnerable.

Table 4-1 The Millennium Development Goals 6: HIV/AIDS, Malaria,

and other disease

Target 6. A Halt and begin to reverse, by 2015, the spread of HIV/AIDS

6.1 HIV prevalence among population aged 15-24 years

6.2 Condom use at last high-risk sex

6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge

of HIV/AIDS

6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged

10-14 years

Target 6. B Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who

need it

6.5 Proportion of population with advanced HIV infection with access to antiretroviral

drugs

170
Target 6. C Halt and begin to reverse, by 2015, the incidence of malaria and other major

disease

6.6 Incidence and death rates associated with malaria

6.7 Proportion of children under 5 sleeping under insecticide-treated bednets

6.8 Proportion of children under 5 with fever who are treated with appropriate

anti-malarial drugs

6.9 Incidence, prevalence and death rates associated with TB

6.10 Proportion of TB cases detected and cured under directly observed treatment short

course

Reference: official development assistance of international cooperation (ODA), Ministry

of Foreign Affairs of Japan as a reference

4.2.2.2 The relationship between TB and poverty

Looking at nature of TB, TB is big aspect of social disease. In particular, when

considering the circumstances leading to the disease TB, rather than the onset of a disease,

it is often connected to social problems such as poverty and social structure, and it is more

likely that it is deeply involved with the development of the disease. Figure4-1 shows

their relationships clearly.

As the cause of spread of TB in developing countries, including the urban poor areas

in the Philippines, there are three reasons in general. The first one is related to unsanitary

171
living environment. In fact, when we went to the urban poor areas in the Philippines, we

were able to observe the actual situation. Under these circumstances, access to safe water

is difficult, and people are living in overcrowded housing. Due to poor ventilation,

infection can easily spread to other people in the same household. The delay in the

detection of the disease, therefore it is easily to spread TB. The second reason is unstable

income. It becomes difficult to continue the treatment because the amount of one’s

income is insufficient to pay for treatment costs or transportation costs to hospitals.

Widespread TB in developing countries has a major impact on the economy due to the

concentration of TB cases being high among productive age groups between 15 years to

below 65 years. The poor becomes poorer because they use up all their money and

allocate it for medical/treatment costs. These circumstances lead to low productivity

because the time they spend working also becomes less and this results in reduced income.

Decrease in income leads to nutrient deficiency due to less food intake, and therefore

increases the risk of contracting infectious diseases including TB. The problem of poverty

is a vicious circle. This is described in Figure4-1. The third cause is the lack of knowledge

about TB. This is because poor people have less opportunity to receive education

compared to other people that are likely the reason for their lack of knowledge about TB.

Also, many people have wrong information about TB. In a survey conducted to

172
inhabitants, some of the responses were "TB infection leads to death" or "getting infected

with TB is embarrassing".

Thus, TB is most closely related to various social backgrounds, and therefore we

should think of solutions that will solve not only TB but also social problems, including

poverty.

In the next section, we will explain a description of the present situation of TB in the

Philippines when we conducted a field survey and TB control programs.

Figure 4-1 TB and poverty linked in vicious cycle

Reference: Prepared by author based on a document of WHO (2002)

173
4.3 The Philippine with TB

In this section explain about the present situation of the Philippines and TB control by

government.

4.3.1 The present situation of the Philippines

According to World Health Organization, The Philippines is the 9th in the top 22

high-burden countries of TB. In the Philippines, TB is still one of the common diseases.

According to the national TB prevalence survey in 1997, there are regional differences,

and the TB prevalence rate in the urban poor area is about 4 times higher than the rate in

the other urban area. It is clear that the TB situation in the urban poor area is alarming.

Table4-2 compared the TB situation in other Southeast Asian countries with in the

Philippines. It shows the highest infection country is China; second is Indonesia in 2010.

However, the highest diseased number per 100,000 populations is 275 people in the

Philippines. It points out as the highest number in the Southeast Asia, compare to 185

people in China and 189 people in Indonesia .So we can find that the Philippines has a

higher rate of people infected with TB than China and Indonesia. It is because these two

countries have larger population than the Philippines.

This is the reason why we focus on Philippines which urgently needs to improve the

TB situation in the urban poor area.

174
 Table 4-2 Major 22 high-burden country in the world

Total (number in thousands) Rate per 100,000 population

Country

Prevalence incidence mortality prevalence incidence mortality

Bangladesh 610 330 64 411 225 43

China 1,500 1,000 54 108 78 4.1

Congo 350 220 36 535 327 54

Ethiopian 330 220 29 394 261 35

India 3,100 2,300 320 256 185 26

Indonesia 690 450 64 289 189 27

Nigeria 320 210 33 199 133 21

Pakistan 630 400 58 364 231 34

Philippine 470 260 31 502 275 33

South Africa 400 490 25 795 981 50

Vietnam 290 180 29 334 199 34

Reference: Prepared by author based on a document of WHO (2011)

4.3.2 TB control in the Philippines

The Philippine Department of Health has established the National TB control Program

(NTP) as TB control policy. It is a fourth revised version of the current state.

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 First, give an account of TB control. Today TB control has vision of a country where

TB is no longer public health problem, mission of ensuring that DOTS services are

available to the communities in collaboration with the local governments and other

partners, goal of 85% treatment success rate of the new sputum smear-positive TB cases

discovered and 70% case detection rate of estimated new sputum smear-positive TB cases.

Problems of TB are considered as one of the highest priority issues in the Department of

Health, moreover cooperation with various agencies such as international agencies, local

governments and NGO are needed for overcoming the problem of the TB control. The

government is currently offering some of free TB drugs or medicines of need in step for

tests and treatments.

Next, what kind of approach has been done for TB control until now in the Philippines.

Table4-3 explains that the main flow of TB control in the Philippines. In the Philippines,

TB control started with the establishment of a TB hospital in Quezon City in 1910.

However, treatment of TB at the time still had not been established, so treatment was

limited to patients only to rest and isolation. In 1930s and 1940s, due to the increased

number of cases, many of organized efforts had been seen. In the 1950s, the treatment of

TB had dramatically evolved all over the world. Also, since BCG treatment or MMR

vaccine containing the streptomycin-TB drugs had been introduced in the Philippines, TB

176
treatment had incredibly developed. In addition, TB centers were established in the

Department of Health, so TB diagnostic tests or x-ray inspection had been increased. In

1964, the first TB prevalence survey was conducted at Cebu. During the late 1960s and

the mid-1970s addition, TB was promoted by local governments, expanded to nationwide

TB.

Since 1968, it has been incorporated into general health services even TB, and health

centers and those branch offices mainly in the municipalities have been discovered and

treated patients. Patients with suspected TB because of symptoms such as cough more

than two weeks, need to go to the health center three times also take smear examination

performed in the laboratory. If the tests were positive, a patient would be registered with

the health department as a smear-positive TB patient.

In 1976, the National Institute of TB (NIT) was established, with supports of

UNICEF and WHO. In addition, the BCG vaccine was mandated the same year. In the

early 1990s, it was transferred to the jurisdiction of local health services from the

Department of Health. Therefore, local governments managed TB control programs and

provided services to the inhabitants through the Barangay5 Health Stations and local

health centers. In addition, because JICA introduced the DOTS TB control recommended

by the WHO in Cebu, testing equipment and data collection were improved. This measure

5
Barangay is the smallest unit of government in the Philippine
177
became a showcase of new TB model. Then, for forming the assisted partnership such as

NGOs, government agencies, the private sector, unions and researchers, PhilCAT were

formed in 1994. In 1990, for TB control various sectors cooperated mutually and held

activity. TB control center is a reliable as early diagnosis and treatment of TB, therefore

DOTS (short-course chemotherapy medication directly confirmed) was introduced in

Philippine Department of Health as a national strategy for TB control since the late 1990s

for promoting TB control and striving to improve the treatment success rate and improved

case detection rates of TB. In 2003, for integrating TB control measures between the

private sector and government, Department of Health and PhilCAT promoted

Comprehensive and Unified Policy.

The Philippine Department of Health adopted Public-Private Mix DOTS (PPMD) in

TB control strategy, advocated to carry out TB control by cooperation with the public

sector such as health centers and the private sector such as NGO and private hospitals

since 2003. Philippines is becoming increasingly decentralized, has been delegated to

local authority policy implementation. However, because only local governments lack the

money and resources, it is considered to be effective that implement TB control in

collaboration with an NGO who has personnel and facilities, which is lack in the local

health centers.

178
Table 4-3 Transition of TB control in the Philippine
year History

1910 TB hospital establish in Quezon City

1964 First time about the TB prevalence survey in Cebu Island

1976 ・National Institution of TB(NIT) was established support by WHO and

UNICEF

・make BCG vaccine obligatory

1982-83 The first national TB prevalence survey conducted by NIT

1986 Health public and TB Control Service(TBCS)

In early ・Transfer of jurisdiction to local governments from the Department of

1990s Health Services.

• Health implementation of DOTS in TB control was introduced by JICA in

Cebu.

1990 Financial assistance and technical cooperation in health development projects

in the Philippines for five years by Italian government and World Bank

1994 Government and NGO agencies, private sector, the establishment of a

cooperative partnership PhilCAT like to help researchers

1995 Government policy Preparation of guidelines for the diagnosis of TB

management and revision of the direction of TBCS

1996 ・Create of the National TB Day and the National World TB Day introduction

of DOTS in TB

・Department of Health implemented CRUSH-TB project through the DOTS

strategy

2002 • National TB Reference Laboratory (NTRL) was established

179
 2003 ・DOH and PhlilCAT cooperating to forward Comprehensive and Unified

Policy

・Adopted PPMD as a national strategy of TB by DOH

Reference: Made from DOH resource

4.4 Need for relationships between stakeholders in the TB control

programs

This section explains the current of global TB control programs and previous studies,

refer about relationships between the stakeholders in the TB control programs.

4.4.1 The current of global TB control programs

4.4.1.1 DOTS strategy

The chemotherapy of TB was established in the 1940s. Subsequently the numbers of TB

patients were decreased in developed countries. But the numbers have not been

decreased in developing countries, because the developed countries could not

effectively transfer the treatment techniques to the developing countries. In the 1970s,

the TB control programs including the microscopic examination, BCG vaccination, and

Direct Observed Treatment (DOT) were managed. In the 1990s, the pandemic of

HIV/AIDS and the increase of the patients of MDR-TB became serious. According to

M C Raviglione, A Pio (2002), the major socioeconomic crisis that happened with the

180
dissolution of the Union of Soviet Socialist Republics (USSR) made situations for the

USSR countries to have the following things: the deteriorated economic situation, the

existence of poverty, concentration of population, and malnutrition, which are favorable

to the transmission of the TB infection and the progression of infection to disease.

Through this worldwide of TB, TB control programs attracted global attention.

The International Union against TB and Lung Disease (IUATLD) promoted the TB

control programs that mainly focused on improvement of treatment success rate with

the effective short-course chemotherapy regimens, a regular supply of drugs, full

supervision of drug intake, and rigorous cohort analysis. According to Styblo, K (1989),

this approach showed that it was possible to achieve 80% treatment success rate in field

situations in Tanzania, Malawi, Mozambique, and in other poor countries. This

experience proved that effective case management of TB could be achieved in any

situation. In 1991, the two targets of a global TB case detection rate of 70% and a global

TB cure rate of 85% by 2000 were set in the 44th World Health Assembly. In 1993,

WHO declared TB a “Global Emergency”, which cautioned about the expansion of

damages from TB around the world. And in 1994, the DOTS strategy which is the base

of today’s TB control programs was recommended by WHO. The DOTS strategy

composed of five elements. They are sustained political and financial commitment,

181
diagnosis by quality ensured sputum smear test, standardized short-course anti-TB

treatment given under direct and supportive observation, a regular uninterrupted supply

of high quality anti-TB drugs, and standardized recording and reporting. This TB

control program is known as the most cost-effective way. The DOTS strategy was

adopted by at least 127 countries by 1999 and achieved great results. However the two

targets set by WHO had not been achieved. According to WHO (1998), the 22

high-burden countries of TB that were responsible for 80% of the global prevalence rate

became have a particularly severe problem. The coverage reached in many countries

was limited and only 23% of the estimated cases of infection worldwide were treated

under DOTS in 1999. As a consequence, nearly 80% of estimated cases of infection in

1999 still lacked access to rapid diagnosis and proper treatment.

The managerial challenge of TB control, therefore, was not that of adopting DOTS,

but rather of expanding coverage to all countries.

4.4.1.2 STOP TB STRATEGY

In 1998, a WHO ad-hoc committee was convened to discuss the global constraints to

widening TB control and to identify potential solutions. According to the resulting

report, the political will and commitment must be strengthened through increase social

mobilization and the technical consensus could be achieved by a global partnership with

182
non-governmental organizations (NGOs) or the private sector. Correspondingly Stop TB

Partnership was established by public/private sector, domestic/foreign and

organization/individual involved in TB control in 2001 (Mori, 2009). But the two

targets of a global TB case detection rate of 70% and a global TB prevalence rate of

85% by 2005 set by Stop TB Partnership also were not achieved. The TB case detection

rate and the TB cure rate have improved, but remain the two targets keep failing. The

problems that DOTS strategy could not solve emerge from the environment surrounding

TB in developing countries. They are fragile health systems and the lack of the budget

and human resources; inadequate diagnosis and treatment technique; the access to

health and medical service for poor, high immigrant population; lack of knowledge, or

bias to TB; and private medical institutions not implementing DOTS. DOTS strategy

lacks socioeconomic development and poverty programs, which are the most important

in providing health and medical service and the perspective of support to individual

patient (Ishikawa, 2007).

On the basis of these problems, Stop TB Partnership came out with Stop TB Strategy.

This strategy is based on DOTS strategy, but added six components were lacking. The

six components are to pursue high-quality DOTS expansion and enhancement, to

address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations, to

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contribute to health-system strengthening based on primary health care, to engage all

health workers, to empower people with TB and communities through partnership, and

to enable and promote research. The stop TB Partnership is active with these goals

(Table4-4) to achieve the target 6th of MDGs.

Table 4-4 Goals of Stop TB Partnership

Goals

１ Achieve a case detection rate of 70% for new smear-positive cases and a

treatment success rate of 85%

２ Reduce prevalence and death rates by 50%, compared with their levels in 1990

by 2015

３ Eliminate TB as a public health problem, defined as a global incidence of active

TB of less than one case per 1 million popular per year by 2050

Reference: Made from Stop TB partnership

4.4.2 Previous study

Recently, the importance of network in the TB control programs is recognized. A

countermeasure for infectious diseases, including TB, conducted by one organization is

having a small impact. The partnerships as represented by Global Fight AIDS TB

Malaria Fund are promoted worldwide. Due to the presence of a coordinating

organization, which has the macro view of analysis advantages and disadvantages of

several donors in the network, both the effectiveness of this project and the TB control

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programs in the area are improving (Ishikawa, 2007). In many countries, especially in

Asia, the private sector is the dominant medical provider and the first part of call for

most TB patients. The quality of diagnostic and treatments in private medical

organizations is often substandard. According to Lönnroth etc (2010), the necessary

solution will have to include strengthened government stewardship of the private sector.

Kawahara( 2008) mentions that there is a need for private medical institutions of doctor

to get involved in the national TB control programs. And the TB control programs also

need involvement with NGOs and communities. A Mushtaque R Chowdhury (1999)

mentions that grass-roots NGOs are in the right position to hold over and entrench for

the communities. And NGOs facilitate the involvement with the communities by

cooperating with government. Atun, Weil, Eang and Mwakyus (2010) say that the two

major approaches are the use of community health workers and public-private mix

including use of NGOs or the private sector. They expand the access to treatment for

patients and the delivery of services, also improve treatment outcomes and coverage.

For examples include Cambodia, Bangladesh, Ethiopia and Pakistan. In Cambodia, the

health center with medical supervision by foreign NGOs earned inhabitants’ trust and

the number of the health center users have increased. In Bangladesh, a public-private

approach has enabled NGOs to have a key role in the NTP and has expanded access

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through community health volunteers (CHVs), cured patients who provide advocacy

and peer support, and private providers. In Ethiopia, community health workers have

been used widely to improve case detection and treatment success. In Pakistan,

community health workers have been used widely to expand TB control with the Lady

Health Worker Program. Public-private approaches have frequently been used in

high-burden countries of TB to improve care and outcomes, including Kenya, Indonesia,

Burma, Nigeria, Pakistan, the Philippines, and South Africa.

We introduce the projects that established the network in Zambia. According to

Yamada (2005), the characters of this project are involving the inhabitant’s group in the

TB control program. The network is established by JICA, ministry of public health,

health service bureau, health center, health worker, social worker, and CHV. The

activities among organizations are increasing awareness about TB in the communities,

promoting involvement with specialists, implementing DOTS, picking out the problems,

involvement with patients, empowerment of patients, establishing and promoting the

network, coordinating with NGOs, mobilizing the funds, advocacy, monitoring fund

management, development of human resources, and sharing information. As a result, the

analysis of the information gathering in this project was reflected in politics, and human

resources were ensured.

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 According to these previous studies, the TB control programs need to be involved

with the various sectors like international agencies, global funds, central/local

governments, public/private medical organizations, NGOs, CHVs and so on. The

activities among partners are sharing information and development of human resources.

And the network needs the organization coordinating with the partners. The TB control

programs with the network show that improvement of the access to therapy and

knowledge. It also shows the improvement in case detection rate and treatment success

rate.

4.5 Case study of TB control in the Philippines

This section explains about outline of study in the Philippine, consideration from survey

results.

4.5.1 Study outline

4.5.1.1 Survey method

This study focuses on the network between stakeholders of the TB control programs.

This study targets two projects that have different types of the network between

stakeholders of TB control programs as study objects. First is “The TB Control Project

in Socio-Economically Underprivileged Urban Area in Metro Manila, The Philippines.

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‘Stop tuberculosis para sa Lahat’ PhaseⅢ ” conducted by RIT/JATA Philippines,

Inc.(RJPI). Second is “Community-based Rehabilitation Project on Health and

Livelihood” conducted by I-CAN Foundation Philippines, Inc (ICAN). This field survey

interviewed to five organizations related to the projects and an inhabitant in the ICAN’s

action area, also this field survey had questionnaires to eleven CANOSSA’s staff and

twenty inhabitants in CANOSSA’s action area. The details of these organizations are

explained in the next section. Table 4-5 is the survey items used by our interview to the

organizations, and Table 4-6 is the survey items used by our interview to the inhabitants.

Our study had questionnaires that are the same in our interview’s content to get a lot of

information because our field survey had only short time.

Our study had done a comparative analysis of our field survey and previous study

with the three research questions; 1) who are involved in the programs and how are they

involved, 2) what relationships between stakeholders exist in the programs and 3) what

effect do such relationships between stakeholders have in the outcome of the programs.

A comparative analysis of these cases clarifies the effect of the different network on the

TB control programs.

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Table 4-5 Questionnaire to the organizations
Survey items Objects
１What is the present situation of TB in Manila and the WHO, RJPI, DOH,
1 Philippines? CANOSSA, ICAN
２What kind of TB control programs have you WHO, RJPI, DOH,
2 managed? CANOSSA, ICAN
３ WHO, RJPI, DOH,
What is your role on the TB control program?
3 CANOSSA, ICAN
４ WHO, RJPI, DOH,
Who are involved in the programs?
4 CANOSSA, ICAN
５How do you grasp the progress and disadvantages of WHO, RJPI, DOH,
5 the TB control programs? CANOSSA, ICAN
What relationships between the stakeholders exist in RJPI, DOH, CANOSSA,
6 the programs? / ICAN
6 How can TB control programs establish relationships
between the stakeholders?
7 What kind of difficulties did you have when you were RJPI, DOH, CANOSSA,
7 cooperating with the stakeholders? ICAN
8 What effect do such relationships between RJPI, DOH, CANOSSA,
8 stakeholders have in the outcome of the programs? ICAN
9 What kind of new association do you want to RJPI, DOH, CANOSSA,
9 cooperation with in future? ICAN
1 What are the future challenges about the TB control WHO, RJPI, DOH,
10 programs? CANOSSA, ICAN

Source: Made from questionnaire

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 Table 4-6 Questionnaire to the inhabitants

Survey items

What is the present situation of TB in Manila and the Philippines?

1

Are there TB patients close to you?

2

If you suffer from TB, what will you do?

3

What is your daily life like?

4

Did you know about TB before you participate in NGO’s activities?

5
If so, when and where did you learn about TB?
How did you come to participate in the activities by NGOs?
6

How often do you contact with Canossa’s staff members？

7

What do you think is needed to treat TB?

8

Source: Made from questionnaire

4.5.1.2 Study object

There are briefs of study objects.

(a) “The TB control project in socio-economically underprivileged urban area

in metro Manila, The Philippines. ‘Stop TB para sa Lahat’ PhaseⅢ”

This project has many stakeholders, but our study focused on three organizations (RJPI,

DOH, CANOSSA) that contributes to this project and could visit,

(ⅰ) RIT/JATA Philippines, Inc (RJPI)

Japan-Anti TB Association (JATA) has been providing human resources, technical

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assistance and project management on NTP project with JICA since 1992. The project

had finished in 2007, JATA established RJPI in 2008, and continue TB control programs

in the Philippines. RJPI has conducted the TB control programs with establishing the

network between NGOs, inhabitants organizations and public/private medical

organizations in the urban poor areas.

(ⅱ) Department Of Health（DOH）

DOH is the governmental organization and important health organization in the

Philippines. DOH has a responsibility to ensure the access to basic public health

services of the Filipino through providing quality health and medical services

constantly.

DOH instituted the National TB control Programs (NTP) that is public promises for

TB. NTP has worked out in public health center and hospital.

(ⅲ) CANOSSA

CANOSSA is catholic health center in Tondo, Manila where called urban poor area.

CANOSSA set out improving the community health by helping particularly poor and

patients.

(b) “Community-based Rehabilitation Project on Health and Livelihood”

(ⅰ) I-CAN Foundation Philippines, INC (ICAN)

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ICAN is established to improve children well-being in Japan in 1994. ICAN has

conducted education, medical care and increasing the livelihood. Our study takes up the

TB control program in Community-based Rehabilitation Project on Health and

Livelihood from 2007 to 2010.

(ⅱ) PICO

PICO is the cooperative association organized in ‘Community-based Rehabilitation

Project on Health and Livelihood’ by ICAN. PICO aims the inhabitants to make income

not collecting govern dumpsite but sustainable way.

PICO’s members were 80 Community Health Volunteers in 2008. PICO’s activities

are independent of ICAN’s activities like daycare, job training, pharmacy etc. All staffs

are allotted several parts. Each part holds the annual meetings. The meetings held

semimonthly, the leaders of several parts report and discuss about the activities and

management of funds. PICO is monitored by ICAN. But ICAN will transfer the

project to PICO. Instead of ICAN, PICO will conduct the project.

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4.5.2 Case study

4.5.2.1 “The Tuberculosis Control Project in Socio-Economically Underprivileged

Urban Area in Metro Manila, The Philippines. ‘Stop TB para sa Lahat’ PhaseⅢ”

This project started PhaseⅠ in 2008, PhaseⅡ in 2009 and PhaseⅢ in 2010. Then this

project had finished in 2011. Our study takes up the phaseⅢ.

This project conducted by RJPI aims to decrease mortality and prevalence rate by

2015 in Tondo, Manila and in Payatas, Quezon where are known as the urban poor areas.

And this project targets on improvement access to quality DOTS by 2010. Therefore,

RJPI set some indexes including the treatment success rate of new smear-positive is not

less than 85% in project areas, the registration rate of new smear-positive in the project

areas, increasing the case detection of new smear sputum by non-governmental medical

organizations like NGOs in project areas. The main activities are providing quality

DOTS service, establishing the network between the stakeholders and empowerment

through advocacy. RJPI established the referential system between the DOTS centers

and referential organizations. The main system is; the organization that found the new

patient hand over the referential form to go to DOTS centers, and the patient go to the

DOTS center. The patient gets a diagnosis by the sputum smear test. If the patient was

smear-positive, they start the treatment.

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 And RJPI integrates the report from diagnosis to treatment to grasp the process from

diagnosis to treatment.

The following is the results of interview to the several organizations’ staffs. To the

question “What is the present situation of TB in Manila and the Philippines”, RJPI,

DOH and Canossa answered the Philippines is 9th of 22 high-burden countries of TB,

TB is the 6th cause of death in the Philippines. The stakeholders in this project are

WHO, global funds, DOH, CHD, health centers, RJPI, hospitals, clinics and NGOs.

RJPI monitors the partners by quarter. At which time, RJPI brings the local

governmental staffs to look the present situations, promotes understanding toward TB.

If the referential system did not work out, RJPI arranges a face-to-face meeting called

‘Tapatan’ for the concerned parties. The concerned parties check the referential systems

in the meeting. As a result, they became to refer smoothly. Therefore RJPI holds the

workshops. At the workshop, the delegates of several partners report them activities. To

the question “What kind of difficulties did you have when you were cooperating with

the stakeholders”, DOH answered political commitment, funds, human resources, and

community involvement. RJPI answered that the problem is health-seeking behavior.

Canossa was badly off human resources, but Canossa did not have the difficulties. To

the question “What effect do such relationships between stakeholders have in the

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outcome of the programs”, CANOSSA’s CHV answered “I took the effort to detect the

new TB patient” and “I got to know about what is possible for me to eliminate TB. To

the question “What kind of new associations do you want to cooperation with in future”,

RJPI answered church organizations. WHO, DOH, RJPI, Canossa answered active case

finding as the future challenges.

Table 4-7 Answer from WHO, DOH, RJPI and CANOSSA

Q: What is the present situation of TB in Manila and the Philippines?

A:

WHO: Estimate number of TB (all forms) is 1.9 million. Estimate number of deaths

due to TB is 260,000 in the Western Pacific.

DOH: The Philippines is 9th of 22 high-burden countries, 3rd in the Western Pacific

Region. And TB is the 6th cause of prevalence and mortality in the

1 Philippines.

RJPI: The Philippines is 9th of 22 high-burden countries. TB is the 6th cause of

mortality. The Philippines reached the Global targets of 70% Case Detection

Rate and 85% Success rate in 2006. There is the issue of Local Variance

Persists.

CANOSSA: The Philippines is 9th of 22 high-burden countries. TB is the 6th cause

of mortality.

Q: What kind of TB control programs have you managed?

A:
2
WHO: WHO don’t make a commitment to the individual projects outside the field

of the pilot projects.

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 DOH: TB-DOTS in jails/prisons, indigenous populations, elderly, urban poor,

Public-Private Mix DOTS, community-based DOTS, CATCH-TB Project

and TB-LINC Project.

RJPI: ‘TB Control and Prevention Project in Socio-Economically Underprivileged

Areas in Metro Manila, the Philippines’

CANOSSA: Management of information and supply, DOTS, examine by

microscope

Q: What is your role on the TB control program?

A:

WHO: Collecting dates、policy making, providing technical assistances

DOH: Formulate plans, policies, to standards, advocate, implementation of oversee

programs, provide technical or assistance, monitoring, evaluating and

3
information analysis

RJPI: establishing the referral network, building the relationships between the

stakeholders, providing technical assistances, training, monitoring

CANOSSA: documentation, provision of information, implementing DOTS,

diagnosis with microscope

Q: Who are involved in the programs?

A:

WHO: international organizations, governments, NGOs

4 DOH: international organizations, Local Government Units, Private sectors

RJPI: DOH, CHD, NGOs, hospitals, health centers, clinics, volunteers, health

workers

CANOSSA: RJPI, JICA, health center, DOH. NGOs, MHD, PhilCAT, CHVs

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 Q: How do you grasp the progress and disadvantages of the TB control programs?

A:

WHO: Exchanging information with each governments

5
DOH: No answer

RJPI: monitoring quarter, workshop, tapatan

CANOSSA: visitation, seminar/training, meetings, evaluation

Q: What relationships between the stakeholders exist in the programs? /

How can TB control programs establish relationships between the stakeholders?

A:
6
DOH: No answer

RJPI: No answer

CANOSSA: increasing the facilities.

Q: What kind of difficulties did you have when you were cooperating with the

stakeholders?

A:

7 DOH: Less political commitment, Issues on resources (Financial and human

resources), Health-seeking behavior, Less community involvement

RJPI: health seeking behavior

CANOSSA: Nothing. But mention to one, lack of human resources.

Q: What effect do such relationships between stakeholders have in the outcome of

the programs?

8 A:

DOH: decreasing the prevalence rate, 80% Case Detection Rate of new

smear-positive, treatment success rate of 90%

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 RJPI: implementation the TB control programs.

CANOSSA: increasing the information, improving the treat programs, collaboration

with other NGOs, creating incentives.

Q: What kind of new association do you want to cooperation with in future?

A:

9 DOH: No answer

RJPI: church organizations

CANOSSA: all organizations (particularly private medical)

Q: What are the future challenges about the TB control programs?

A:

WHO: active case finding, addressing the risk populations.

DOH: Finding more and finding fast the TB cases, Addressing “difficult” and

“costly” groups of cases, Introducing, adopting and sustaining the new tools

for diagnosis, Addressing limited human resources, particularly at

10
implementing levels, Balancing partner’s support with their contribution to

the Program

RJPI： addressing the risk population, active case finding, obtaining consent from

patients and communities.

CANOSSA: active case finding, protect health workers against TB, diffusion of

knowledge.

Source: Made from questionnaire

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4.5.2.2 “Community-based rehabilitation project on health and livelihood”

This project has the targets that the inhabitants sustain adequate health environment

personally, go forward localizing the health project. ICAN strengthened grouping the

inhabitants, and established a cooperative association. ICAN gives the management of

health project to the cooperative association. ICAN supports PICO function as the main

actor of not only health program but improvement of livelihood program. This study

focuses on TB control program in the health program.

The following is the results of interview to ICAN staff. To the question “what is the

present situation of TB in Manila and the Philippines”, ICAN answered the numbers of

death by TB are 75 people per day in the Philippines. TB is the 6th cause of death in the

Philippines. The inhabitants answered TB is spread in the area, bias to TB and lack of

knowledge. The main TB control programs are supply of milk and supplement, health

education, home visitation and feeding. ICAN’s roles of the TB control programs are

coordinating assignment with the health center and superintendence of PICO. The

stakeholders in this project are health centers, health services bureau, JICA and Orione

foundations. It can be said that the grass-roots TB control program is conducted.

Because PICO consists of inhabitants, conducts the meetings with patient monthly and

does home visitation, health education. To the question “What kind of difficulties did

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you have when you were cooperating with the stakeholders”, ICAN answered lack of

medicine and human resource, constant change of the health center staffs. To the

question “What kind of new associations do you want to cooperation with in future”,

ICAN answered government and private sectors. To the question “What are the future

challenges about the TB control programs”, ICAN answered case finding as soon as and

funds. PICO could not conduct the enough TB control programs by limiting of times

and funds at present.

ICAN has held the monthly meetings named Barangay TB Management Council

(BTBMC) in 2011 to share the information. The participants are barangay chairman,

health centers, NGOs conducting the TB control programs, doctors in Payatas. Then, the

new TB control programs are designed

Table 4-8 Answer from ICAN

Q: What is the present situation of TB in Manila and the Philippines?

A: The number of deaths due to TB stands at an average of 75 Filipino

everyday. Diagnosed as curable, it ranks 6th among the top leading

1
causes of mortality and morbidity in the Philippines. DOH reported

a decrease in the number of mortality due to TB from 38.2 deaths

per 100,000 populations to a rate of 31 per 100,000.

Q: What kind of TB control programs have you managed?

2 A: Supplemental feeding, milk and multivitamins supplement, health education

session, house visit.

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 Q: What is your role on the TB control program?

A: Coordinate with Bgy. Health Center. Orient and talk to patient and their
3
family members, Provides tasks and supervise CHV in-charge, monitors

records and medicines, follow-up patients.

Q: Who are involved in the programs?

4 A: The treatment partners, Bgy. Health Center, CHV, JICA, JATA, Orione

foundations, PICO

Q: How do you grasp the progress and disadvantages of the TB control

5 programs?

A: No answer

Q: What relationships between the stakeholders exist in the programs? / How can

TB control programs establish relationships between the stakeholders?

6 A: Visit and coordinate with organizations, joining conference and seminars,

partnership with Quezon City Health Office, monthly meeting with TB

patient, house visit with treatment partner, health education with the patient.

Q: What kind of difficulties did you have when you were cooperating with the

stakeholders?

A: No enough supply of medicines, lack of health staff and health facilities,

transition of staff, schedule or availability of the patient for the medication

7
and appointment for laboratory test, financial limitation on laboratory fees and

transportation, misinformation or lack of about TB, social stigma on people

with TB, different priorities, never give-up vices like smoking and drinking

alcohol that will hinder the effect of medicines.

8 Q: What effect do such relationships between stakeholders have in the outcome

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 of the programs?

A: Having a confidence

Q: What kind of new association do you want to cooperation with in future?

9
A: Government and private agencies.

Q: What are the future challenges about the TB control programs?

10 A: Increase rate of MDR-TB, lack of funds from LGU for diagnosis and

treatment of TB, more trainings on management of TB program.

Source: Made from questionnaire

4.5.3 Consideration

In this section, we explain the answer of three research questions and the sum of our

research. Before that, it states that there is the difficulty of treating network that we

can’t see. It takes long time to bother what can it be said between organizations in

cooperate. Should just know each organization? Should measure frequency to contact

between institutions? And so on. What was very useful in this study are interview and

questionnaire for persons concerned with the project. Based on the information

provided from persons concerned with the project and the contents that were

investigated in Japan, we want to inspect what kind of influence a network had on TB

control program.

First, here we clarify the research question 1) who are involved in the programs and

how are they involved? Through the study in Japan and field survey, we could get so

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much information. About the case of RJPI, we could survey in Japan what kind of

stakeholders is concerned before field survey. And among the field survey, we surveyed

actual situation. About the case of ICAN, we surveyed most in Philippines and after

returning Japan because there was no time to spent survey before going to Philippines

for convenience of appointment. But, because this case is comparatively small, we met

various stakeholders in the Philippines and we could get so much information.

In the both cases, we learned that there are not only medical organizations but also

many related stakeholders while there are differences of stakeholder’s number. In the

case of RJPI, Global funds, WHO, central/local governments, health centers, health

service bureaus, public/private clinics, inhabitants and so on are related as stakeholders.

In the case of ICAN, Global fund, WHO, central/local government, health center, health

service bureau, public/private clinic, inhabitants, CHVs and so on are related as

stakeholders, too. Each case can be seen to cooperate with DOH that centre government

gives medicine and local government join the case. But there are differences between

the numbers of related stakeholders while each case relates similar stakeholders. In the

case of RJPI, RJPI is being professional for the role of coordination, which acts as an

intermediary between government and local institutions. There is cooperation system

include local coordination institutions. On the other hand in the case of ICAN, ICAN

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also cooperates with government, and more, ICAN acts as an intermediary between

institutions and supports the activity of PICO. ICAN works in a wide range of areas.

Most of previous studies in section4 explain the importance of cooperate with various

institutions on the recently projects of TB control and health. For example, A

Mushtaque R Chowdhury (1999) says the importance that local NGOs involve in TB

control programs. Atun, Weil, Eang and Mwakyus (2010) say that private organizations

including the NGOs became cooperate with the government and the outcome of the

treatment would spreads. This trend can be seen in global TB control programs by

WHO and in the National TB control Program by DOH in the Philippines. And, on

National TB program in Cambodia, Bangladesh, Ethiopia, Pakistan, Zambia and so on,

various organizations actual relates to TB control program, which is WHO, foreign

government, central /local government, public/private clinic, NGOs, inhabitants,

community and so on. The point is the existence of private clinic. According to previous

study of Zambia, it is clear that private clinic has important place in TB control program.

Kawahara says the importance too. But it could say not to enough emergence of private

clinic on the each case we surveyed.

Second, we clarify the research question 2) what relationships between stakeholders

exist in the programs? Especially, through the interview and questioners for local people

204
in the Philippines, we could get so much information. In the case of RJPI, the system to

deal with various problems is already established, which government inspects the field

with NGO staff and RJPI coordinates the meeting if there is problem. RJPI organizes

the workshop to share information regularly. And CANOSSA, we visited to in the field,

make a home visit to TB patient who didn’t come to office to take medicine. CANOSSA

supports continually DOTS. RJPI gives equipment and material based on JICA. DOH

also gives facility and materiel for free. In the case of ICAN, there is meeting to share

information. In addition, since September 2011, the staff of the local public health

center, NGO which actives for rerated TB, doctors in the area and so on gathers and

conducts a meeting for sharing information to think about the TB problem of the vast

area.

In others, the activity for development of human resources to CHVs is carried out in

the both cases, too. In the previous study of Zambia as we explain in 4.4.2, the necessity

of sharing information in such a meeting and the development of human resources is

expressed to effect. Ishikawa states that it is effective in TB control program that there

is a coordination organization in a network. In addition, it is said the importance of

development of human resources in a case. Because according to lonnorth (2010), it

cannot be said that all has enough quality in the private medical organization.

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 Finally, we clarify the research question 3) what effect do such relationships

between stakeholders have in the outcome of the programs? The answer here sum

comprehensively based on working papers, interview and questionnaire on the field

survey. In both cases, the number of the case detection and treatment success increase,

and it can be said to be effective TB control program. And a network of stakeholders is

how affected this, at first, point worth making is the case detection of patient. All

institutions where we interviewed stated that the most important problem is the case

detection of patients. DOH has realized to need local community and the NGO rooted in

the community in order to detect patient, and the importance is explain in the global TB

strategy by WHO. Because most of the poor do not go to the hospital as has been

understood above from the investigation of Kawahara in the previous study and an

interview to WHO on the spot. Therefore it is difficult to detect the TB patient who is

the poor with special needs. About this, RJPI is going to detect more patients by

carrying out a project with local NGO. In addition, it is possible to put cooperation with

more NGOs or the private medical organization. ICAN moves the weight of the activity

of the TB control program at the organization called PICO by inhabitants. As explain

the previous study of Bangladesh and Zambia, in this way, poor develop confidence in

the TB control program and TB control program become more effective. In addition, by

206
interview on the field survey, it was found that this activity adds incentive to spread this

more and contribute to cure a patient more for CHVs who are same poor. In this way,

the effect of TB control programs is not only treatment success rate and case detection

rate are increase as outcomes of TB control programs but also a wide variety effect.

As observed above, it is effective for TB control program to cooperate with various

stakeholders. Following is a summary of what has been researched about both cases and

what has been compared with previous studies. Both cases have a similarity that there

are various stakeholders from the international organization to inhabitants and they

share information by having a meeting regularly in that. Both cases have activity of

personal training, too. Both cases have been effective as TB control program.

Meanwhile, as difference, both cases have difference of the effect and width of the

activity from a difference of the number of the collaboration organizations. And, both

cases have coordinator but the way of coordination is difference. The entry situation to

the TB control program by the private medical organization is different too.

4.6 Conclusion

In this sections summarize what we had discussed so far and explain the conclusions of

our study.

In the 1990s, especially aggravated the spread of TB in developing countries, WHO

207
has recommended DOTS which is the most effective TB control program. By the grace of

DOTS, the TB situation in the world was much improved, but the high prevalence of TB

was still a serious situation in the 22 high-burden countries of TB. Thus the new Stop TB

Strategy was announced in 2005. This strategy, targets an individual patient, those close

to the patient, family, and neighbors that based on DOTS have set to work on the issue. In

addition, activities involving health workers are urged to enhance cooperation. The turn

out of being close to an individual patient or TB control had important works with many

stakeholders from this strategy. So our study is devoted to stakeholders among

networking, and a survey conducted for the two cases have been in cooperation with

various stakeholders in the Philippines. Our study visited their cooperation organizations,

conducted surveys and interviews. It follows from the results found in previous study and

field survey in the Philippines. This includes previous study dealing with importance of

WHO and foreign governments, the country's central or local governments, public and

private medical organizations, NGOs, local inhabitants and their community involvement

in a variety of global TB control and meeting between their organizations to exchange

information or coordinate network formation with various stakeholders. In addition,

studies about two projects that were conducted in cooperation with organizations in

various sectors like previous study, and meetings for those various stakeholders were

208
conducted. These things were common throughout the previous study and case studies. In

both projects, DOTS has increased the number of patients with successful detection and

treatment of TB, can be said is valid. Both projects have received the drugs and

equipment such as provided free of charge for those that interact with government and

other organizations. From previous study, TB cooperation between the organizations

made a greater impact by working to win high credibility about TB control from being

involved with inhabitants themselves, and by increased numbers of patients with

successful detection and treatment. These previous studies were also found to be common

throughout the case. Using different networks in TB control, the difference in effect size

and spread of activity that has been the same effects is presented. This factor, involving

various stakeholders, coordination between the partners and development of human

resource were common in the previous study and case study.

On the other hand, the difference in the case study and previous study was whether

or not the network was contained in private organizations. In previous studies,

participation in private hospitals was stated to be critical. From this, future work in the

Philippines is the entry of private hospitals, and entry to TB control programs that is

considered to contribute to improve a case detection rate.

From the above, relationships between stakeholders, said to be a valid approach to

209
TB control. It is important to cooperate with all organizations involved in the treatment

of TB found in laboratory diagnosis. Organizations to distribute throughout the country

for TB control system, authority to oversee the medication and treatment of inhabitants,

and organizations that mediate respective roles of various stakeholders have been

measured together. Our study has hope in the opportunity to think about the problems

of TB in the Philippines, plus developing countries.

210
References
Abmad N. (2003), Voice of Stakeholders in the Health Sector Reform in Bangladesh,

World Bank.

Atun, R. D. (2010), Health-system strengthening and tuberculosis control, THE LANCET,

Vol 375, 2169-2178.

Chowdhury, A. M. (1999),Success with the DOTS strategy, THE LANCET, Vol 353,

1003-1004.

Grange, m. J. (1999), Paradox of the global emergency of tuberculosis, THE LANCET,

Vol 353, 996.

Ishikawa N, K. M. (2007), kekkaku kara mieru ningen no anzenhosyou(Human Securith

with a View of TB Control Projects), Japan International Cooperation Agency

Research Institute.

Kawahara, K. (2008), Philippine kyouuwakoku no hokeniryoujijyou to

iryouhokenjijyou(Health Situations and Medical Insuarance System of the

Philippines), Iryo To Shakai(medical care and Society), 18(2), 189-204.

LönnrothK. G. Castro, J. M. Chakaya, L. S. Chauhan, K. Floyd, P. Glaziou and M. C.

Raviglione.K.,. (2010), Tuberculosis control and elimination 2010–50: cure,

care, and social development, THE LANCET, Vol 375, 1824-1829.

Ministry of Foreign Affrica of Japan. (2012), International Cooperation, Retrieved from

Official Development Assistance:

http://www.mofa.go.jp/mofaj/gaiko/oda/doukou/mdgs.html

Mori, T. (2009, 11 15),wagakuni no kekkaku taisaku no genjyou to kadai 12 kekkaku

taisaku no aratana senryaku (Our country TB control of situation and problems

aThe new TB control Strategy-Stop TB Partnership),

nihonkousyuushi(Japanese Society of Health), 56(11).

211
Partnership, Stop TB. (2011, 12), kekkaku ni tsuite (About TB), Retrieved 10 2010, from

Stop TB Partnership: http://www.stoptb.jp/about/dots/

Raviglione, C. M. (2002, 3), Evolution of WHO policies for tuberculosis control,

1984-2001, THE LANCET, Vol 359, 775-780.

Styblo, K. (1989). Overview and epidemiological assessment of the current global

tuberculosis situation with an emphasis on control in developing countries.

OXFORD JOURNAL.

Tao, Y. (1997), kekkaku ha ima (Today's TB), Bungei Sya.

The Department of Health. (2005), The NTP Manual of Procedures, DOH.

United Nations. (2010), The Milleunnium Development Goals Report 2010, United

Nations.

WHO. (1994), Framework for effective TB control, WHO.

WHO. (1998), Global TB Control-WHO Report 1998, WHO.

WHO. (2002), Community Contribution to TB Care: an Asian Perspective, WHO.

WHO. (2002), Global TB control-surveillance, planning, surveillance, WHO.

WHO. (2009), Global TB Control-epidemiology, strategy, financing, WHO.

YamadaN. (2005), HIV/AIDS projects to kyoudousita chiiki DOTS no arikata-Zambia

Lusaka City no torikumiyori-DOTS: Service extension to communities in

conjunction with HIV/AIDS Control Project(JICA) in Lusaka, Zambia: A

observation report, Journal of Amori University of Health and Welfare, 6(3),

309-314.

212
Analysis and Conclusion

Seoungho Kim
Analysis

As referred to in the introductory chapter, this study focused on stakeholder cooperation

and education in the four themes (mother and child care, sanitation, nutrition, infectious

disease). In this chapter, we analyze the four themes based on the two focuses.

Stakeholder cooperation

First of all, we analyzed the effectiveness of peer education in chapter 1, which observes

the field of maternal and child health. In order to conduct peer education, international

organizations like UNFPA planned the program, public sector like schools and regional

government engaged in adopting the program, and NGOs provided education. Various

stakeholders were involved in the execution of peer education, and they contributed to

improving access to reproductive health by leveraging their strengths. In the Philippines,

which has the same situation indicated in the previous studies of stakeholder cooperation,

government and NGO were involved in the field of maternal and child health. They plan

to improve the situation by coping with barangays and local communities.

In the next place, sanitation facilities are pubic goods. However in the current

situation, it is difficult to distribute sanitation facilities throughout the country just by the

public sector. Therefore, supports from private sector are important for the distribution to

215
the poor. Efforts in adopting appropriate technology with the high regard for low cost and

cost-benefit are required in order to disseminate facilities throughout the country. In the

Philippines, private sector, like NGOs, and public sector, including the Department of

Education and regional government, plan to improve the sanitation situation by coping

with schools and communities. Public sector is beneficial in financial assistance,

distribution of supplies, and school education. By comparison, private sector makes effort

to diffuse sanitation facilities using low-cost and appropriate technology to schools and

communities.

Next, we discussed the possibility of private-public partnership in the nutrition field

in chapter 3. We looked into cooperation among stakeholders, for example government

and companies, companies and NGOs, and government and NGOs. Although PPAN,

taken up in 3.4, is a governmental policy implemented by NNC, companies and NGOs

related to nutritious issues also work in the plan. Filipino government gets technical and

financial assistance from foreign capitalized companies like Ajinomoto. On the other

hand, it supports local companies for nutritious improvement by tax reduction and

technical assistance. Whereas the previous studies refers to the importance of cooperation

between government and NGOs based on literature and hearing, it did not research the

actual relationships.

216
 Last of all, in the field of infectious disease, tuberculosis is a particular disease which

requires surrounding recognition of tuberculosis for its solution, as it was expressed in the

previous research. Also, cooperation among various stakeholders including public sector,

private hospitals, and NGOs deeply rooted in the region is crucial for the solution. As it

was referred in the previous research, NGOs have close relationship with local

communities and assume significant role in tuberculosis treatment, which necessitates

lasting supervision. Therefore, the government assimilates tuberculosis countermeasure

into its policy and tries to tackle tuberculosis issues with supports of private hospitals,

NGOs and local communities. Through on-the-spot investigation in the Philippines,

importance of both public and private sectors was clarified.

Education

Firstly, the approach called peer education, which we have dealt in chapter 1, is an

educational approach for improving maternal and child health. As you may notice from a

speculation of the fourth research question, peer education not only improved the

knowledge of its participants, but also changed their awareness and actions. Since

environment sensitive to sexual issues exists in the Philippines, familiarity is a huge

advantage of peer education and it enhanced the effectiveness of education. Thus,

education holds significant potentiality and it is an important key for the problem solving

217
in the field of maternal and child health, as it was seen in the previous studies. On the

other hand, we could also hear opinions that improving access to health services is the

most urgent issue. We have recognized that more comprehensive approach is

indispensable.

In addition, education is an important issue in the field of sanitation. Through our

study, we verified that formation of hygienic habit via education is considerable, as it was

expressed in the previous studies. Various stakeholders conducted hygienic education in

schools and communities in order to form hygienic habit. Moreover, enlightenment

activity to the people concerned with diffusing sanitation facilities promotes development

in sanitation awareness of citizen and stakeholders. It also leads their participation to

projects to diffuse sanitation facilities and contributes to the solution of sanitation

problems.

Furthermore, education also assumes substantial role in nutritious improvement. As it

is referred in previous studies, lack of nutritious knowledge causes unbalanced nutrition

intake and consequently induces malnutrition. In order to resolve inadequate knowledge,

education is necessary. As we have seen the possibility of improving recognition

concerned with nutrition through case analysis of 3.2.3.3 in chapter 3, nutritious

improvement project and advancing visibility of nutrition is essential in the field of

218
nutrition.

Lastly, it is true that approaches from government, hospitals and NGOs are critical to

spot and treat tuberculosis, but citizens also need to understand what tuberculosis is and

put efforts in medical treatment. To do so, education and advocacy campaigns dealing

with health and diseases within the community are required. Through these activities,

knowledge of the citizens improves, as it was mentioned in the previous studies.

219
Conclusions

This research pays attention to relationships among stakeholders and education. Based on

the on-the-spot investigation, it examines and analyzes the four topics in the field of

health and sanitation: maternal and child health, sanitation, nutrition and infectious

diseases.

Ahmad(2003), a preceding study which focuses on child health, reproductive health

(RH), and countermeasures of infectious disease among various health and sanitation

problems in Bangladesh and analyzes those topics based on the opinions of stakeholders,

is referred to in this research to set the topics and focuses. We researched into maternal

and child health, sanitation, nutrition, and infectious diseases to improve the health and

sanitation problems.

As for the focal point 1, relationships among stakeholders, we referred to

Ferranti(2004), which is about the roles and partnerships of public and private sectors.

This preceding study describes that both public and private sectors have their roles in the

field of health and sanitation and cooperation between them is important. Concerning the

second focus, education, we referred to World Bank (2005), which insists that education

is important to improve health and sanitation issues, and explains the methods of health

220
and sanitation education in developing countries.

According to the preceding studies, this thesis takes up the four topics: maternal and

child health, sanitation, nutrition and infectious diseases. The problems related to these

topics are very serious in the Philippines. Mainly because of the influence of religion, the

national framework of RH is needed to cope with the RH problem. The low diffusion rate

of sanitary facilities is a severe sanitation problem in the Philippines. Moreover, hunger

and micronutrient deficiencies exist and tuberculosis is still common. Urgent action is

necessary to overcome these problems.

In this way, we paid attention to relationships among stakeholders and education in

maternal and child health, sanitation, nutrition, and infectious diseases, and carried out

analysis in each chapter. Through the on-the-spot investigation, we found out that peer

education improves the knowledge of RH and changes the action and behavior of people.

As for sanitation, we focused on diffusing sanitary facilities and making the practice of

using them through education. In the Philippines, the roles of the private sector to

improve and diffuse sanitary facilities are essential because the government cannot

diffuse sanitary facilities on its own. Furthermore, it is necessary to adopt the habit of

using them. Education is the key to improve the situation. Regarding nutrition, we

focused on public-private partnership for nutritional improvement of the Filipinos. There

221
are various forms of cooperation between public and private sectors and both sectors

direct their energies to improve nutrition. About infectious diseases, we discussed the

possibility of cooperation among stakeholders in measures for tuberculosis through the

two case studies. The various stakeholders are involved in the tuberculosis control

program, such as the governmental organizations, the organizations which observe the

patients to take the drug, those who connect each stakeholder, and local communities.

Each of them has its own role and the cooperation between them is important.

The focal point 1, relationships among stakeholders, is proved to be essential for

improving health and sanitation problems. Various stakeholders are working together and

utilizing each advantage to improve the situation. Peer education as a method to improve

the access to RH was examined in the maternal and child health issue. In the research, the

examples of peer education in schools and communities provided together by

international organizations, governments, and NGOs were observed. About sanitation, it

was difficult for the public sector to diffuse sanitary facilities on its own due to financial

restrictions, so the technologies of the private sectors largely NGOs, such as the low cost

technology, are needed. The importance of public-private partnership in nutritional

improvement was shared among governments, companies, and NGOs and various

nutritional improvement projects were carried out. The possibility of improving the state

222
of infectious diseases through the partnerships of the central and local governments,

private hospitals, and NGOs was also investigated. As mentioned in Ferranti (2004),

which is related to the first focus, relationships among governments, private companies,

NGOs, and communities is the key for development in developing countries. Of course,

there is a limitation. For example, lack of awareness by governments and differences in

objectives between organizations are the common problems among four topics. The

solutions for these problems could be further researched.

The focal point 2, education, could make people realize the problems of health and

sanitation. Peer education was effective not only for the adolescents but also for a wide

range of age groups involving twenties. The improvement of knowledge and the positive

changes of action and behavior were observed. Sanitation education changes the

behaviors of local people and makes the stakeholders aware of the need of sanitary

facilities, which leads to their diffusion. The problems of the misunderstanding of

fortified food and the lack of knowledge are serious, so nutrition education should be

offered. Since the lack of knowledge on tuberculosis prevents complete recoveries, the

improvement of knowledge on infectious diseases is the key. Therefore, as stated in

World Bank (2005), the importance of education and its positive effects were proved.

However, this research had limited time and case studies. The on-the-spot

223
investigation was only two weeks long and the target areas were limited in Metro Manila

and its suburbs. The number and range of visited international organizations,

governmental organizations, companies, NGOs, schools, and communities were also

limited. We also researched into just the small parts of each topic. Maternal and child

health has other problems such as the approaches to improve the health of pregnant

women and infants. As for sanitation, this research could not go further into the work of

companies to diffuse sanitary facilities. About nutrition, the work of NGOs and domestic

companies, and nutrition problems in communities were not clear.ly observed In the

research of infectious diseases, although most of the patients are in the lower class,

enough interviews with them were not conducted. In conclusion, this research does not

cover the whole health and sanitation problems in the Philippines. Therefore, it is difficult

to generalize the research result. The further research involving more study cases,

detailed examination, and comparative analysis is needed.

224
References

Ahmad, N. (2003). Voices of Stakeholders in the Health Sector Reform in

Bangladesh : Building Capacity for Reform. In A. S. Yazbeck, & D. H. Peters

(Eds.), Health Policy Research in South Asia (pp. 369-400). Washington,

D.C.: World Bank.

Ferranti, D. (2004). Public and Private Roles in Health: Theory and financing

patterns. In P. Musgrove (Ed.), Health Economics in Development (pp.

35-76). Washington, D.C.: World Bank.

The World Bank. (2005). Improving health, nutrition, and population outcomes in

Sub-Saharan Africa : the role of The World Bank. Washington, D.C.: World

Bank.

225
Appendixes

Schedule for Field Survey

in the Philippines in 2011

Visiting List
 Schedule for Field Survey in the Philippines in 2011
HAYASHI Seminar, Chuo University, Tokyo, Japan

DATE AM PM

Flight PRO431 (Terminal

2)Narita to Manila Oxford Suites
28-Aug
Durban Corner P. Burgos Streets,
(Sun)
Makati City 1200,Philippines
PHILIPPINE AIR LINE 9:30
- 13:10

Asian Development
Bank(ADB)
(8:30-13:30)
29-Aug <Ms. Harumi Kodama>
(Mon) Headquarters: 6 ADB
Avenue, Mandaluyong City
1550, Metro Manila,
Philippines

The Philippine Center for Water

and Sanitation (PCWS)
(14:00-17:00)
30-Aug
< Ms. Lyn N. Capistrano>
(Tue)
Penthouse 3, Minnesota
Mansion267 Ermin Garcia Street,
Cubao1102 Quezon City

Food and Nutrition

University of the Philippines
Research Institute (FNRI)
Diliman
(8:30-11:30)

31-Aug <Dr. MARIO V.

(14:30-18:30)
(Wed) CAPANZANA>

DOST Compound, Bicutan, U.P. Campus, C.P.Garcia Avenue,

Taguig City Quezon City

229
 DATE AM PM
United Nations Population
Fund
(10:00-)
31-Aug < Ms. Arlene Calaguian Alano>
(Wed) 30th Floor, Yuchengco Tower 1
RCBC Plaza, 6819 Ayala
Avenue
1229 Makati City
Canossa (local NGO)
(13:30- 17:00)
01-Sep
(Thu) <Sister Eline Pascaldo>

E.Jacinto St., Magsaysay Village,

Tondo, Manila

Health Human Resource

Development Bureau
Department of Health
(8:30-12:00)
<Ms. Jackeline Acosta、
02-Sep
(Fri) Ms. Dinna Sane >
San Lazaro Compound, Sta.
Cruz, Manila
UNICEF Philippines
<Mr. Timothy Grieve>
31st Floor, Yuchengco
Tower,Rizal Commercial B
anking Corporation (RCBC)
Plaza, Ayala Avenue corner Gil
Puyat Avenue, Makati City,
Philippines

Family Planning Organization

of the Philippines(FPOP) I-CAN Foundation
(9:00-12:00) Philippines, INC
National office
03-Sep
(Sat) <Mr. Gessen Rocas> ＜Ms. Yukiyo Nomura ＞
38 Don Doroteo Street, Don
50 Doña Hemady St. New
Enrique Heights, Brgy Holly
Manila, Quezon City 1112
Sprits, Quezon City, Metro
Philippines
Manila, the Philippines
230
 DATE AM PM

04-Sep
Internal Meeting
(Sun)

Olongapo City Hall / UNFPA

WASH meeting
Field Office

<Dr. Angel Umali > <Mr. Timothy Grieve>

05-Sep
(Mon) Usec Quijano's Office Department of
Education
Rizal Ave, Olongapo City 4F Bonifacio Bldg., DepED
Complex, Meralco Ave., Pasig City
Philippines

Japan Anti-Tuberculosis
Cent for Advanced Philippines
Association (JATA)
Studies(Caps)
06-Sep (9:30-11:10)
(Tue)
<Ms. Mami Kon> <Mr. Dan Lapid>
1853 Tayuman Road, Manila, 120-A K-8th Street, East Kamias,
Metro Manila, Philippines Quezon City, Philippines 1102

Family Planning Organization AJINOMOTO PHILIPPINES

of the Philippines(FPOP) CORPORATION
(9:00-15:00) (14:00-17:00)

<Mr. Gessen Rocas>National

<Ms. Ecille Go>
office

50 Doña Hemady St. New

331 Sen. Gil J. Puyat Avenue,
Manila, Quezon City 1112
Makati City
Philippines
07-Sep
(Wed) Bagong Ilog elementary School.

<Ms. Irene Mercado>

Bagong Ilog Elementary School,

Bagong Ilog, Sgt.L.Pasua, Pasig
City, Metro Manila, Philippines

231
 DATE AM PM

World Health Organization(WHO)

08-Sep <Dr. Kenji Amamoto>

(Thu)
Western Pacific Regional Office
PO Box 2932 (United Nations Avenue)
1000 Manila, Philippines

Flight PRO432 Manila to

09-Sep Narita
(Fri)
PHILIPPINE AIR LINE
14:30 – 19:55

232
 Visiting List

Maternal and child Team

Place: UNFPA National Office Date:2010/08/31

Interviewee(s):Ms. Arlene Calaguian Alano/Mr.Mario Balibago/
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of peer education project
Contents :
■ To get detailed information of peer education projct
■ To get information of present situation about RH of the Philippines

Place: Family Planning Organization of the Philippines National

Date:2010/09/03
office
Interviewee(s):Mr. Gessen Rocas/Mr.Brayant Gonzales
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of the peer education project
Contents:
■ Presentation of the YES4YES Project
■ Interview with Peer Educators and Youth Volunteers
■ Interview with Youth Clients

233
Place: The Olongapo City Date:2010/09/05
Interviewee(s):Dr. Angelito Umali
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose:
■ To know the experience of peer education in Olongapo City
■ Visit to UNFPA Field Office
■ Briefing at Dep. Ed Division Office
■ Field Visit: Kalalake National High School School-based Teen Wellness Center
and ALS Center
■ Field Visit: Barangay Banicain Community-based Teen Wellness Center
■ Field Visit: Social Ddevelopment Center(VAWC Referral Center)
■ Courtesy Call and Dialogue with mayor James Gordon Jr.
Contents:
■ Q&A session with school faculty and peer educators(students)
■ Meeting with Village Officials and Out-of-school youth
■ Interactive disucussions with the facility social workers and youth residents
■ Q&A session with Mayor on RH Programs in the city

Place: FriendlyCare Clinic Date:2010/09/06

Interviewee(s): Ms.Lourdes A.Manuel
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of the peer education
Contents:
■ Presentation
■ Interview
■ Inspection of a facility

234
Place: Family Planning Organizationof the Philippines Pampanga
Date:2010/09/07
Clinic
Interviewee(s):Mr.Brayant Gonzales
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of the peer education
Contents:
■ Interview Youth Clients, Peer Educators, Volunteers and Service Providers

Place: WHO Pacific Regional office of the Philippines Pampanga Date:2010/09/08

Clinic
Interviewee(s): Dr.A.Kaptiningsih
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose:
■ To get information of present situation of RH
Contents: Presentation and interview

235
 Water and Sanitation Team

Place: JFE Engineering Corporation Date:2011/05/24

Interviewee(s): Mr. Hideaki Noma
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To learn about water treatment system in the Philippines
Contents:
■ To get information of sewage system in the Philippines
■ To get some knowledge the difficulty of installing sewage system

Place: Asian Development Bank Date:2011/08/29

Interviewee(s): Mr. Alan Baird, Ms. Harumi Kodama
Group: All Team Members
Interviewers: All Team Members
Purpose: To get information of sanitation situation in the Philippines
Contents:
■ To learn about present situation of sanitation facilities in the Philippines
■ To get some knowledge of appropriate technology
■ To find out the situation of Pasig river

Place: Philippines Center for Water and Sanitation Date: 2011/08/30

Interviewee(s): Ms. Lyn N. Capistrano, Mr. Apol T. Jimenez, Mr. Percival M. Abad
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To get information of WASH
Contents:
■ To learn what the low cost technology is
■ To learn how important relationship between stakeholders is

236
Place: Department of Health Date: 2011/09/02
Interviewee(s): Mr. Rolando
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To learn the policy of the Philippine government.
Contents:
■ To learn about the national policy of water and sanitation
■ To get information of national budget of water and sanitation

Place: UNICEF Philippines Date: 2011/09/02

Interviewee(s): Mr. Timothy Grieve
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To get information of WASH in schools
Contents:
■ To learn the present situation about water and sanitation in the Philippines
■ To find out that advocacy campaign is effective to spread water supply and sanitation
facilities

Place: WASH meeting Date: 2011/09/05

Interviewee(s): Mr. Timothy Grieve, Mr. Melf Kuehl
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To get information of WASH in schools.
Contents:
■ To learn what kind of toilet is the best for schools
■ To learn how to make such facilities
■ To get the various specific examples of criteria for constructing sanitation facilities

237
Place: Center for Advanced Philippines Studies Date: 2011/09/06
Interviewee(s): Mr. Dan Lapid, Ms. Lilia GC Casanova
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To get information of Ecological sanitation toilets.
Contents:
■ To get the various specific examples of the way of making fertilizer using ECOSAN
■ To learn about advocacy campaign
■ To learn how important ECOSAN is

238
Place: Bagong Ilog elementary School Date: 2011/09/07
Interviewee(s): Ms. Irene Mercado
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To learn about sanitation education and how to make facilities.
Contents:
■ To learn how important to use proper technology is
■ To get information of sanitation education
■ To see its facilities
■ To interview the pupils and the teachers

Place: World Health Organization Date: 2011/09/08

Interviewee(s): Dr. Kenji Amamoto, Dr. Nobuyuki Nishikiori, Ms. Mien LingChong,
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To learn about the present situation

Contents:
■ To learn what behavior change is
■ To get information of sanitation situation in the Philippines

Place: Oji Nepia Co. LTD Date:2011/10/24

Interviewee(s): Ms. Eiko Ohori, Mr. Takashi Saito
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To get information about 1000 toilets Project
Contents:
■ To learn sanitation situation in East Timor
■ To get information of awareness program
■ To learn how to support for East Timor

239
 Food and Nutrition Team

Place: Asian Development Bank Date:2011/08/29

Interviewee(s): Mr. Gerard Servais
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of Public Private Partnership strategies to improve nutrition
problems
Contents:
■ To learn about how to improve nutrition problems
■ To get some knowledge of Public Private Partnership

Place: Food and Nutrition Research Institute Date:2011/08/31

Interviewee(s): Ms. Czarina Martinez
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of nutrition condition and practicing to improve nutrition
problems in the Philippines
Contents:
■ To learn about present situation of nutrition condition in the Philippines
■ To get information of PPP practing to improve nutrition problems

240
Place: Department of Health Date:2011/09/02
Interviewee(s): Ms. Maria Lourdes A. Vega
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of nutrition condition and practicing to improve nutrition
problems in the Philippines
Contents:
■ To learn about present situation of nutrition condition in the Philippines
■ To get information of PPP practicing to improve nutrition problems

Place: Ajinomoto Philippines Corporation Date:2011/09/07

Interviewee(s): Ms. Helen Q. Lim, Mr. Andrew D. Ong, Mr. Kazuki Tsumagari
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of practicing to improve nutrition problems in the
Philippines
Contents:
■ To get detailed information of practicing to improve nutrition problems
■ To get detailed information of the nutrition improvement project cooperated with
FNRI

241
 Infection disease Team

Place: Japan Anti-Tuberculosis Association(JATA) Date: 2011/06/03

Interviewee(s): Mr. Akihiro Ohkado, Ms. Mami Kon, Ms.Yuriko Oda
Group: Infection Disease Team
Interviewers: Infection Disease
Purpose: To get information about TB and the TB project.
Contents:
■ To get information about TB.
■ To get information about TB control program.
■ To get answer about our questioner.

Place: Canossa Health and Social Center Foundation,Inc. Date: 2011/09/01

Interviewee(s): Sister Eline Pascaldo

Group: Infection Disease Team

Interviewers: All team members

Purpose: To get information about situation of TB and the project.
Contents:
■ To get information about a TB control program.
■ To visit Smokey Mountain.
■ To get answer about the relationships with other agencies.

Place: RIT/JATA Philippines INC. Date: 09/06/2011

Interviewee(s): Ms. Mami Kon
Group: Infection disease Team
Interviewers: All team members
Purpose: To get information about situation of TB and the project.
Contents:
■ To get information about a TB control program.
■ To get information about a present situation of TB in the Philippines.
■ To get answer about the relationships with other agencies.

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Place: I-CAN foundation Philippines, INC. Date: 09/03/2011

Interviewee(s): Ms. Yukiyo Nomura/Staffs/Inhabitant

Group: Infection Disease Team

Interviewers: All team members
Purpose: To get information about situation of TB and the project.
Contents:
■ To get information about a TB control program.
■ To get answer about the relationships with other agencies.
■ To get interview with staffs and inhabitants.

Place: WHO-WPRO Date: 09/08/2011

Interviewee(s): Dr. Nobuyuki Nishikiori
Group: Infection disease
Interviewers: All team members
Purpose: To get information about situation of TB and the project.
Contents:
■ To get information about a TB control program.
■ To get answer about the relationships with other agencies.
■ To get information about a present situation of TB in the world.

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 Postscript

Just a year ago, on February, 2011, our study has started. The time has passed so

quickly but it was the best and the deepest year in our lives. I am sure that, for 21

members here, all of what we have experienced this year is worth it.

The major characteristic of our study is that it focuses on one big theme “health

and sanitation”. Seniors of Hayashi seminar had set a theme to suit their interests

like education, environment, business and so on in their studies. But this year,

every student studied with “health and sanitation” at the basis, in order to connect

four teams deeply and sophisticate the study as a whole. However, since the way of

the study has changed, we constantly stumbled from the beginning. Thinking back

now, we got here taking a lot of time and such a long way round. But it is definite

that the time we have spent to think brought us many great things.

In addition, since there are unique 21 members in this seminar, we often got

into arguments. Owe we could get to finish, I think that there was passion of going

for the best and sence of responsibility fulfilling own role to all of us.

Finally, we would like to express our deepest appreciation to all of the people

who supported our study, especially, to Professer Mr. Hayashi who warmly

watched over us throughout the year. Prizing our autonomy, he allowed us to

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decide everything. It must have been easier for him to give us directions, but he

didn’t daresay. He always watched over us patiently beside us. We feel great

pleasure that we could study with him. Thank you very much.

And I would like to tell 21 members who have been studying together, “You

worked so hard. Well done.”

Miha Matsubayashi

Representative, Hayashi seminar in 2011

Chuo University, Tokyo, Japan

28 January 2012

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