Cloa 2

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/364238086
Rural Physicians' Experiences with Diagnosis, Treatment, and

Management of Pediatric Tuberculosis Before and After Disasters
in Bohol
Article · January 2022
CITATIONS READS
0 1,186
8 authors, including:
Nina Castillo-Carandang Lauren Leining

University of the Philippines Manila Baylor College of Medicine
48 PUBLICATIONS 242 CITATIONS 10 PUBLICATIONS 69 CITATIONS
SEE PROFILE SEE PROFILE
Anna Mandalakas Kristy O Murray

Baylor College of Medicine Baylor College of Medicine
192 PUBLICATIONS 3,982 CITATIONS 225 PUBLICATIONS 6,558 CITATIONS
SEE PROFILE SEE PROFILE
All content following this page was uploaded by Lauren Leining on 07 October 2022.
The user has requested enhancement of the downloaded file.

Volume 46 (2022) l Number 2
Boosting the Productivity of Agrarian Reform
Beneficiaries through Parcelization of Collective
Certificate of Land Ownership Awards
Ivory Myka R. Galang
Analyzing the Diversity and Inclusivity of Philippine

Exports to the European Union Under the GSP+
Brynn Jonsson R. Julia
Rural Physicians’ Experiences with Diagnosis,

Treatment, and Management of Pediatric Tuberculosis
Before and After Disasters in Bohol
Nina T. Castillo-Carandang, Lauren M. Leining,
Anna Maria Mandalakas, Kristy O. Murray,
Jo Anne Claire M. Liao, Maureen Mae Cabatos-Riña,
and Salvacion R. Gatchalian
Learning from Stories Behind Unexpected Results:

A Qualitative Follow-up Study on the Third Impact
Evaluation of 4Ps
Nina Victoria V. Araos, Kris Ann M. Melad,
and Aniceto C. Orbeta Jr.
PHILIPPINE JOURNAL OF DEVELOPMENT
Editorial Board
Paul Hutchcroft Dante B. Canlas (chair) Shujiro Urata
Australian National University University of the Philippines School of Economics Waseda University
Ian Coxhead Aniceto C. Orbeta Jr. (co-chair) Yasuyuki Sawada
Institute of Developing Economies Philippine Institute for Development Studies University of Tokyo
Roberto S. Mariano Gilberto M. Llanto Eli M. Remolona
University of Pennsylvania Philippine Institute for Development Studies Asia School of Business
Ann E. Harrison Emma E. Porio Naohiro Ogawa
University of California, Berkeley Ateneo de Manila University Asian Development Bank Institute
Elizabeth M. King Jesus C. Dumagan Ramon Moreno
Brookings Institution De La Salle University Bank for International Settlements
Associate Editors
Agham C. Cuevas Geoffrey M. Ducanes Gay D. Defiesta
University of the Philippines Los Baños Ateneo de Manila University University of the Philippines Visayas
Sarah Lynne S. Daway-Ducanes Majah-Leah V. Ravago Pedro A. Alviola IV
University of the Philippines Ateneo de Manila University University of the Philippines Mindanao
School of Economics
Krista Danielle S. Yu
De La Salle University
Editorial and Production Team

Managing Editor
Sheila V. Siar
Philippine Institute for Development Studies
Production Assistant Editorial Assistant
Gizelle G. Manuel Elshamae G. Robles
Philippine Institute for Development Studies Philippine Institute for Development Studies
The Philippine Journal of Development (PJD) is a professional journal published by the Philippine
Institute for Development Studies (PIDS). It accepts papers that examine key issues in development
and have strong relevance to policy development. As a multidisciplinary social science journal,
it accepts papers in the fields of economics, political science, public administration, sociology, and
other related disciplines.
The views expressed in the PJD are exclusively those of the authors and do not necessarily reflect
the views and policies of PIDS.
Any reader who is interested in submitting a manuscript or a book review may refer to
the Guidelines in the Preparation of Articles available on the PJD section of the PIDS website
(www.pids.gov.ph). Queries or comments may be sent to PJD@pids.gov.ph. Each manuscript is
reviewed by two referees under a double-blind peer review process.
This journal is under the Creative Commons Attribution Noncommercial License. The use for
commercial purposes of any article published in the journal is not allowed. Anyone can use, reuse,
and distribute an article as long as proper attribution is made.
Annual subscription is PHP 900 or USD 60, which includes mailing cost. Electronic copies are
available, free of charge, on the PIDS website.
Printed in the Philippines, 2022
ISSN 2508-0954
ISSN 2508-0849 (electronic)
RP 09-22-600
Philippine Journal of Development
Volume 46 (2022) | Number 2
Contents
Boosting the Productivity of Agrarian Reform Beneficiaries through

Parcelization of Collective Certificate of Land Ownership Awards..................1
Ivory Myka R. Galang
Analyzing the Diversity and Inclusivity of Philippine

Exports to the European Union Under the GSP+................23
Brynn Jonsson R. Julia
Rural Physicians’ Experiences with Diagnosis, Treatment, and Management

of Pediatric Tuberculosis Before and After Disasters in Bohol................49
Nina T. Castillo-Carandang, Lauren M. Leining, Anna Maria Mandalakas,
Kristy O. Murray, Jo Anne Claire M. Liao, Maureen Mae Cabatos-Riña,
and Salvacion R. Gatchalian
Learning from Stories Behind Unexpected Results: A Qualitative

Follow-up Study on the Third Impact Evaluation of 4Ps................71
Nina Victoria V. Araos, Kris Ann M. Melad, and Aniceto C. Orbeta Jr.
Volume 46 (2022) Number 2
Boosting the Productivity of Agrarian

Reform Beneficiaries through
Parcelization of Collective Certificate
of Land Ownership Awards
Ivory Myka R. Galang1
ABSTRACT
Farmers awarded with lands under the collective Certificate of Land Ownership
Awards (CCLOAs) encounter various problems (e.g., boundary issues,
disputes with other members) that discourage them from making long-term
investment decisions on their lands and often result in lower productivity.
To address these issues, the Department of Agrarian Reform (DAR) has
committed to implement the parcelization program, which aims to subdivide
CCLOAs whose farmers are not engaged in collective farming. This paper
identifies the benefits and problems in the subdivision of collective land titles in
the Philippines. Based on existing studies, individual land ownership positively
impacts farmers’ decisionmaking and farming outcomes. The analytical exercise
using Project Convergence on Value Chain Enhancement for Rural Growth and
Empowerment’s (ConVERGE) baseline survey data provides additional evidence
favoring to accelerate the subdivision of CCLOAs. Other rural development
strategies, such as farm consolidation, can be undertaken while pursuing
parcelization. In addition, DAR must adopt a modern cadaster and record
system to improve the agrarian justice delivery system in the country and
ensure a faster and more effective implementation of the parcelization program.
1 The author is a supervising research specialist at PIDS. This article is a condensed and revised version of the
PIDS discussion paper titled “Boosting agricultural productivity through parcelization of collective Certificate of Land
Ownership Awards” written by the same author. Email for correspondence: IGalang@pids.gov.ph.
Boosting the Productivity of Agrarian Reform Beneficiaries through Parcelization of CCLOAs
INTRODUCTION
In April 2019, President Rodrigo Duterte ordered to fast-track the implementation of the
Department of Agrarian Reform (DAR)’s parcelization2 program. It aims to subdivide collective
land titles into individual land titles primarily to empower farmers in their decisionmaking.
Out of the 2.25 million hectares (ha) of land under the collective Certificate of Land Ownership
Awards (CCLOAs), 76 percent were awarded to individual agrarian reform beneficiaries (ARBs)
under the co-ownership basis, including those who were not engaged in collective farming.
These farmers often face various problems in their lands, such as boundary issues. With the lack
of individual ownership, farmers under a CCLOA arrangement have little to no incentive for
long-term investments in their lands, which affects their income and livelihood opportunities.
This paper discusses the benefits and problems in the subdivision of collective land titles.
It provides insights on the impact of land tenure on agricultural performance and conducts an
empirical exercise using Project Convergence on Value Chain Enhancement for Rural Growth and
Empowerment’s (ConVERGE) baseline survey of agrarian reform beneficiary organization (ARBO)
members to explore the possible relationship between land tenure (i.e., collective or individual
CLOA) and farming outcomes (e.g., yield and farm income).
COMPREHENSIVE AGRARIAN REFORM PROGRAM
When the 1987 Constitution was ratified, it included the provision: “The state shall promote
comprehensive rural development and agrarian reform” (Article 2, Section 21). In 1988,
the Aquino government enacted the Comprehensive Agrarian Reform Law, promoting not
only social justice, but also rural development and industrialization (Republic Act [RA] 6657).
To be implemented in 10 years, the law intends to “encourage the formation and maintenance of
economic-size family farms to be constituted by individual beneficiaries and small landowners”
(RA 6657, Section 2). Each agrarian reform beneficiary (ARB) was allowed to have a maximum of
3 ha of land (RA 6657, Section 25).3 Emancipation patents (EPs), transfer certificate of title (TCT),
and CLOAs were used to certify the ownership of distributed lands.4
When the Comprehensive Agrarian Reform Program (CARP) ended in 1998, then president
Fidel V. Ramos signed RA 8532 into law. It extended the CARP’s implementation for another
10 years and provided additional funds for the program (RA 8532). However, shortcomings
were identified in the program. With loopholes in the original law and resistance from big
landlords, about 1.2 million ha of land were needed to be distributed by the end of 2008.
Thus, another extension called the Comprehensive Agrarian Reform Program Extension with
Reforms (CARPER) was enacted (RA 9700).
2 DAR defines parcelization as the “process of subdividing and determining the exact meters and bounds of the areas,
allocation of lots to ARBs in a CCLOA, determination of common use areas, portions with common service facilities, and
establishment of areas capable of being alienated and disposed of by the government” (Administrative Order [AO] 2,
series of 2019).
3 The law requires new owners to settle their annual amortization. They are restricted to sell or transfer their lands for
10 years, except for hereditary succession (RA 6657, Section 27).
4 EPs indicate ownership rights over a parcel of land distributed through Presidential Decree 27 (series of 1972).
Registered at the Land Registration Office, EPs are used to obtain a TCT, which certifies that land ownership is transferred
from the state to a private owner. Those distributed through RA 6657 are awarded through CLOAs, which serve as the
final proof of ownership. These documents are maintained by the Register of Deeds (Vargas 2003). A Supreme Court
ruling, however, states that CLOAs do not have the same status as TCTs (GR No. 176549) (de los Reyes 2016).
2
Galang
In 2019, the Philippine Statistics Authority (PSA) released the publication Redistribution
of Land Report, which contains data on the country’s accomplishments in land distribution
and registration (Table 1). DAR had distributed and registered a total of 4.80 million ha of
land by 2018. The top three regions with the largest land distribution areas were Regions 12
(South Cotabato, Cotabato, Sultan Kudarat, Saranggani, and General Santos [SOCCSKSARGEN])
(693,163 ha), 8 (Eastern Visayas) (436,466 ha), and 3 (Central Luzon) (434,442 ha). The cumulative
number of CLOA beneficiaries from 2000 to 2015 was about 2 million and 67 percent of them
were males (PSA 2019).
Table 1. Scope of land registration and accomplishment of land distribution and registration
by region, Philippines, 2014–2018
Scope Accomplishment (1971–2018)
Region
(gross area, CY 2018, ha) ha percentage
Philippines 5,418,735 4,798,556 88.55
CAR 105,312 102,693 97.51
Ilocos Region 144,893 143,769 99.22
Cagayan Valley 417,812 386,084 88.10
Central Luzon 453,303 434,442 95.84
CALABARZON 218,769 191,474 87.52
MIMAROPA 191,360 181,043 94.61
Bicol Region 408,631 372,405 80.12
Western Visayas 561,998 418,490 74.46
Central Visayas 202,791 184,935 91.19
Eastern Visayas 494,121 436,466 88.33
Zamboanga Peninsula 237,182 229,612 96.81
Northern Mindanao 363,779 342,686 94.20
Davao Region 260,946 249,490 95.61
SOCCSKSARGEN 730,951 693,163 94.83
Caraga 294,162 273,004 92.81
ARMM 332,725 221,728 66.64
CY = calendar year; ha = hectare; CAR = Cordillera Administrative Region; CALABARZON = Cavite,
Laguna, Batangas, Rizal, and Quezon; MIMAROPA = Mindoro, Marinduque, Romblon, and Palawan;
SOCCSKSARGEN = South Cotabato, Cotabato, Sultan Kudarat, Saranggani, and General Santos;
ARMM = Autonomous Region in Muslim Mindanao
Source: PSA (2019)
COLLECTIVE CERTIFICATE OF LAND OWNERSHIP AWARDS
Distributed CLOAs are either individual or collective. In case it is “not economically feasible
and sound to divide the land,” qualified beneficiaries can opt to collectively own land through
a cooperative, association, or any organization and should be issued a CCLOA. The award ceiling
of 3 ha per ARB is maintained (RA 6657, Sections 25 and 29).
3
Based on DAR AO 3, series of 1993, the three types of CCLOAs are co-ownership basis,
farmers’ cooperatives, and other forms of farmers’ collective organization. Co-ownership refers to
the case wherein the CLOA is under the name of all beneficiaries. Idle or untenanted lands are
usually distributed through co-ownership CCLOA, because the potential beneficiaries are not
organized and not tilling specific land parcels yet. Meanwhile, lands currently tenanted or worked
on by farmworkers are likely to be distributed through individual CLOAs (World Bank 2009).
The cooperative or farmers’ organization CLOA is issued under the organization’s name with
the annotation of all the beneficiaries’ names. Commercial and multinational agribusiness farms
are usually distributed under this type of CCLOA (World Bank 2009).
The issuance of collective land titles was a pragmatic approach for DAR because it “[did] away
with subdivision surveys and individual titling, which would take a much longer time at very high
costs” (Eularia 2015, p. 3). DAR’s estimated administrative cost for transferring land per ha was
PHP 36,000 from 2003 to 2007.5 Zooming in on the cost of transferring private land, which
was more expensive, the costs range from PHP 86,076 to PHP 101,857 (World Bank 2009).
The CCLOAs were intended to be subdivided shortly thereafter, but the DAR field offices were
not inclined to achieve this goal (de los Reyes 2016). They were incentivized to distribute new
lands rather than subdivide already distributed CCLOAs, because their performance was assessed
based on the number of lands covered and the distributed CLOAs (Eularia 2015).
Related statistics on CCLOA

After cleansing the database in April 2016, it was found that CCLOAs constituted 46 percent of
the 4.72-million ha of land distributed in the past decades. Regions 12 and 8 posted the highest
number of areas with CCLOAs, while Negros Occidental, North Cotabato, and Bukidnon had the
biggest numbers at the provincial level (de los Reyes 2016). The Philippine Statistical Research
and Training Institute’s (PSRTI) survey of ARBs in 20166 show that 53 percent of beneficiaries
have been issued with CCLOAs. There were about 2.45 million unique ARB names in the database
(PSRTI 2016). Based on the regional distribution in 2015, most of the CLOA beneficiaries
were from Regions 6 (Bicol) (13%) and Region 12 (13%) (Table 2). Meanwhile, individual CLOA
beneficiaries were concentrated in Luzon, particularly in Region 3 (Central Luzon) (20%),
Region 4-A (Cavite, Laguna, Batangas, Rizal, and Quezon [CALABARZON]) (13%), and Region 2
(Cagayan Valley) (12%) (PSRTI 2016).
Table 2. Number of ARBs by region and type of CLOA

Region Individual CLOA Collective CLOA Total
1 72,192 50,529 122,721
2 135,867 54,634 190,501
3 224,018 41,664 265,682
4 142,724 95,558 238,282
5 87,928 96,886 184,814
6 89,383 171,440 260,823
7 44,426 90,535 134,961
5 This estimate includes all lands under various modes of acquisition.

6 The survey was commissioned by DAR in 2015. Data collection period was from January to May 2016. The reference
period was either the last cropping or the last 12 months depending on the crop planted.
4
Galang
Table 2. (continuation)
Region Individual CLOA Collective CLOA Total
8 57,861 131,149 189,010
9 23,052 86,399 109,451
10 63,730 98,751 162,481
11 39,915 115,857 155,772
12 89,742 167,164 256,906
Caraga 46,275 77,164 123,439
CAR 24,059 35,311 59,370
Grand total 1,141,172 1,313,041 2,454,213
CLOA = Certificate of Land Ownership Award; ARBs = agrarian reform beneficiaries; CAR = Cordillera
Administrative Region
Source: PSRTI (2016)
The average farm income of collective ARBs amounting to PHP 142,869 was higher than
the income of individual ARBs at PHP 101,475 (PSRTI 2016). The same pattern was observed
in the average total household annual income. The total annual income of collective ARBs was
PHP 195,150 on average, which was higher than the income of individual ARBs at PHP 155,113.
The contributions of farm income to total income were 65 percent among collective ARBs and
67 percent among individual ARBs. Collective ARBs derived 55 percent of the total income from
crop production, while individual ARBs obtained 59 percent. Collective ARBs pooled the size of
their land, which led to more efficient production and other income opportunities (PSRTI 2016).
Box 1. Is collective farming a viable strategy?

Farmers in a collective farming system pool their resources together, such as land, labor, other inputs, and
harvests. The following are some of the benefits and problems associated with collective farming:
Benefits
• Economies of scale. Co-owners can break seasonal labor shortage under a collective system and invest
in infrastructures (Boserup 1965; Dong 1996 as cited in Deininger 2003; Mearns 1996). They can also
improve efficiency and internalize harm. If individual titling is enforced, it can be extremely costly to
establish and maintain infrastructures by themselves. In China, former Soviet Union, and Viet Nam,
landlord estates converted into family farms were reconsolidated into collectives (Deininger 2003).
• Collective farming serves as local insurance when an area is high-risk and lacks a well-developed
insurance market. According to Ellickson (1993), local communities usually have better access to
private information than formal institutions. Thus, they can provide some form of insurance against
idiosyncratic and covariate shocks (as cited in Deininger 2003, p. 29).
• Bargaining power. Farmers engaged in collective farming do not only pool their resources
but also their collective voice to have a stronger bargaining power. Organizing smallholder
farmers and/or farmworkers enables them to gain some leverage and pursue common interests
(Leder et al. 2019).
5
Box 1. (continuation)
Problems
• A self-governing group is hard to create or cultivate. This entails having a management person or
a group to solve conflicts, deal with internal and external problems, and handle financial resources
efficiently and with integrity (Deininger 2003). These characteristics cannot be acquired overnight
or by attending seminars, but rather by doing the tasks, making mistakes, and learning from
these mistakes. Apart from requiring competence from the management side, educating members
on their responsibilities and rights also matters a lot in building group cohesiveness. Without
cohesion, members may lose confidence in the management’s decisions, which, in turn, can lead to
the group’s breakup.
• Authority of new managers over collective members is weak. The human behavior dimension
is not considered in collectivization. The change in agrarian relations from landlord-worker to
farm managers-collective members has greatly affected the way workers behave. According to
Kay (1998), with less authority and experience in actual farm management, new managers are
unable to incentivize workers to do productive farm-related work while attracting free riders
(Casidsid-Abelinde 2017, p. 18).
• Inexperienced new managers are unable to make good business decisions. The redistribution of
profits is done more often than investing them (Kay 1998 as cited in Casidsid-Abelinde 2017, p. 18).
• Collective farming has become less attractive with increasing economic development.
Deininger (2003, p. 31) described the examples of desirable situations under a well-developed
economy, such as when (1) mechanisms to manage risk are available; (2) markets for output, capital,
and insurance are well-developed; (3) there is technical progress that allows for greater diversification
and yields improvement; (4) the institutional environment and access to economic activities outside of
agriculture are improved; (5) benefits of exchanging property rights among cultivators are increased
with higher land values; and (6) off-farm migration leads to the emergence of long-term rights and
land rental markets, which give lands to farmers with the highest ability.
Source: Author’s compilation
Issues that farmers encounter under CCLOAs

Farmers awarded with CCLOA titles encounter problems that result in the actual splitting of
groups into subgroups or co-owners opting for individual ownership of land. The following are
some of the issues in the CCLOA scheme:
• Identification of beneficiaries (inclusion or exclusion of ARBs). Many of the original
ARBs have died since the issuance of CCLOAs. Disputes in the inclusion and
exclusion of ARBs have worsened in the absence of a proper succession policy
(Ballesteros 2003; Casidsid-Abelinde 2017; DAR 2019a). Some ARBs had stopped tilling
lands and transferred their rights. Other tillers were not in the original list of ARBs
(de los Reyes 2016).
• Membership in the organization takes precedence. According to Batt et al. (2016), there
are cases when farmers decide to leave the organization and must essentially surrender
their rights to the awarded land, especially if the CCLOA lacks the annotation of the
individual beneficiaries’ names (as cited in Casidsid-Abelinde 2017, p. 20).
• Land management disputes. Most CCLOA holders are not from organized farmer
associations and are inexperienced in collective land management.
• Boundary conflict. There are no subdivision surveys and farmers do not know which
parcels of land belong to them (Ballesteros 2003; Casidsid-Abelinde 2017).
6
Galang
• Land taxation. Payment rates of real property tax among CCLOA holders are low.
Eleazar et al. (2016) found that aside from the lack of proper land valuation, some ARBs
are not paying their taxes because they are not installed in the areas and not tilling the
land (as cited in Casidsid-Abelinde 2017, p. 20).
• Titling problem due to unpaid amortization. ARBs are supposed to pay land amortizations
to the Land Bank of the Philippines (LBP) to facilitate the processing of their formal
titles. However, with the said issues, they do not feel incentivized to pay amortizations,
which can result in further land insecurity (Ballesteros 2003; Casidsid-Abelinde 2017).
• Agribusiness venture arrangements (AVAs) with organizations. Batt et al. (2016)
found that some of the ARBs engaged in AVAs are forced to enter into agreements
with large corporations even if they are not fully aware of the stipulations in the
contracts. There is also a lack of technical and legal assistance for ARBs (as cited in
Casidsid-Abelinde 2017, p. 20).
Parcelization of CCLOAs
An amendment in the CARPER aims for the immediate parcelization of CCLOA issued lands
that are not collectively farmed or operated in an integrated manner (DAR 2019a). In 2016, DAR
issued AO 03, or the “Guidelines and procedures to stabilize ownership and tenureship of agrarian
reform beneficiaries with collective Certificates of Land Ownership Award”. It seeks to perform
a stabilization process by ensuring clear and well-defined ownership of parcels of lands under
CCLOAs. AO 03 sets the rules in the settlement of disputes and transfer of rights pertaining
to the stabilization of CCLOA ownership.
Casidsid-Abelinde (2017) identified various issues in the subdivision of CCLOAs, such as
the need for improved coordination among government institutions involved in the process.
DAR must coordinate with other institutions (Olano 1996, as cited in Hirtz 1998, p. 251), including
the Geodetic Engineers of the Philippines for the survey of lands; the Land Management Services
of the Department of Environment and Natural Resources for survey approval; LBP for land
valuation, claims processing, and payment; Register of Deeds for registration; and the Assessor’s
Office for preliminary documentation. The agency’s low priority for the subdivision of CCLOAs
at the time was a concern, which worsened with the lack of sufficient funding for land survey
activities (Casidsid-Abelinde 2017). According to John Castriciones, former Agrarian Reform
secretary, DAR issued 2.251 million ha of agricultural lands under CCLOAs. Out of this number,
76 percent were awarded to ARBs who were not engaged in collective farming (Balinbin 2019).
DAR also issued AO 02, series of 2019, or the “Guidelines and procedures on the parcelization
of landholdings with collective Certificates of Land Ownership Award”. Based on DAR (2019a),
collective ownership of land remains if any of the following circumstances applies:
1. The farm management system is not appropriate for individual farming or farm parcels;
2. When farm workers do specialized labor activities (e.g., spraying, packing) not by
specific parcel;
3. Farming is done collectively and in a large contiguous area; and
4. Multiple crops are planted and there are noncrop production facilities or areas that are
impossible to subdivide among farmers (e.g., storage areas, packing plants).
7
Figure 1 shows the seven main steps of parcelization, starting from the inventory and
verification of CCLOAs and ending with the updating or generation of land distribution
information schedule (LDIS). Figure 2 illustrates the detailed process in steps 4 to 5. The process
may take longer if there is no annotation of the ARBs’ names in the CCLOA. It can take much
longer if there are protests for the inclusion or exclusion of ARBs. Figure 3 contains the process in
steps 5 to 6. The municipal agrarian reform program officer discusses the parcelization process with
the ARBs in a meeting. The process can be executed if there is already a lot allocation agreement.
It is followed by the parcelization survey and execution of the deed of parcelization.
Figure 1. General process flow of parcelization
Step 1: Inventory Step 2: Prioritization Step 3: Field

and verification of of CCLOA for validation of the
CCLOAs parcelization status of CCLOAs
Step 4: Firming up
Step 6: Generation
Step 5: Parcelization of the list of
and registration of
process collective owners of
individual CLOAs
awarded lands
Step 7: Updating or
generation of LDIS
CCLOAs = collective Certificate of Land Ownership Awards; LDIS = land distribution information schedule
Formatted: Patt
Source: DAR (2019a)
Figure 2. Step 4: Firming up of the list of collective owners of awarded lands
Final and
With protest for executory
If the duly the inclusion or judgment of the Proceed to step 5
approved exclusion of ARBs regional director
masterlist of or secretary
ARBs or qualified
ARBs is available
Step Proceed to
Without protest
4 step 5 Final and
With protest for executory Proceed
the inclusion or judgment of the to
Preparation of exclusion of ARBs regional director step 5
If there is no
the masterlist Approval and or secretary
approved
of ARBOs or posting of the list
masterlist
co-owners
Proceed to
Without protest
step 5
ARBs = agrarian reform beneficiaries; ARBOs = agrarian reform beneficiary organizations

Source: DAR (2019a)
8
Galang
Figure 3. Step 5: Process of parcelization
Conduct of
Approval of Deed of Proceed
parcelization
survey plan parcelization to Step 6
Sending of survey
invitations to Execution of
Actual
Step 5 attend a lot allocation
meeting/s
discussion with agreement
registered ARBs Ground
For CCLOAs
validation of Deed of Proceed
with approved
approved parcelization to Step 6
survey plan
survey plan
ARBs = agrarian reform beneficiaries; CCLOAs = collective Certificate of Land Ownership Awards
Source: DAR (2019a)
In 2020, DAR announced the implementation of the Support for Parcelization of Lands for
Individual Titling (SPLIT) project. With funding from the World Bank, the program aims to
improve land tenure security and stabilize the property rights of ARBs (DAR 2020).
CONCEPTUAL FRAMEWORK
Many studies have concluded that more secure tenure can lead to greater incentives for farmers
to undertake long-term investments in their farm plots. The four possible pathways toward
agricultural productivity are through (1) more secured tenure (formal or informal), (2) formal
tenure (land titling or registration), (3) land titling that serves as a prerequisite for better
credit access, and (4) transferrable property rights. All pathways can lead to higher investments
(i.e., current inputs and modern technologies) and eventually increase productivity.
More secure tenure under a formal or informal property rights regime can lead to increased
investment and productivity.
Pathway 1: Tenure security  higher investment  increased productivity
The presence of property rights can ease farmers’ anxiety in sudden expropriation or eviction
from their lands (Tenaw et al. 2009). In turn, it increases their confidence in making long-term
investment decisions and enables them to adopt the best cropping systems.
Under formal and informal regimes, owners with greater tenure security increase their
investments (Deininger 2003). Jacoby et al. (2002) observed that farmers in rural China applied
greater amounts of manure and labor on privately owned plots than on those with different tenure
regimes while controlling for the type of crop. This led to a significantly higher yield (as cited in
Deininger 2003, p. 45).
Another study in China by Yao (1996) attributed tenure security to a higher level of green
manure application (as cited in Deininger 2003, p. 45). In Niger, Gavian and Fafchamps (1996)
wrote that the amount of manure applied by farmers was significantly lower on rented plots than
on owned plots, but there was no difference “between parcels under private ownership and those
held under traditional usufruct” that had a shorter time frame because they could reap the benefits
in the near term (as cited in Deininger 2003, p. 46). In India, Pender and Kerr (1998) observed the
same pattern of lower investments on leased plots than on those with secure land rights (as cited
in Deininger 2003, p. 46).
9
Formal property rights regime, such as land registration and titling, are important to increase
investment and productivity.
Pathway 2: Land registration/titling  higher investment  increased productivity
Feder et al. (1988) found that land ownership titles in Thailand prompted more investments in
farming capital and led to higher productivity per unit. The output was 14 to 25 percent higher
on lands with titles than those without titles while controlling for the quality of lands (as cited in
Deininger 2003, p. 45). In Viet Nam, Do and Iyer (2002) observed an increase in the levels of
perennial crop cultivation and irrigation among registered lands (as cited in Deininger 2003, p. 45).
Pathway 3: Land registration/titling  increased access to credit  greater agricultural investment

and adoption of modern technology  increased productivity
Having a title for a parcel of land makes it easier for farmers to access credit because they can use
land titles as collateral (Tenaw et al. 2009). Greater access to credit has allowed farmers to invest
in durables and apply inputs more intensively (Platteau 1993). It resulted in higher agricultural
productivity in Sub-Saharan Africa (as cited in Tenaw et al. 2009, p. 8). However, the results were
inconclusive and should be taken with caution.7
In the case of Thailand, Feder et al. (1988) observed a surge in the demand for land
improvements and supply of credit when property rights are secured and that land can be used as
collateral (as cited in Tenaw et al. 2009, p. 9). In the Philippines, ownership of titled land positively
affects access to formal lending. The probability of accessing credit increases by 1.4 percent for
every additional ha of titled land. Thus, a 3-ha farm can increase the beneficiary’s probability of
accessing formal credit by 4.2 percent (World Bank 2009). Moreover, ARBs who have not secured
full ownership of their lands are less inclined to invest in improvements (World Bank 2009).
Transferability of property rights is an important factor in increasing investments

and productivity.
Pathway 4: Transferability of property rights  higher investment  increased productivity
More secure tenure can mean that there is transferability of property rights. Carter’s study (2002)
involving panel data from China found that transfer rights could boost agricultural investment
while controlling for other possible factors (as cited in Deininger 2003, p. 45). Besley (1995)
observed the same in Ghana, where individual farmers had a higher tendency to plant trees and
make investments when tilling plots with greater transferability (as cited in Deininger 2003, p. 46).
It can be inferred that tenure security does not require fully individualized rights or titles to change
the farmers’ investment behaviors (Deininger 2003).
In the Philippines, CARP was supposed to transfer individual land ownership titles to
small farmers and landless farmworkers ultimately to improve their household welfare. Titles
are expected to incentivize beneficiary-farmers to make short- and long-term investments in
their agricultural lands (World Bank 2009). With the issuance of CCLOAs, asset redistribution
could be considered complete in the absence of proper assignment of individual property rights.
The ability of CCLOA beneficiaries to access credit and modern farming technologies was also
hampered (World Bank 2009).
7 Migot-Adholla et al. (1991) did not find a significant relationship between land rights and productivity in Ghana, Kenya,
and Rwanda after running a regression analysis (as cited in Tenaw et al. 2009, p. 9).
10
Galang
EMPIRICAL ANALYSIS FOR PATHWAY 2
This paper utilized available data from the baseline survey under Project ConVERGE to analyze
the difference between the agricultural performance of farms under collective and individual
CLOAs. With loan financing from the International Fund for Agricultural Development (IFAD),
DAR’s Project ConVERGE aims to reduce poverty in 10 provinces across Regions 9 (Davao),
10 (Northern Mindanao), and 13 (Caraga) by promoting sustainable livelihood activities based on
key competitive commodities in these areas. One of the project’s components is the Subdivision
of Collective CLOA and Facilitation of Land Transfer.8 It addresses tenure and other land-related
issues that prohibit beneficiaries from accessing credit, improving their productivity, and
fostering agribusiness partnerships with the private sector. The subdivisions of CCLOAs are based
on written requests from ARBs. Only nonproblematic landholdings are pursued in the project.
Due to limited budget, landholdings that have legal problems owing to multiple claims and fake
documents are excluded.
In 2018, the project facilitated the approval of survey plans for 655 ha of agricultural lands.
It redocumented lands as CCLOAs in 2,012-ha agrarian reform community (ARC) clusters
(Table 3). Moreover, about 1,200 ARBs were issued with individual CLOAs.
Table 3. Project ConVERGE land tenure services, 2017–2018

Target Actual
Output 2017 2018 2017 2018
Output 3:
Subdivided CCLOA
Output 3.1:
1,136 655 1,136 655
Approved survey plans (in ha)
Output 3.2:
Redocumented individual or 4,192 2,012 4,192 2,012
CCLOAs/titles (in ha)
Output 3.3:
4,077 1,200 4,077 1,200
ARBs with individual CLOA
ConVERGE = Convergence on Value Chain Enhancement for Rural Growth and Empowerment Project;
CCLOAs = collective Certificate of Land Ownership Awards; ha = hectare; ARBs = agrarian reform beneficiaries
Source: DAR 2018
PIDS baseline survey

DAR, together with IFAD, engaged PIDS to conduct an evaluation of the Project ConVERGE
using a baseline-endline impact evaluation method. The baseline survey was completed in 2019.
It covers a random sample of ARBO members and gathered data on farmers’ demographic
characteristics (e.g., age, sex), farm-level information (e.g., number of parcels, type of harvested
crop, yield per hectare, gross income per ha, total farm income) and household-level information.
The reference period was from June 2018 to May 2019.
8 This component was originally not part of the project, but DAR proposed to include it using government
counterpart funds.
11
The baseline survey respondents were screened based on a set of criteria, such as not
having received any hard infrastructure nor benefitting from any of the project’s programs
(e.g., value chain development support). The baseline survey captured the lives of beneficiaries
before the project’s implementation. An endline survey will be conducted after three years to get the
same set of information and determine any changes or improvements, such as in their income level
and production volume.
There are 364 parcels of CLOA-covered lands based on data (Table 4). Out of this number,
266 were being cultivated by the sampled households at the time of the survey (Table 5).
There are 193 parcels under individual CLOA, while 171 are covered by CCLOA. The average size
of parcels is 1.66 ha for individual CLOAs and 1.74 ha for CCLOAs. It is possible that a household9
owns more than one CLOA-issued parcel, since ARBO members may live together in a single
household. Those who hold both individual and collective CLOAs are excluded (Table 6).
Table 4. CLOA parcels owned by sampled households

No. of parcels
Individual CLOA 193
Collective CLOA 171
Total 364
CLOA = Certificate of Land Ownership Award
Source: Author’s calculations
Table 5. CLOA parcels owned and cultivated by sampled households

No. of parcels No. of households Average parcel size (ha)
Individual CLOA 188 140 1.66
Collective CLOA 78 62 1.74
Total 266
CLOA = Certificate of Land Ownership Award; ha = hectare
Table 6. CLOA parcels owned and cultivated by sampled households after removing
households with individual and collective CLOAs
No. of parcels No. of households
Individual CLOA 185 137
Collective CLOA 74 59
Total 259
The analysis considered sales and yield per ha (per type of crop) in measuring agricultural
performance. Sales (in PHP per ha) refers to the household’s annual revenue from selling their crop
output on a per-ha basis. On the other hand, yield (in tons per ha) refers to the ratio of volume of
production to the area harvested. Land tenure dataset was merged with crop dataset.
9 PSA’s definition of household membership is based on the usual place of residence of the person (i.e., where the
member usually sleeps) (https://psa.gov.ph/content/members-household [accessed on May 1, 2021]).
12
Galang
Among 259 parcels, 138 have corresponding yield and sales information, 110 parcels are
owned by individual CLOA holders, and 28 parcels by CCLOA holders (Table 7). One main reason
for the lack of yield data is the planting style of permanent crops; some are scattered while others
are compact. Only those planted in a compact manner have accurate information on the size of
area harvested.
Table 7. CLOA parcels with crop yield and sales information

No. of parcels No. of households
Individual CLOA 110 91
Collective CLOA 28 23
Total 138
Household-level analysis: Sales per ha

Before looking at the differences in the crop sales of collective and individual CLOA households,
the two have almost the same demographic characteristics (Table 8). The average household
size is six for individual CLOA households and five for CCLOA households. Both have four
working-age household members. Based on their characteristics, the main agricultural operators in
the household are mostly male, 57 to 58 years old, and elementary graduate.
Table 8. Demographics of individual and collective CLOA household members (household and
primary production operator levels)
Individual CLOA household Collective CLOA household
Number of observations (households) 91 23
Number of household members 6 5
Number of working-age members 4 4
Maximum years of schooling reached
11.6 11.2
by household member
Number of household members 2 2
working as primary production operators
Sex of primary production operator
Female 29 6
Male 62 17
Age of primary production operator 58 57
Years of schooling of primary
8.0 7.5
production operators
Note: Primary production operator refers to the household member who works as a farm operator.
If there are two farm operators in the household, the head will be considered as the main one.
13
It is ideal to use net farm income as an indicator if available. Unfortunately, farm-level costs
in the survey are not disaggregated by parcel and type of crop. Given this limitation, the study
used sales per ha as a proxy. The average annual sales per ha of individual CLOA households is
PHP 34,894 accounting for all types of crops planted (Table 9). The advantage in the average
annual sales per ha of individual CLOA households is greater for permanent crops, which amounts
to PHP 17,568, than for temporary crops at PHP 4,169.
Table 9. Average annual sales per ha by types of crops and CLOAs

Average annual sales per ha Obs.
All crops (planted in CLOA covered land)
Individual CLOA HH 34,894 91
Collective CLOA HH 29,511 23
Difference 5,383
Permanent crops (planted in CLOA covered land)
Difference 17,568
Temporary crops (planted in CLOA covered land)
Difference 4,169
ha = hectare; CLOA = Certificate of Land Ownership Award; Obs. = observations; HH = household
Contrary to the results of the PSRTI (2016), the analysis using a subset of the Project
ConVERGE baseline survey dataset show that individual CLOA households are better off than
CCLOA households in various measures (Table 10). Total household income, other sources of
income, and net income from all businesses are all greater in amount among individual CLOA
households. In this case, farm income refers to all agricultural activities done by the household
aside from crop farming activities.
Because of the small sample size used in the analysis (randomly selected), the results should
be interpreted with caution. Both internal and external validity are undermined because of this
limitation. This means that the analysis cannot strongly conclude that individual CLOA households
enjoy higher income due to the fact that they received individual CLOAs rather than CCLOAs.
Table 10. Household income of individual and collective CLOA households (in PHP)
Individual CLOA households Collective CLOA households
Total household income 267,077 (n=91) 215,066 (n=23)
Employment income 157,316 (n=59) 186,845 (n=19)
Other sources of income 27,434 (n=91) 25,604 (n=23)
Net income from all businesses
137,648 (n=91) 35,111 (n=23)
(farm and nonfarm)
14
Galang

Individual CLOA households Collective CLOA households
Gross farm income
206,695 (n=91) 51,837 (n=23)
(e.g., crops, livestock, poultry)
Net farm income 122,697 (n=91) 22,051 (n=23)
Net agri-based business income 78,094 (n=5) 50,592 (n=2)
Net non-agri-based business income 46,191 (n=21) 33,201 (n=6)
CLOA = Certificate of Land Ownership Award; PHP = Philippine peso
Parcel-level analysis: Yield per ha

Parcels that do not have yield information are excluded from the analysis. Thus, only 145 parcels
remained (Table 11). Only four crops, namely, copra, banana, palay (temporary crop), and corn,
have parcels under both types of CLOAs. Although the number of observations (parcel) is small,
especially for CCLOA, the analysis below illustrates the extent of difference in the yield between
collective and individual CLOA farms.
Table 11. Number of parcels by types of crops planted and CLOA

Type of crop Individual CLOA Collective CLOA Total
Permanent crops 49 15 64
Temporary crops 123 22 145
For copra, 17 out of 21 parcels are covered by individual CLOA ownership, while 4 are
under CCLOAs (Table 12). The average yield is 1.37 tons per ha for individual CLOA and
1.20 tons per ha for CCLOAs. For banana, individual CLOA parcels have lower yield, with
a difference of about 1.81 tons per ha. Yield figures for banana are far too low compared with
PSA data (20.46 tons per ha). This may be because only one household is engaged in AVA,
contrary to common knowledge that banana producers are usually engaged in multiple AVAs.
Table 12. Average yield of copra and banana by type of CLOA

Individual CLOA Collective CLOA
Copra 1.37 (n=16) 1.20 (n=4)
Banana 1.24 (n=7) 3.05 (n=9)
Note: The average yield of banana for regions covered in Project ConVERGE for the period 2016 to 2019 was
20.46 tons per ha based on PSA data. For copra, 2 tons per ha was considered good annual yield (PCA 2010).
Unit for yield: tons per ha
15
For palay, 72 out of 77 parcels are under individual CLOA ownership, while 5 are covered by
CCLOA. On a per cropping basis, the average palay yield is 2.34 tons per ha for individual CLOA
and 1.95 tons per ha for CCLOA (Table 13). For corn, individual CLOA parcels have a higher yield
of about 1.24 tons per ha than CCLOA parcels.
Table 13. Average yield of palay and corn by type of CLOA

Individual CLOA Collective CLOA
Palay 2.34 (n=72) 1.95 (n=5)
Corn 3.02 (n=39) 1.78 (n=10)
Note: Based on PSA data, the average yield of palay and corn for regions covered in Project ConVERGE for
the period 2016 to 2019 was 3.89 tons per ha and 2.88 tons per ha, respectively.
Unit for yield: tons per ha
Why pursue a more secure and individualized form of tenure?

Another way of putting this question is “Why is individualized form of land ownership more
preferred than collective ownership?” Ellickson (1993) argued that “individual land ownership
provides the greatest incentive for its efficient use” (as cited in Deininger 2003, p. 28). Latin
American countries implemented the decollectivization of landholdings. De Janvry et al. (n.d.)
noted that in Peru, the government distributed collectively owned titles into smaller-sized parcels
of 4 to 6 ha and developed a modern cadaster. The government ensures that all properties are
properly registered (as cited in Casidsid-Abelinde 2017). In addition, farmers in Latin American
countries are allowed to sell their lands, which essentially enables the replacement of older and less
skilled farmers with younger and more skilled ones (Casidsid-Abelinde 2017).
In China, large increases in productivity were associated with the shift from collective to
privately owned farms (McMillan 1989, as cited in Deininger 2003, p. 44; Lin 1992). In Thailand,
Feder et al. (1988) saw how land titling increased land value and investments in farming capital.
Titled lands were also said to have higher productivity (14% to 25% higher output) than untitled
lands after controlling for the quality of land (as cited in Deininger 2003, p. 45).
Perennial crops
Land registration in Viet Nam encouraged the planting of perennial crops (Do and Iyer 2002,
as cited in Deininger 2003, p. 45). Time is an essential factor in cultivating perennial crops.
More investments can be poured into perennial crops if tenure is more secure and the rights are
transferrable. Given the long gestation period of perennial crops, especially trees, it is important
that farmers can transfer their rights to other farmers or to their heirs. This allows for long-term
planning and investments for these types of crops.
Plantation crops and contract farming

The empirical exercise using Project ConVERGE’s survey data supports the argument that
individualized tenure has a positive correlation with yield and gross sales. Only the results for
banana are contrary to this. This might be because banana is a plantation crop, which means that
it is more efficient if planted on a much larger scale.
Contract farming arrangements are prevalent among banana and pineapple industries in
Mindanao (Digal 2007) and tobacco industry in Northern Luzon (Briones and Galang 2014).
16
Galang
Farmers under contract farming have access to credit and technical assistance and are provided
with guaranteed price (Minot 2007). Agreements for both the buyer and farmer-producers on the
quantity and quality of expected outputs are stipulated in the contract. Buying price may be set prior
to purchasing and depending on the form of contract farming.
However, contract farming cannot be promoted to all commodities. Usually, those that are
highly perishable and technically difficult to produce are suitable for contract farming. Grades and
standards are also developed in commodity markets. Some examples of these commodities are
high-quality fruit and vegetables, organic products, and spices (Minot 2007).
Farm ownership vs. farm management

It is important to reiterate the valuable insight of former National Economic and Development
Authority director general Arsenio Balisacan that the issue of farm management and ownership
should be taken separately. Farmers are free to form or join organizations to take advantage of
the economies of scale while having individual ownership over their respective parcels of land.
Individual titles can serve as collateral when accessing credit facilities (DAR 2011). Thus, while
parcelization is pursued, other rural development strategies like farm consolidation (e.g., contract
farming) should be undertaken concurrently.
Based on the literature and the experiences of ARBs under CCLOAs, pursuing the parcelization
program is important to (1) incentivize farmers to invest more in their lands; (2) enable farmers to
access formal credit, since titles may be used as collateral; (3) encourage the planting of perennial
crops; (4) allow farmers to sell their lands to younger and more skillful farmers; and (5) allow
farmers to transfer land to their heirs without restrictions.
Other factors affecting agricultural productivity and the need for support services
Apart from inequality in the distribution of assets, especially land, de Janvry and Sadoulet (2010),
as cited by Amare et al. (2016), noted other factors that limit farmers’ productivity and household
welfare, such as the following:
• Inability to mitigate economic and natural risks (e.g., price fluctuations, drought);
• Lack of information on technical production methods and the market;
• Poor access to credit and/or insurance;
• Inability to respond to technological changes and quality standards set by modern
commodity chains; and
• Poor infrastructure system that links production areas with markets.
The government needs to address these limitations through direct provision of assistance and
support services and facilitation of private sector investments. This will enable farmers, particularly
smallholders, to make better farming decisions and earn decent profits to support their next
production cycle and the needs of their households.
CONCLUSION AND RECOMMENDATION
The parcelization of CCLOAs into individual CLOAs is one of the many priority tasks of DAR.
As a response, it undertakes measures to fast-track the implementation of the program. This paper
discusses how the subdivision of CCLOAs can improve the agricultural performance of farmers.
Several studies have shown that individually owned land positively affects farmers’ decisionmaking
and farming outcomes. Although limited in the sample observations, the analytical exercise using
17
Project ConVERGE’s baseline survey data provided additional evidence favoring the acceleration
of the subdivision of CCLOAs. The agricultural performance of individual and collective CLOA
farms (i.e., yield and gross sales) differ based on the type of crop. A more complete picture,
however, would have been painted if the data allowed for the comparison of net farm income
rather than gross sales.
Farmers can be encouraged to plant more perennial crops if they have more secure land tenure
and the rights are transferrable. The two desirable properties—tenure security and transferability
of rights—are both present under individualized land ownership. Moreover, other rural
development strategies should be undertaken while parcelization is being pursued. For instance,
the consolidation of individualized farms through contract farming can be done to take advantage
of the economies of scale. Other support services (e.g., access to credit, market linkage) should
also be considered. This study recommends the following ways for an expedient and smoother
implementation of the parcelization program:
1. Use a modern cadaster and record-keeping system that concerned government agencies
can easily access. Cadastral surveys are important in pursuing rural development and
planning the type of appropriate investments for various areas (e.g., irrigation scheme,
farm road construction). For example, under the Ministry of Rural Development, India
implemented the Digital India Land Records Modernization Programme and achieved
more than 90 percent of its target for the digitization of land records (Sharma 2020).
A more advanced design of cadastral system is also pursued in Singapore to support not
only digital cadaster but also 3D (three-dimensional) cadasters (Khoo 2012).
2. DAR should continue to improve the agrarian justice delivery system for issues in land
tenure. The balance of cases related to agrarian law implementation were 3,871 in 2004
and 38,419 in 2007 (World Bank 2009). During the first semester of 2019, DAR reported
to have a resolution rate of 71 percent, which means that it resolved 17,588 out of the
24,579 total caseloads (DAR 2019b). Disputes in the validation of the list of beneficiaries
have excessively prolonged the parcelization process. Thus, cases must be resolved as soon
as possible.
REFERENCES
Amare, M., J. Cisse, N. Jensen, and B. Shiferaw. 2016. The impact of agricultural productivity of welfare growth
of farm households in Nigeria: A panel data analysis. https://www.fao.org/3/bp143e/bp143e.pdf
(accessed on November 15, 2021).
Balinbin, A. 2019. Palace orders Agrarian Reform dep’t to break up collective land titles. https://www.
bworldonline.com/palace-orders-agrarian-reform-dept-to-break-up-collective-land-titles/
(accessed on October 1, 2019).
Ballesteros, M. 2003. Property rights in land reform areas. PIDS Policy Notes 2013-14. Makati City,
Philippines: Philippine Institute for Development Studies. http://dirp4.pids.gov.ph/ris/pn/
pidspn0314.pdf (accessed on January 20, 2020).
Batt, P., A. Salvador, H. Soliman, G. Tumbali, and D. Vhugen. 2016. Multi-sectoral study on the Agribusiness
Venture Arrangement policy and implementation under the Comprehensive Agrarian Reform
Program. Rome, Italy: Food and Agriculture Organization. http://www.fao.org/3/a-i6239e.pdf
(accessed on January 20, 2020).
Boserup, E. 1965. The conditions of agricultural growth: The economics of agrarian change under population
pressure. New York, NY: Aldine Publishing.
18
Galang
Briones, R. and I.M. Galang. 2014. Linking small farmers to modern markets: The role of contract
farming. PIDS Policy Notes 2014-09. Makati City, Philippines: Philippine Institute for
Development Studies. http://dirp3.pids.gov.ph/webportal/CDN/PUBLICATIONS/pidspn1409.pdf
Carter, M. 2002. Land and other factor markets in Latin America. Paper presented at the World Bank
Regional Land Workshop, May 19–22, Pachuca, Mexico.
Casidsid-Abelinde, J. 2017. Subdividing collective Certificates of Land Ownership Awards: A strategy
paper for Center for Agrarian Reform and Rural Development. Quezon City, Philippines:
Center for Agrarian Reform and Rural Development. https://www.carrd.org.ph/uploads/db/
research/pdf/1531824682/researchPDF.pdf (accessed on January 20, 2020).
De Janvry, A., E. Sadoulet, and W. Wolford. n.d. From state-led to grassroots-led land reform in Latin
America. Indiana University Bloomington, Indiana, USA. http://dlc.dlib.indiana.edu/dlc/
bitstream/handle/10535/5690/from%20state%20led%20to%20grassroots.pdf ?sequence=1
De Janvry, A. and E. Sadoulet. 2010. Agricultural growth and poverty reduction: Additional evidence.
World Bank Research Observer 25(1):1–20.
Deininger, K. 2003. Land policies for growth and poverty reduction (English). A World Bank Policy
Research Report. Washington, DC: World Bank Group. http://documents.worldbank.
org/curated/en/485171468309336484/Land-policies-for-growth-and-poverty-reduction
De los Reyes, V. 2016. End of term report of Secretary Virgilio de los Reyes: For the term from
July 2010–June 2016. Department of Agrarian Reform report. Quezon City, Philippines:
Department of Agrarian Reform. https://www.scribd.com/document/328514575/Copy-of-DAR-
Secretary-s-End-of-Term-Report-Final (accessed on May 1, 2021).
Department of Agrarian Reform (DAR). 2011. DAR leaves choice to farmers: collective or individual CLOA.
Quezon City, Philippines: DAR. https://www.officialgazette.gov.ph/2011/11/28/fdar-leaves-choice-
to-farmers-collective-or-individual-cloa/ (accessed on January 20, 2020).
———. 2016. Administrative Order 03, series of 2016. Guidelines and procedures to stabilize ownership
and tenureship of agrarian reform beneficiaries with collective Certificates of Land Ownership
Award (CLOA). Quezon City, Philippines: DAR. https://media.dar.gov.ph/source/2018/09/04/ao-
2016-03.pdf (accessed on May 1, 2020).
———. 2018. Project ConVERGE 2018 Annual Report. https://projectconverge.ph/wp-content/
uploads/2019/08/2018-Annual-Report-07032019.pdf (accessed on July 1, 2021).
———. 2019a. Administrative Order 02, series of 2019. Guidelines and procedures on the parcelization of
landholdings with Collective Certificates of Land Ownership Award. Quezon City, Philippines: DAR.
https://media.dar.gov.ph/source/2019/05/17/ao-02-guidelines-procedures-on-the-parcelization-of-
landholdings-with-collective-certificates-of-land-ownership-award.pdf (accessed on May 1, 2020).
———. 2019b. Accomplishment report, January to June 2019. Prepared by the Plan Implementation
Monitoring and Evaluation Division Planning Service. Quezon City, Philippines: DAR.
https://media.dar.gov.ph/source/2019/10/01/dar-s-1st-sem-2019-report.pdf (accessed on March 1, 2020).
———. 2020. DAR creates SPLIT Project Management Offices to subdivide collective CLOAs. Quezon City,
Philippines: DAR. https://www.dar.gov.ph/articles/news/101929 (accessed on July 1, 2021).
Digal, L. 2007. Agricultural contracts in Mindanao: The case of banana and pineapple. PIDS Discussion
Paper Series 2007-24. Makati City, Philippines: Philippine Institute for Development Studies.
http://dirp3.pids.gov.ph/ris/dps/pidsdps0724.pdf (accessed on January 20, 2020).
Do, Q.T. and L. Iyer. 2002. Land rights and economic development: Evidence from Vietnam. Department
of Economics, Massachusetts Institute of Technology. Cambridge, MA: Massachusetts
Institute of Technology.
19
Dong, X. 1996. Two-tier land tenure system and sustained economic growth in post-1978 rural China.
World Development 24(5):915–28.
Eleazar, F., R. Ravanera, J. Gatus, and B. Masangcay. 2016. Land governance and jobs in Mindanao. Washington,
DC: World Bank. http://siteresources.worldbank.org/INTLGA/Resources/MinLGAF_Synthesis_
Report_Final_August_2016.pdf (accessed on January 20, 2020).
Ellickson, R. 1993. Property in land. Yale Law Journal 102(6):1315–1400.
Eularia, M. 2015. Farm land policy and financing program for young generation in the Philippines.
Taipei, Taiwan: Food and Fertilizer Technology Center. https://ap.fftc.org.tw/article/882
(accessed on May 1, 2020).
Feder, G., T. Onchan, Y. Chalamwong, and C. Hongladarom. 1988. Land policies and farm productivity
in Thailand. Baltimore, MD: The John Hopkins University Press.
Gavian, S. and M. Fafchamps. 1996. Land tenure and allocative efficiency in Niger. American Journal of
Agricultural Economics 78(2):460–71.
Hirtz, F. 1998. The discourse that silences: Beneficiaries’ ambivalence towards redistributive land reform
in the Philippines. Development and Change 29(2):247–275.
Jacoby, H., G. Li, and S. Rozelle. 2002. Hazards of expropriation: Tenure insecurity and investment in rural
China. American Economic Review 92(5):1420–1447.
Kay, C. 1998. Latin America’s agrarian reform: Lights and shadows. Rome, Italy: FAO.
http://www.fao.org/docrep/x1372t/x1372t00.htm#1_toc (accessed on January 20, 2020) .
Khoo, V. 2012. Towards “smart cadastre” that supports 3D parcels. Paper presented at the 3rd International
Workshop on 3D Cadastres: Development and Practices, October 25–26, Shenzhen, China.
https://www.fig.net/resources/proceedings/2012/2012_3dcadastre/3Dcad_2012_44.pdf
Leder, S., F. Sugden, M. Raut, D. Ray, and P. Saikia. 2019. Ambivalences of collective farming:
Feminist political ecologies from the Eastern Gangetic Plains. International Journal of the Commons
13(1):105–129.
Lin, J. 1992. Rural reforms and agricultural growth in China. American Economic Review 82(1):34–51.
McMillan, J. 1989. A game-theoretic view of international trade negotiations: Implications for the
developing countries. In Developing and the global trading system: Volume 1, Thematic Studies
from a Ford Foundation Project, edited by J. Whalley. London, UK: Palgrave Macmillan.
Mearns, R. 1996. Community, collective action, and common grazing: The case of post-socialist Mongolia.
Journal of Development Studies 32(3):297–339.
Migot-Adholla, S., P. Hazell, B. Blarel, and F. Place, 1991. Indigenous land rights systems in Sub-Saharan
Africa: A constraint on productivity? World Bank Economic Review 5(1):155–175.
Minot, N. 2007. Contract farming in developing countries: Patterns, impact, and policy implications:
Case study 6–3. In Case studies in food policy for developing countries: Policies for health, nutrition,
food consumption, and poverty. Ithaca, NY: Cornell University Press.
Olano, J. 1996. My years with DAR. Intersect: The Stanford Journal of Science, Technology, and Society
11(2):14–19.
Pender, J. and J. Kerr. 1998. Determinants of farmers’ indigenous soil and water conservation investments in
semi-arid India. Agricultural Economics 19(1–2):113–125.
Philippine Coconut Authority (PCA). 2010. Understanding right, the productivity (yield) of coconut from
the Philippines’ research and field experience: A knowledge tool for industry development and
management (A research notes). Quezon City, Philippines: PCA.
Philippine Statistical Research and Training Institute (PSRTI). 2016. 2015 Survey of Agrarian Reform
Beneficiaries. Quezon City, Philippines: PSRTI.
Philippine Statistics Authority (PSA). 2019. Agricultural indicators system: Redistribution of land 2018.
Quezon City, Philippines: PSA. https://psa.gov.ph/content/agricultural-indicators-system-
redistribution-land-0 (accessed on January 20, 2020).
20
Galang
———. 2016. Statistical handbook on women and men in the Philippines. Quezon City, Philippines: PSA.
https://psa.gov.ph/content/women-and-men-philippines-statistical-handbook-0 (accessed on
January 20, 2020).
Platteau J. 1993. The evolutionary theory of land rights as applied to Sub-Saharan Africa: A critical
assessment. Development and Change 27(1):29–86.
Republic Act 6657. 1988. An act instituting a Comprehensive Agrarian Reform Program to promote social
justice and industrialization, providing the mechanism for its implementation, and for other
purposes. Manila, Philippines: Congress of the Philippines.
Republic Act 8532. 1998. An act strengthening further the Comprehensive Agrarian Reform
Program (CARP), by providing augmentation fund therefor, amending for the purpose section
63 of Republic Act No. 6657, otherwise known as “The CARP Law of 1988”. Manila, Philippines:
Congress of the Philippines.
Sharma, Y. 2020. Finance ministry clears advance funding proposal for Digital Land Records programme.
https://economictimes.indiatimes.com/https://economictimes.indiatimes.com/news/economy/
policy/finance-ministry-clears-advance-funding-proposal-for-digital-land-records-programme/
articleshow/73427634.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst
(accessed on March 10, 2021).
Supreme Court of the Philippines. Department of Agrarian Reform, Quezon City and Pablo Mendoza,
petitioners, vs. Romeo C. Carriedo, respondent. GR No. 176549. Manila, Philippines: Supreme
Court of the Philippines.
Tenaw, S., K.M.Z. Islam, and T. Parviainen. 2009. Effects of land tenure and property rights on agricultural
productivity in Ethiopia, Namibia and Bangladesh. University of Helsinki, Department of
Economics and Management Discussion Papers 33. Helsinki, Finland: University of Helsinki.
https://www.fao.org/fileadmin/user_upload/fsn/docs/HLPE/Discussion_Paper_33.pdf
Vargas, A. 2003. The Philippine country brief: Property rights and land markets. Land Tenure Center,
University of Wisconsin-Madison. https://rmportal.net/framelib/ltpr/052709/philippinesbrief.pdf
World Bank. 2009. Land reform, rural development, and poverty in the Philippines: Revisiting the agenda.
Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/18545
Yao, Y. 1996. Three essays on the implications of imperfect markets in rural China. Ph.D. thesis.
University of Wisconsin, Madison, Wisconsin, USA.
21
Analyzing the Diversity

and Inclusivity of Philippine
Exports to the European
Union Under the GSP+
Brynn Jonsson R. Julia1
ABSTRACT
This study assesses the diversity and inclusivity of Philippine export activities
to the European Union (EU) amid the country’s status as a beneficiary of the
Generalised Scheme of Preferences Plus (GSP+). The GSP+ is a trade agreement
that removes EU tariffs in exchange for the compliance of developing countries
with international conventions, such as on human and labor rights, environmental
protection, and good governance. To assess the economic incentives of GSP+
and determine how and why its outcomes evolved in such a manner, this paper
gathered official statistics and documents as well as open-ended questionnaires
and email correspondence with experts and key informants from the government
sector. The study argues that factors beyond the scope of the GSP+, including the
country’s reliance on transnational migration, trade and investment liberalization,
and private consumption, and challenges pertaining to the capacities of exporters,
local supply chains and infrastructures, public institutions, and income and
political inequalities, can be attributed to the peculiar political economy of the
Philippines, which scholars touted as an antidevelopmental state.
1 The author is an Administrative Officer V at the Department of Trade and Industry. Email for correspondence:
b.julia@alumni.maastrichtuniversity.nl.
Analyzing the Diversity and Inclusivity of Philippine Exports to the EU Under the GSP+
INTRODUCTION
The Philippines officially became a beneficiary of the European Union’s (EU) Generalised Scheme
of Preferences Plus or GSP+ in December 2014. The GSP+ is a trade agreement that removes
tariffs on 6,274 export categories in exchange for the conformity of developing countries to
7 human rights conventions (United Nations [UN]), 8 labor rights conventions (International
Labour Organization), 8 conventions on environmental protection and climate change (UN), and
4 conventions on good governance (UN) (Legaspi 2015; European Commission 2018b). To monitor
the Philippines’ compliance with these 27 conventions, the European Commission evaluates through
a biennial report whether the trade preferences can be continued (European Commission 2019).
Studies on the development of the country’s export sector under the GSP+ remain limited.2
For instance, Galace (2018) argued for the GSP+’s benefits and identified the Philippine food and
agricultural exports as the biggest gainers. Other arguments pertaining to the GSP+ can be sourced
mostly from news reports (e.g., Isip 2017; Rosales 2018; Desiderio 2019).
In view of the gap in the Philippine literature and the limited catalogue of studies on GSP+
beneficiary countries, which are currently dominated by cases in Sri Lanka (e.g., Sarvananthan and
Sanjeewanie 2008; Abayasekara 2013; Kelegama 2016; Prasanna 2018; Berggren 2019), this paper
takes on the following questions:
1. How have the diversity and inclusivity of Philippine export activities to the EU taken
shape in the context of the country’s status as a GSP+ beneficiary?
2. As a corollary, why did the diversity and inclusivity of Philippine export activities to the
EU develop in such a manner?
In the context of the Philippines’ GSP+ beneficiary status granted by the EU, this study
operationalizes diversity and inclusivity through the following:
a. Diversity of export activities – This study explores whether new sectors exporting products
to the EU have emerged or if the established ones remain and why this is the case.
b. Inclusivity of export activities – This study explores whether firms in emerging or
established export sectors are geographically distributed in the country’s poorer regions
or are concentrated in wealthier regions and why this is the case.
In addition to exporters, this study considers the Philippine government as a key stakeholder
that can potentially gain from the research findings. This is in line with the country’s continued
efforts to further optimize and liberalize its trade relations with the EU (Legaspi 2015; DTI 2017;
Mina 2017; Desiderio 2020).
However, the thrust for optimization and greater liberalization of the Philippine-EU trade
relations is not without challenges. Concerns over the Philippines’ “war on drugs” and issues
on death penalty and age of criminal responsibility, among others, have been raised, and seem
to undermine the GSP+ status of the country (Galace 2018; Tomacruz 2018; Desiderio 2020;
Ibañez 2020).
With Germany as the most vocal of the EU member countries (Lim 2019; Rosales 2019),
civil society groups keep a keen eye on the Philippines (O’Reilly 2020), and some of them
are campaigning for the EU’s withdrawal of the GSP+ status of the Philippines (Focus on the
Global South 2019).
2 Benedict M. Uy, director and commercial counsellor at Philippine Trade and Investment Center, Brussels, Belgium,
email correspondence with the author on October 18, 2019.
24
Julia
This paper views the trade benefits acquired from the EU’s GSP+ against the backdrop of
the Philippine political economy. Comparing the country with its more economically successful
East Asian neighbors, scholars (e.g., Bello et al. 2004; Kondo 2014; Kleibert 2018) touted the
Philippines as an antidevelopmental state, which stems from an arguably neoliberal turn in the
1980s that persisted over the decades. This study offers an alternative perspective that was not
given sufficient attention in the prevailing GSP+ discourse, as previous research on the economic
impacts of GSP+ tend to lean heavily toward quantitative approaches. The succeeding sections
provide a literature review of the EU’s GSP+ and a theoretical framework shaped largely by the
Philippines’ alleged antidevelopmental state. The methodology, findings, and conclusions build up
the argument that the diversity and inclusivity of Philippine export activities to the EU are limited
amid the GSP+.
REVIEW OF RELATED LITERATURE
Philippine compliance with the EU’s GSP+

Borne out of the initiative of the UN Conference on Trade and Development nearly five decades
ago, the main principle behind the GSP was for the Global North to aid the Global South in
the latter’s international economic participation. For its part, the EU offers the GSP+ status
not only to create employment and alleviate poverty in developing countries, but to endorse
social, environmental, and political norms, calling it the formation of a “values-based economy”
(European Commission 2019, 2020b). These norms are translated into 27 conventions that the
Philippines must conform to as a GSP+ beneficiary for duty-free access of 6,274 product
categories to the EU market (Galace 2018). Table 1 shows the highlights of the EU’s assessment of
the Philippine compliance with the GSP+ conventions from 2018 to 2019.
Table 1. Highlights of the Philippines’ compliance with EU-GSP+ obligations, 2018–2019

Convention Notable remarks
- Abuses against Lumad (indigenous) peoples were reported since the May 2017
declaration of martial law in Mindanao.
- Between 5,425 and 27,000 people reportedly died due to Oplan Tokhang
(antidrugs campaign) from July 2016 to April 2019.
- The government’s conditional cash transfer Pantawid Pamilya Pilipino Program
UN human rights
has benefitted approximately 4.4 million households since 2016.
conventions3
- The Magna Carta for Women was enacted in 2009.
- Philippine jails housed nearly 140,000 prisoners against an estimated capacity
of 20,000.
- A bill was filed in Congress lowering the age of criminal responsibility from
15 years old to either 9 or 12 years old.
3 (1) Convention on the prevention and punishment of the crime of genocide; (2) International convention on the
elimination of all forms of racial discrimination; (3) International covenant on civil and political rights; (4) International
covenant on economic, social, and cultural rights; (5) Convention on the elimination of all forms of discrimination
against women; (6) Convention against torture and other cruel, inhuman or degrading treatment or punishment; and
(7) Convention on the rights of the child
25
Convention Notable remarks
- Progress in the protection of overseas Filipino workers (OFWs) was noted.
- Extrajudicial killings of labor union leaders were reported.
ILO labor rights
- New legislation extended the maternity leave from 60–78 days to 105 days
conventions4
beginning February 2019.
- Convictions for child trafficking remained low.
- The mandatory reporting of steps taken to address the country’s role in illegal
UN conventions
ivory trade was removed.
on environmental
- Plans to increase the capacity of coal-based electricity were announced.
protection and
- Instances of illegal traffic of hazardous waste were reported.
climate change5
- The trend in loss of biodiversity remained a cause for concern.
- Bills were introduced in Congress to include death penalty for drug-related

UN conventions on crimes deemed as heinous.
good governance6 - The country’s score in the 2018 Corruption Perception Index remained below
the average in the Asia Pacific region.
EU = European Union; GSP = Generalised System of Preferences; UN = United Nations; ILO = International
Labour Organization
Source: European Commission (2020d)
In addition to issues pertaining to the drug war, death penalty, and age of criminal
responsibility in the country (Galace 2018; Tomacruz 2018; Desiderio 2020; Ibañez 2020), the EU
identified other areas of concern related to abuses against indigenous peoples and labor union
leaders, prison conditions, child trafficking, nonrenewable energy, hazardous waste, biodiversity
loss, and corruption. Such issues repeatedly led to fraught political relations between the EU and
the Philippines in the previous and latest monitoring period (Cruz 2018; Cahiles-Magkilat 2020).
Despite the concerns and criticisms from the EU member countries and civil society groups
(Focus on the Global South 2019; Lim 2019; Rosales 2019; O’Reilly 2020), the Philippines retained
its GSP+ beneficiary status for the next two years (2020 to 2021). Achievements were also noted,
particularly in areas of social protection, women and migrant worker rights, and animal trade
(European Commission 2020d).
Economic impact of EU’s GSP+ on other beneficiary countries

In view of the challenges pertaining to the Philippines’ GSP+ compliance and the gap in local
literature, it is important to look into the questions of actual economic advances made by other
GSP+ beneficiary countries. In Pakistan, Fatima (2018) found the diversity of export activities
4 (8) Convention concerning forced or compulsory labour, no. 29; (9) Convention concerning the abolition of forced
labour, no. 105; (10) Convention concerning freedom of association and protection of the right to organise, no. 87;
(11) Convention concerning the application of the principles of the right to organise and to bargain collectively,
no. 98; (12) Convention concerning equal remuneration of men and women workers for work of equal value,
no. 100; (13) Convention concerning discrimination in respect of employment and occupation, no. 111; and
(14–15) Conventions concerning minimum age for admission to employment, nos. 138 and 182
5 (16) Convention on international trade in endangered species of wild flora and fauna; (17) Montreal protocol;
(18) UN framework convention on climate change; (19) Basel convention; (20) Convention on biological diversity;
(21) Cartagena protocol on biosafety; (22) Stockholm convention on persistent organic pollutants; and (23) Kyoto protocol
6 (24) UN single convention on narcotic drugs; (25) UN convention on psychotropic substances; (26) UN convention
against illicit traffic in narcotic drugs and psychotropic substances; and (27) UN convention against corruption
26
Julia
to be lacking despite the scope of GSP+ benefits. In Sri Lanka, Berggren (2019) noted that
large companies were more likely to gain from the GSP+ incentives than small and medium
enterprises (SMEs), while Sarvananthan and Sanjeewanie (2008) dismissed the ability of the
country’s apparel industry to reduce poverty through employment as a benefit of the scheme.
Several authors (e.g., Słok-Wódkowska and Folfas 2012; Kahn 2014; Berggren 2019)
who used quantitative methods, such as gravity equations and models, discovered that the GSP+
hardly impacted the overall trade formation in beneficiary countries. Kahn (2014) found the
scheme to be more relevant at the product level, although it could either move in a positive or
negative direction. Słok-Wódkowska and Folfas (2012) commented that countries in the Global
South had little to gain economically from the scheme as a political project of the EU than what
was expected of them in return. In her study on Ecuador, a GSP+ beneficiary from 2005 to 2015
(Berggren 2019; Lebzelter and Marx 2020), Wong (2010) used computable general equilibrium
and microsimulation models and found mixed results. She noted that extreme poverty could
be potentially reduced in rural areas, but a similar scenario in urban areas was contingent on
two factors: the extent of trade liberalization and market access for bananas, Ecuador’s top
agricultural export.
The literature highlighting the positive economic impacts of GSP+ in a more unanimous
but generalized manner came from the EU itself (European Commission 2016a, 2018a, 2020b).
Considering this and the precedents in other past and current GSP+ beneficiary countries,
there are good reasons to believe that the economic incentives the Philippines stands to gain from
the scheme are also limited. This study measures GSP+’s economic incentives through a more
contextual approach and provides an alternative perspective to the common quantitative methods.
THEORETICAL FRAMEWORK
In his research on supply and demand constraints on export performance, Fugazza (2004) noted
that “poor supply-side conditions have often been the more important constraint on export
performance” (p. iii). Following Fugazza’s thesis, this study posits that beyond the opening of
the EU market through GSP+, the success of the scheme depends on supply-side conditions in
the Philippines, which is seen in this paper through the lens of the country’s political economy.
In their seminal work on the topic, Bello et al. (2004) characterized the Philippine political
economy as that of an antidevelopment(al) state and identified the following as its salient features:
1. A weak neoliberal bureaucracy diluted of “its ability to lead the process of change” (p. 5);
2. A deregulated economy controlled by an oligarchic private sector and influenced by
foreign investors;
3. Prioritization of foreign debt payments over development investments, resulting in capital
starvation and further reliance on foreign aid;
4. Privatization of state enterprises and services, especially utilities;
5. Crony, even mafia, capitalism, which can be tied to the oligarchic private sector;
6. A political environment comprised of factions of corrupt elites—the most powerful of
whom also comprise the crony-capitalist class;
7. A concentration of power and wealth reinforcing social and geographic inequalities; and
8. A large and growing diaspora currently responsible for sending the fourth largest
remittances of any nationality in the world and contributes to one-tenth of the national
economy (Ochave 2020).
27
Also referring to the antidevelopmental state, Kondo (2014) and Shiraishi (2014) added
that poverty alleviation in the Philippines has remained sluggish. Moreover, they mentioned
how a combination of private consumption and outsourced services, instead of traditional
industrialization and manufacturing, affected the country’s economic growth. Private consumption
fueled by remittances from the diaspora, especially overseas Filipino workers (OFWs), in turn,
was a byproduct of both high population and jobless growth in the country.
Kleibert (2018) and Maca and Morris (2012), citing Bello (2009), traced the country’s
antidevelopmental tendencies to the legacy of American colonialism, which prevented the
Philippines from treading the developmental path taken by its more successful East Asian
neighbors. Given this divergence, Hau (2016) called the Philippines an “emblematic other” in the
region. Among other terms used to describe the Philippine political economy are “booty capitalism”
(Hutchcroft 1998), “anarchy of families” and “cacique democracy” (McCoy 1993, 1994), “rent
capitalism” and “bossism” (Sidel 1999), and “ersatz capitalism” (Yoshihara 1988).
Another feature of an antidevelopmental state is trade liberalization (Bello et al. 2004).
The Philippines embarked on a gradual liberalization policy in the 1980s (Serrano 2007;
Wacziarg and Welch 2008; Corong et al. 2010; Briones and Galang 2014) and closely aligned
with the antidevelopmental state timeline that Bello et al. (2004) set. This began with unilateral
tariff reductions during the 1980s and followed by the Philippines’ accession to regional and
multilateral treaties in the 1990s. From the 2000s onwards, the country moved toward free trade
agreements (FTAs) at the regional and bilateral levels (Medalla 2012; Aldaba 2013).
Amid further liberalization, the country continued to face the risks of economic
disparities (Briones and Galang 2014), economic volatility and stagnation (Serrano 2007; Wacziarg
and Welch 2008), heightened nationalism (EDC 2019), and persistent criticism of neoliberal
approaches (Öniş 1991; Serrano 2007).
Because of the limited economic impact of the EU’s GSP+ in other beneficiary countries,
the assertion that supply rather than demand-side conditions play a larger role in export
performance, and the Philippines’ political economy of an antidevelopmental state, this study finds
good reasons to believe that the materialization of economic incentives, which the country stands
to gain from the scheme, is limited (Figure 1). Since quantitative approaches have predominated
previous research, this paper provides a more qualitative context behind the numbers.
Figure 1. Conceptual framework of the study
Opening of Political economy of

beneficiary country
the EU market
(e.g., Philippine
through the antidevelopment[al]
GSP+ state
Supply-side
Demand-side (Limited) condition
condition Materialization
of economic incentives
in the Philippines
(Limited) Economic impact

in beneficiary countries
EU = European Union; GSP+ = Generalised Scheme of Preferences Plus

Source: Author’s deliberation
28
Julia
METHODOLOGY
Research design
In determining how the diversity and inclusivity of Philippine export activities to the EU have
taken shape in the context of the country’s status as a GSP+ beneficiary, both qualitative and
quantitative data were gathered based on the following methods of Thomas (2017):
a. Document interrogation of news articles, white papers, press releases, special
publications, conference presentations, and official reports (17 documents published
from February 2015 to February 2020);
b. Official statistics from reports, white papers, conference presentations, and statistical
datasets (12 documents presenting official figures from 2015 to 2019); and
c. Open-ended questionnaire on the GSP+ in the Philippines, with a former official of the
Department of Trade and Industry (DTI) as an expert and key informant.
In determining why the diversity and inclusivity of Philippine export activities to the EU have
taken shape as such, the following qualitative and quantitative data were gathered based largely
also on the methods of Thomas (2017):
a. Open-ended questionnaires on the GSP+ in the Philippines with three experts and key
informants consisting of former and current DTI officials and personnel;
b. Email correspondence on the GSP+ in the Philippines with two experts and key
informants consisting of current DTI personnel;
c. Document interrogation of special publications, book chapters, news reports,
conference presentations, and journal articles (five documents published from May 2014
to June 2019); and
d. Official statistics from special publications, statistical datasets, and official reports
(6 documents containing official figures from 2013 to 2019).
Sampling strategies
The documents and official statistics gathered were published from 2014 onwards, the same year
that the Philippines first became a beneficiary of the EU’s GSP+. Limitations in the sufficiency
of the principal datasets in some of the years meant that those from 2016 to 2018 were mainly
used to assess export diversity referred to as diachronic case selection, while that of 2019 was used
to assess export inclusivity referred to as snapshot case selection (Thomas 2017).
Due to the absence of official statistics on firms that export under the GSP+, the inclusivity
of export activity was instead measured using official data on the top 100 Philippine exporters to
the EU in general. While this posed a restriction to the study’s ability to fully assess inclusivity,
it used figures on the sectoral distribution, average export revenue, geographical location, and zone
of operations of firms in the top 100 list to provide the closest picture possible for the analysis.
Open-ended questionnaires and email correspondence were gathered through expert and key
informant sampling strategies (Ravitch and Carl 2016; Dito 2019).
Data collection procedures

Documents and official statistics were collected online from February to June 2020. The documents
were gathered from news outlets, government departments and ministries, international and
supranational organizations, and consultancy and publishing firms, while the official statistics
29
were collected from international and supranational organizations, and government departments
and ministries. The first set of questionnaires was collected in April 2020 and the second one in
June 2020. Email correspondence was conducted from mid to late April 2020.
Data analysis procedures

A mixed-method approach was employed for this study. Quantitative data comprised of official
statistics were mainly aimed at providing a concrete picture of the diversity and inclusivity
of Philippine export activities to the EU. Meanwhile, qualitative data sought to complement or
supplement, in the case of documents—as well as contextualize, in the case of open-ended
questionnaires and email correspondence—this concrete picture further.
Moreover, quantitative data were analyzed through eyeballing and descriptive statistics, while
qualitative data were evaluated using grounded theory (Thomas 2017) and what Bazeley (2009)
referred to as returning to substantive and theoretical literature. Relevant literature consisting
of doctorate dissertations, policy studies, journal articles, book chapters, discussion papers,
monographs, and news reports allowed the information generated to be situated within existing
and wider discourse.
RESULTS AND DISCUSSION
This study delves into the materialization of economic incentives that the Philippines stands
to gain from the EU’s GSP+ with the country’s political economy touted as antidevelopmental.
GSP+ exports comprised more than one-fourth of total Philippine exports to the EU from 2016
to 2018. It comprised more than 3 percent of the total Philippine exports to the world during the
same period although declining by a total of 0.19 percentage point.
Table 2. Relative importance of Philippine GSP+ exports, 2016–2018

Share (%)
Philippine GSP+ exports
2016 2017 2018
Share of Philippine exports to the EU 26.66 26.76 25.56
Share of Philippine exports 3.29 3.17 3.10
Source: European Commission (2020a) and EMB (2021)
This materialization is reviewed in the following ways:

1. The first half assesses the diversity of Philippine export activities to the EU in the context
of the GSP+ by identifying established, emerging, and declining beneficiary sectors and
correspondingly discussing the factors that contributed to their performance. A quantitative
measurement was also performed using the Herfindahl-Hirschman index (HHI) to present
a broader perspective of export diversity.
2. The second half provides a more general assessment of the inclusivity of Philippine export
activities to the EU by analyzing the nature and profiles of established and emerging
beneficiary sectors and identifying the geographical distribution and zone of operations
of the top firms from these sectors. It also discusses the factors that contextualize the
generated picture.
30
Julia
Diversity of Philippine export activities to the EU

Data from 2016 to 2018 revealed that 3 out of 17 export sectors consolidated their position as the
largest beneficiaries of the EU’s GSP+ (Table 3). Combined, these three sectors expanded their share
of the total GSP+ exports from 56.73 percent in 2016 to 62.60 percent in 2018. This study classifies
the three largest sectors as established beneficiary sectors, given their continued dominance:
1. Animal or vegetable fats, notably coconut oil and agri-oil products (European
Commission 2016b, 2018b, 2020c; EU Delegation and EUPBN 2018; Desiderio 2019;
Ibañez 2020);
2. Prepared foodstuffs, notably canned and preserved tuna; processed and prepared meat
and fish; pineapple-based products; fruit jams; and processed vegetables, fruits, and nuts
(European Commission 2016b, 2018b, 2020c, 2020d; EU Delegation and EU-PBN 2018;
Desiderio 2019; Ibañez 2020); and
3. Machinery and mechanical appliances, notably electrical, office, and telecommunication
equipment (European Commission 2018b, 2020c, 2020d; Ibañez 2020).
Table 3. Value of Philippine GSP+ exports to the EU, 2016–20187

Value (in EUR millions)
GSP+ export
2016 2017 2018
Animal or vegetable fats 462.86 570.91 466.26
Prepared foodstuffs 264.08 355.58 375.46
Machinery and mechanical appliances 226.92 298.96 356.99
Other export sectors 8
727.68 712.16 716.07
GSP+ exports total 1,681.54 1,937.61 1,914.78
EU = European Union; GSP+ = Generalised Scheme of Preferences Plus; EUR = euro
Source: European Commission (2020a)
Experts and key informants pointed out several factors explaining why these sectors
continued to benefit the most from the GSP+. First, established beneficiary sectors had already
made a headway into the EU market. This is especially true for animal or vegetable fats, particularly
coconut oil. For instance, the Netherlands, the EU’s largest importer of coconut oil, sourced nearly
nine-tenths of its imports from the Philippines, as the latter first became a GSP+ beneficiary
(CBI 2016).
This headway and familiarity with the EU market enabled firms from these sectors to take
advantage of the GSP+ benefits right away in a bid to cut costs, make prices flexible, and, ultimately,
increase market share in the EU.
Second, transnational Filipino migrants in the EU, especially OFWs, make up a significant
share of consumers, particularly of prepared foodstuffs. More than 800,000 Filipino migrants hold
permanent, temporary, or irregular status in the EU (CFO 2014). Mabayo (2017) theorized the
consumption behavior of Filipino-Americans as a manifestation of migrants maintaining their
ethnic culture and identity in the face of acculturation in their host countries. This is likely the case
for Filipinos in the EU.
7 See Appendix A for the expanded table.
8 (1) Chemical products; (2) plastics and rubber; (3) measuring and musical instruments; (4) textiles and textile articles;
(5) miscellaneous; (6) transportation equipment; (7) footwear and headgear; (8) hides, skins, and leather; (9) base metals
and articles thereof; (10) animals and animal products; (11) pearls, (semi-)precious stones, and metals; (12) vegetable
products; (13) wood and wood products; and (14) articles of stone, plaster, cement, and asbestos.
31
Research by Intharacks (2016) on Filipino-Australians and Filipinos in Australia revealed similar

outcomes. The propensity to purchase Filipino food was the strongest among the studied products.
Third, machinery and mechanical appliances were already submanufactured in the Philippines
and directly integrated into value chains in the EU. In fact, 39 out of the 43 largest machinery
and mechanical appliance exporters to the EU are multinational companies operating in both
parts of the world (EMB 2020). Aldaba (2017) characterized the Philippines’ participation in such
value chains as one confined to labor-intensive back-end assembly, testing, cleaning, and packaging
for semiconductor manufacturing and labor-intensive high-capital logistics, assembly, testing,
and shipping for electronics manufacturing.
Economic incentives from the GSP+ materialize through the consolidation of established
beneficiary sectors identified in this study. While gains were indeed made in these sectors—save for
animal or vegetable fats in 2018—such gains hint at a concentration in export activities to the EU,
in line with the lack of diversity that Fatima (2018) warned about. In addition, explanations from
experts and key informants imply that the materialization of economic incentives, while primarily
an outcome of the GSP+, goes beyond the scheme itself. For the most part, this materialization
is shaped by wider phenomena, which may be attributed to the characteristics of the Philippine
antidevelopmental state, such as (1) transnational migration due to the country’s high population
and jobless economic growth resulting in a large and growing Filipino diaspora, which the national
economy depends on, not only for remittances but even its exports; and (2) entrenched participation
in global value chains—an effect of the country’s increasing reliance on multinational companies
and foreign investors—especially as the Foreign Investment Act is being amended to make way for
further removal of restrictions (Bello et al. 2004; Kondo 2014; Baguisi 2019).
Since the classification of established beneficiary sectors was primarily based on the annual
value of GSP+ exports, this study looked further into changes in these values to identify emerging
beneficiary sectors. Five out of 17 export sectors achieved continued growth from 2016 to 2018
despite the total GSP+ exports declining slightly during the 2017–2018 period. Four of these five
export sectors achieved more than 40 percent cumulative growth and were classified as emerging
beneficiary sectors (Table 4). Two of the four sectors were also grouped as established beneficiary
sectors whose robust growth contributed to their continued dominance as two of the largest
GSP+ beneficiaries:
1. Footwear and headgear – more than nine-tenths of which were comprised of the former
(European Commission 2020a). The sector’s cumulative growth of 105.04 percent allowed
it to leap from the 10th largest GSP+ export in 2016 to the 7th largest in 2018.
2. Animals and animal products like fresh, chilled, and frozen tuna (EMB 2019). The sector’s
cumulative growth of 81.91 percent allowed it to rise from the 13th largest GSP+ export
in 2016 to the 12th largest in 2018.
3. Machinery and mechanical appliances
4. Prepared foodstuffs
Table 4. Change in value of Philippine GSP+ exports to the EU, 2016–2018

Change (%)
GSP+ export
2016–2017 2017–2018 2016–2018
Footwear and headgear +80.08 +13.86 +105.04
Animals and animal products +56.23 +16.43 +81.91
Machinery and mechanical appliances +31.75 +19.41 +57.32
32
Julia
Change (%)
GSP+ export
2016–2017 2017–2018 2016–2018
Prepared foodstuffs +34.65 +5.59 +42.18
Transportation equipment +29.95 -8.22 +19.26
Miscellaneous +15.22 +1.21 +16.62
Hides, skins, and leather +30.17 -13.01 +13.24
Base metals and articles thereof -13.99 +29.32 +11.23
Pearls, (semi-)precious stones, and metals -15.42 +20.48 +1.90
Animal or vegetable fats +23.34 -18.33 +0.74
Textiles and textile articles +10.83 -10.69 -1.02
Vegetable products +11.32 -23.41 -14.74
Measuring and musical instruments -8.12 -8.08 -15.55
Chemical products -28.70 +6.16 -24.31
Articles of stone, plaster, cement,
-30.29 +4.56 -27.11
and asbestos
Plastics and rubber -31.41 +2.27 -29.86
Wood and wood products -44.87 -29.24 -60.99
GSP+ exports total +15.23 -1.18 +13.87
GSP+ = Generalised Scheme of Preferences Plus; EU = European Union
Experts and key informants pointed out that these sectors grew the most during the
period because they had already developed maturely in the Philippines. They were also more
capable of exporting to EU and taking advantage of GSP+. This holds true for established
beneficiaries classified as emerging sectors, namely, machinery and mechanical appliances and
prepared foodstuffs. Meanwhile, Kondo (2014) cited footwear as one of the prominent sectors
in domestic manufacturing, whereas Vera and Hipolito (2006) stated the importance of tuna
industry in the Philippines since the 1970s. The industry is responsible for the country’s leading
animal and animal product exports to the EU.
Two export sectors are classified as both established and emerging beneficiaries. This
supports the argument that the materialization of economic incentives from GSP+ may lead
to the concentration and lack of diversity of Philippine export activities to the EU. It is shaped
by the wider phenomena of entrenched participation in global value chains and transnational
migration. The other emerging export sectors were already developed domestically with seemingly
little intervention from the government. This corroborates the assertion of Bello et al. (2004)
on the weak and neoliberal Philippine bureaucracy and its limited ability to effect change.
Aside from the total GSP+ exports declining slightly during the 2017–2018 period,
2 out of 17 export sectors had been contracting since 2016, specifically (1) wood and wood
products with a cumulative decline of 60.99 percent and (2) measuring and musical instruments,
such as for medical and timekeeping purposes (European Commission 2020a), whose cumulative
decline of 15.55 percent led to the sector slipping from the 6th largest GSP+ export in 2016 to the
8th largest in 2018.
33
The possible factors leading to an underwhelming performance that experts and key informants
brought up are discussed below:
1. Unpredictability, inefficiency, and other hurdles in the production, costs, and logistics
of the local supply chain (Desiderio 2019). These tie in with challenges identified by
Patalinghug (2015) in the Philippine supply chains, in reference to logistics, on top of
structural problems affecting these linkages, and in reference to costs and production.
2. Inadequacy of government support for exporting firms in the form of assistance on
financial risks, technical rules, and scaling up of export operations to the EU under the
GSP+, and stronger commercial and diplomatic relations with relevant EU bodies.
3. Persistence of nontariff barriers to the EU, such as the accreditation of exporters and
certification by third party bodies (Desiderio 2019). Another nontariff barrier was
GSP+’s stricter rules of origin, which require the development of local supply chains.
Austria (2001) noted the high import content of Philippine industrial exports, which
makes the compliance of such sectors more challenging.
4. Competition in terms of supply from other countries in the Global South, especially the
neighboring ones and those with colonial ties with EU member countries. For example,
under the declining wood and wood products sector, Viet Nam, a former French colony,
was cited as a growing competitor in the furniture market. While the Philippines itself
was a Spanish colony, the country’s trade relations with its succeeding colonizers, the
United States and Japan, are better entrenched.
5. Competition in terms of demand from other markets, both foreign and domestic, offers
advantages in terms of costs, prices, and familiarity (Desiderio 2019). Examples include
foreign markets like Japan, the Association of Southeast Asian Nations, and China.
All of these have FTAs with the Philippines (Benedictos 2019) on top of clear geographic
proximity. Meanwhile, the Philippines comprises a sizeable domestic market with its
population of nearly 107 million in 2018 (World Bank 2020).
The identification of established, emerging, and declining beneficiary sectors as the country’s
overall GSP+ performance fluctuated during the three-year period strengthened the claim of
Kahn (2014) about the scheme becoming more relevant at the product level.
The materialization of the GSP+’s economic incentives is potentially shaped by the wider
phenomena attributed to the characteristics of the Philippine antidevelopmental state, such as
the following:
1. Fragile institutional capacities, the result of (a) a capital-starved state with limited ability to
invest in development, and, instead, has privatized essential public services that could have
strengthened local supply chains; and (b) weak and neoliberal bureaucracy with the same
limited ability to effect change.
2. Liberalization of international trade with multiple partners and reliance on imports, such
as industrial goods for subsequent export production.
3. A private consumption-driven national economy (Austria 2001; Bello et al. 2004;
Kondo 2014).
However, there are wider phenomena that go beyond the scope of an antidevelopmental
state, such as the persistence of trade protectionism and maintenance of colonial ties with
other countries.
34
Julia
Figure 2 illustrates the factors influencing the diversity of Philippine export activities to
the EU in the context of the GSP+. They are categorized as occurring at either global or local level
and those linked with the characteristics of an antidevelopmental state.
Figure 2. Summary of global and local factors influencing how the GSP+ shapes the diversity of
Philippine export activities to the EU
Transnational
migration
Foreign investment
Global factors Trade protectionism Import dependence

(Limited) Diversity of Philippine
export activities to the EU
Colonial ties
GSP+
Trade liberalization
Other factors Exporter and supply Institutional capacity

chain capacities
Local factors
Private consumption
GSP+ = Generalised Scheme of Preferences Plus; EU = European Union

Some of these factors are interrelated. Local institutional capacity shapes local exporter and
supply chain capacities. EU’s nontariff protectionism affects exports from the Philippines due to its
dependence on imports for subsequent production, which, in turn, is a byproduct of the country’s
trade liberalization. It is important to acknowledge that these characteristics are not exclusive to an
antidevelopmental state and are regarded as such primarily for this study.
In view of the profiles of established, emerging, and declining beneficiary sectors identified
in this paper, the diversity of Philippine export activities to the EU remains limited in the context
of GSP+ and reflects the lack of diversity that Fatima (2018) has hinted at. An alternative and
quantitative analysis of the country’s GSP+ performance from 2016 to 2018 using the HHI supports
this and shows fluctuating levels of diversification (Figure 3). The increase in HHI from 2016
to 2017 translates to lower diversification even when total GSP+ exports expanded. Meanwhile,
the succeeding decrease in HHI from 2017 to 2018 translates to higher diversification even as
total GSP+ exports slightly contracted. This is potentially explained by a polarization in the GSP+
performance of export sectors, especially the established, emerging, and declining beneficiary
sectors cited and elaborated in this section.
35
Figure 3. HHI of Philippine GSP+ exports to the EU, 2016–20189
0.2000
0.1800
0.1591
0.1600
0.1479
0.1435
HHI
0.1400
0.1200
0.1000
2016 2017 2018
Year
HHI = Herfindahl-Hirschman index; GSP+ = Generalised Scheme of Preferences Plus; EU = European Union
Inclusivity of Philippine export activities to the EU

A closer look at the established and emerging beneficiary sectors identified in this study reveals
that three of these sectors are agriculture-based, namely, (1) animal or vegetable fats, (2) prepared
foodstuffs, and (3) animals and animal products. These sectors are essentially involved in the
production and export of food, which Kondo (2014) described as a low-productivity good
requiring little inter- or intra-firm coordination. While productivity in these agriculture-based
activities was indeed low, Tombe (2015) pointed out that employment was characteristically high.
This indicates a limited form of inclusivity, which favors quantity in terms of employment over
quality in terms of productivity.
The remaining two sectors are industrial in nature, namely, (1) machinery and mechanical
appliances and (2) footwear and headgear. In addition to food, Kondo (2014) described footwear as
a low-productivity good as well. Felipe et al. (2012) have gone further and ranked the footwear and
headgear sector last in terms of product complexity. As Aldaba (2017) mentioned, the Philippine
participation in machinery and mechanical appliance value chains, particularly semiconductors
and electronics, was confined to labor-intensive components, such as assembly and testing.
Patalinghug (2015), citing Austria (2009), emphasized that such activities, unfortunately, belong to
the lowest levels in the hierarchies of these chains. Inclusivity remains limited to quantity in terms
of employment instead of quality of productivity even for industrial exports.
Furthermore, as Austria (2001) noted, high import content characterizes the Philippine
industrial exports. This implies a limited utilization of local supply chains and restricts the
inclusivity of export activities. Much like export diversity explained in the previous section,
the same phenomena shape export inclusivity, which may be attributed to the features of an
antidevelopmental state, particularly (1) international trade liberalization resulting in the
country’s reliance on imports, such as industrial goods for subsequent export production, and
(2) an institutional capacity too fragile to firmly support local supply chains, thereby exacerbating
reliance on imports for subsequent export production. This is a result of a capital-starved state
9 See Appendix B for the full table.
36
Julia
with a limited ability to invest in development and has privatized essential public services
instead (Bello et al. 2004).
Meanwhile, data from 2019 reveal that a total of 2,168 firms in the Philippines exported
goods to the EU. The top 100 firms in terms of export share constitute 88.30 percent of the total
revenue (EMB 2020). Of these top 100 firms, 72 primarily belonged to the established and
emerging beneficiary sectors identified in this study (Table 5).
Table 5. Profile of firms in established and emerging beneficiary sectors included in the top 100
Philippine exporters to EU, 2019
Mean revenue Median revenue
Export sector No. of firms
from the EU from the EU
and classification in the top 100
(in USD millions) (in USD millions)
Established
Animal or vegetable fats 11 37.07 24.02
Established and emerging
Prepared foodstuffs 16 26.49 17.33
Machinery and mechanical
43 122.34 38.13
appliances
Emerging
Footwear and headgear 2 23.46 23.46
Animals and animal products 0 - -
EU = European Union; USD = United States dollar
Source: EMB (2020)
The most notable export sector was machinery and mechanical appliances with 43 firms in
the top 100 list and 2.69 times greater than the next ranked sector, prepared foodstuffs. Moreover,
these 43 firms had a mean export revenue of USD 122.34 million from the EU market, which was
3.30 times greater than the next ranked sector, animal or vegetable fats. Taking distortions by
outlier firms into account, these firms had a median export revenue of USD 38.13 million from the
EU market, which was 58.74 percent higher than the next ranked sector, animal or vegetable fats.
In addition to generating larger revenues in general, 39 of 43 firms were multinational
companies (EMB 2020). The machinery and mechanical appliances sector exhibits reliance
on foreign—instead of homegrown—investment, a feature of the purported Philippine
antidevelopmental state (Bello et al. 2004). This means that lucrative commercial opportunities
for local capital, and by extension, the inclusivity of export activities to the EU, may be challenged.
The country’s Foreign Investment Act is being amended to make way for the further removal of
restrictions (Baguisi 2019).
Moreover, patterns can be seen in the geographical distribution of 72 firms from established
and emerging beneficiary sectors identified in this study. As shown in Table 6, an overwhelming
majority (91.11%) of firms in the industrial sectors were based in Luzon, the wealthiest part
of the country (PSA 2019). Machinery and mechanical appliance exporters tend to earn larger
revenues from the EU. Meanwhile, none of the relatively high-earning industrial firms were based
in Mindanao, the poorest part of the country (PSA 2019).
37
Table 6. Geographical distribution of firms in established and emerging industrial sectors

included in the top 100 Philippine exporters to the EU, 2019
Gross regional No. of firms in the top 100
Geographical domestic product Machinery and
Footwear and Industrial sectors
location per capita (in PHP, mechanical
headgear total
2018 prices) appliances
Luzon 162,896.13 39 2 41
Visayas 104,701.67 4 0 4
Mindanao 96,455.33 0 0 0
PHP = Philippine peso; EU = European Union
Source: EMB (2020) and PSA (2019)
For experts and key informants, the reason why an overwhelming majority of firms in these
sectors were based in Luzon was that such industrial activities—which rely on the flow of raw
materials, parts, and components—require sophisticated logistics and developed infrastructure.
Although Desiderio (2019) and Patalinghug (2015) raised the general problem of logistics and
supply chains in the Philippines, Balisacan et al. (2009) emphasized how Metro Manila and the
adjacent regions of Central Luzon and CALABARZON (Cavite, Laguna, Batangas, Rizal, and
Quezon) have above average physical infrastructure, relative to the rest of the country.
Out of the 41 Luzon-based firms, 39 were in this triumvirate of regions, while 28 were based
in CALABARZON alone. The same authors found that infrastructure development followed per
capita income, with the wealthier regions in Luzon not only having the financial capacity but also
the political clout to fund and launch infrastructure projects. A range of inequalities transpire to
determine an industrial activity in the country, which export activities to the EU reinforce.
Conversely, a sizeable majority (59.26%) of firms in agriculture-based sectors cited were from
Mindanao (Table 7). However, a significant proportion (37.04%) of firms were from Luzon as well.
Taken together with data from the preceding table, the uneven distribution of export activities in
the country was further emphasized. This is in addition to Visayas, which is slightly wealthier than
Mindanao, not featuring prominently either.
Table 7. Geographical distribution of firms in established and emerging agriculture-based

sectors included in the top 100 exporters to the EU, 2019
Gross regional domestic No. of firms in the top 100
Geographical
product per capita Animal or Prepared Agriculture-based
location
(in PHP, 2018 prices) vegetable fats foodstuffs sectors total
Luzon 162,896.13 5 5 10
Visayas 104,701.67 1 0 1
Mindanao 96,455.33 5 11 16
EU = European Union; PHP = Philippine peso
Sources: EMB (2020) and PSA (2019)
For experts and key informants, a sizeable majority of firms in these sectors were
based in Mindanao because the island had been the traditional base of many agricultural
activities in the country, particularly in the adjacent regions of Davao and SOCCSKSARGEN
(South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and General Santos City), where all but 1 of
38
Julia
the 16 Mindanao-based firms were located. Coupled with its limited ability to implement structural
transformation by expanding into industrial activities due to inequalities in infrastructure
development, income level, and political power (Balisacan et al. 2009), Mindanao’s economy was
left to further rely on agriculture and be reinforced by export activities to the EU.
On the other hand, structural transformation worked more effectively in Luzon, given the
relative prominence of industrial and agriculture-based activities, as well as in Visayas, although
in a far more marginal scale. However, looking at the overall picture, structural transformation
in the Philippines largely remained “one-legged” that growth in services, such as business process
outsourcing for the most part, fundamentally supports (Usui 2012). This aligns with the general
assessment of Kondo (2014) and Shiraishi (2014) on the Philippine economy.
Another feature of the Philippine antidevelopmental state is the concentration of wealth and
power in the country (Bello et al. 2004). This mostly revolves on what is commonly referred to as
Imperial Manila in popular discourse. Mendoza and Ocampo (2017) noted how Imperial Manila
receives a disproportionate bulk of public spending including allotments for infrastructure and
influences what little public spending is left, such as allotments for infrastructure for the rest of
the country. This imbalance has significant repercussions for the capacity to implement structural
transformation at the subnational level.
Finally, the machinery and mechanical appliances sector stands out yet again due to
the overwhelming majority (90.70%) of high-earning, predominantly multinational and
Luzon-based firms operating in economic zones identified by the Philippine Economic Zone
Authority (PEZA) (Table 8). This presents another dimension of uneven distribution that even
in relatively wealthy Luzon, industrial export activities to the EU tend to be spatially exclusive
for the most part. In addition, a significant proportion of firms (44.44%) in the agriculture-based
sectors operated in these zones as well. A sizeable majority of firms in these sectors were also
based in the least wealthy Mindanao.
Table 8. Zone of operations of firms in established and emerging beneficiary sectors included
in the top 100 exporters to the EU, 2019
No. of firms in the top 100
Export sector and classification Outside PEZA
Within PEZA economic zones
economic zones
Established
Animal or vegetable fats 5 6
Established and emerging
Prepared foodstuffs 7 9
Machinery and mechanical appliances 39 4
Emerging
Footwear and headgear 0 2
EU = European Union; PEZA = Philippine Economic Zone Authority
Source: EMB (2020)
Experts and key informants pointed out two key factors on why an overwhelming majority
of machinery and mechanical appliance exporters operate in economic zones. First, these zones
attract complementary firms that produce parts and components for exporters and ease supply
chain concerns. These chains are crucial for industrial activities. Second, economic zones offer
39
fiscal and nonfiscal incentives that enable cost-sensitive firms to cut down production expenditures,
including on labor by means of contractualization (Cristobal and Resurreccion 2014). Machinery
and mechanical appliances were said to have low profit margins per unit produced. The sector relied
on high volume and quick turnaround instead, making incentives and the supply chains crucial.
Makabenta (2002) narrated how these zones had become an additional characteristic of
the Philippine economy since the mid-1980s to spur the country’s exports and investments.
This closely aligns with the trade liberalization timeline of Aldaba (2013) and Medalla (2012) and
the antidevelopmental state timeline of Bello et al. (2004). Makabenta (2002) further noted how
the thrust for economic zones culminated in the Special Economic Zone (SEZ) Act of 1995, with
the rapidly urbanizing regions of Central Luzon and CALABARZON. These regions are among the
first and by far the largest beneficiaries that host a multitude of foreign investors and multinational
companies, which the country has increasingly relied on to supplement its economy.
However, Kleibert (2018) referred to the Philippine SEZs as “spaces of exception”, which go
against the notions of inclusive development, while Caraway (2009) reported the propensity to
commit violations of labor rights in these zones. The salience of such zones in the development of
exports and investments in the Philippines may be attributed to the country’s overall drive toward
economic deregulation, empowering private and foreign interests by enforcing as little control
and discipline as possible in the process. This is in line with one of the features of the Philippine
antidevelopmental state (Bello et al. 2004).
In view of the nature and profiles of established and emerging beneficiary sectors identified in
this study and the geographical distribution and zone of operations of top firms in these sectors,
it is asserted that the inclusivity of Philippine export activity to the EU, much like its diversity,
is limited. Figure 4 illustrates factors that influence export inclusivity. They are categorized as
occurring at either national or subnational (island group) level and argued to be related to some
features of an antidevelopmental state.
Figure 4. Summary of national and subnational factors that potentially influence how the GSP+
shapes the inclusivity of Philippine export activities to the EU
Imports
National strategies Foreign investment

Philippine export activities
(Limited) Inclusivity of
Economic zones
to the EU
Subnational structural Supply chain and Income and political

transformation infrastructure development inequalities
Other factors

40
Julia
Factors at the national level include reliance on imports, foreign investment, and economic
zones, which reflect the country’s economic liberalization policies. Meanwhile, interrelated factors
at the subnational level are the capacity of island groups to implement structural transformation,
which determines the nature and productivity of their export activities to the EU. The development
of supply chains and infrastructure, which reflects inequalities in income level and political power,
determines the capacity to implement structural transformation. It is important to acknowledge
that these features are not exclusive to an antidevelopmental state and are regarded as such
primarily for the purpose of this study.
CONCLUSION
Considering the limited economic impacts of the EU’s GSP+ on some of its beneficiary countries,
this study confirms that the materialization of economic incentives that the Philippines stands to
gain from the scheme is limited as well. In terms of the diversity of export activities to EU, this
study found that while some sectors did emerge (i.e., footwear and headgear, animals and animal
products), the established ones (i.e., animal or vegetable fats, prepared foodstuffs, machinery and
mechanical appliances) generally consolidated their dominance of export activities. Some are even
declining in value (i.e., wood and wood products, measuring and musical instruments) despite the
availability of incentives. The fluctuating levels of export diversification measured using the HHI
support this.
In terms of export inclusivity, while the poorest part of the country (Mindanao)
gained from exporting to the region, it was limited to agriculture-based activities with low
productivity. On the other hand, the wealthiest part of the country (Luzon) gained from both
agriculture-based and, even more so, industrial activities with higher productivity. However, even
within the wealthiest part of the country, the materialization of economic incentives is largely
spatially exclusive and limited.
Despite a favorable demand-side condition (opening of the EU market through the GSP+),
a supply-side impediment (antidevelopmental political economy of the Philippines) was likely
to have been highly influential in the process. In terms of diversity of export activities to the EU,
specific factors identified to be potentially linked with antidevelopmental state are the country’s
reliance on transnational migration, foreign investment, import and trade liberalization, and private
consumption, and challenges in the capacities of its exporters, local supply chains, and institutions.
In terms of inclusivity, factors potentially linked with antidevelopmental characteristics are the
country’s reliance on imports, foreign investment, and economic zones; challenges pertaining to the
development of the country’s local supply chains and infrastructure; and income-level and political
power inequalities.
This study delves into the political-economic milieu of the Philippines as a beneficiary of the
GSP+ and explored an alternative approach to enrich perspectives through which discourse on the
scheme is traditionally discussed. It recommends that further research be undertaken once official
statistics on firms exporting under the GSP+ become available to produce more definitive findings
on the inclusivity of Philippine export activities to the EU.
41
REFERENCES
Abayasekara, A. 2013. GSP+ removal and the apparel industry in Sri Lanka: Implications and way forward.
South Asia Economic Journal 14(2):293–316.
Aldaba, R. 2013. Twenty years after Philippine trade liberalization and industrialization: What has happened
and where do we go from here. PIDS Discussion Paper Series 2013-21. Makati City, Philippines:
Philippine Institute for Development Studies. https://dirp4.pids.gov.ph/ris/dps/pidsdps1321.pdf
(accessed on February 25, 2020).
———. 2017. The Philippines in the electronics global value chain: Upgrading opportunities and challenges.
In Production Networks in Southeast Asia, edited by L.Y. Ing and F. Kimura. New York, NY: Routledge.
Austria, M.S. 2001. Liberalization and regional integration: The Philippines’ strategy to global competitiveness.
PIDS Discussion Paper Series 2001-09. Makati City, Philippines: Philippine Institute for
Development Studies. https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps0109.pdf
(accessed on March 2, 2020).
———. 2009. Global production networks and local support structures in the Philippine electronics industry.
In Production Networks, Trade Liberalization, and Industrial Adjustment in the Philippines, edited by
P. Intal, G. Largoza, R. Malabed, and P.J. Mutuc. Manila, Philippines: DLSU-Angelo King Institute
for Business and Economic Research and Development.
Baguisi, K. 2019. The Philippines’ foreign investment act: Amendments may attract FDI from SMEs. ASEAN
Briefing. https://www.aseanbriefing.com/news/philippines-foreign-investment-act-amendments-
may-attract-fdi-smes/ (accessed on March 30, 2020).
Balisacan, A.M., H. Hill, and S.F. Piza. 2009. Spatial disparities and development policy in the Philippines.
In Reshaping Economic Geography in East Asia, edited by Y. Huang and A.M. Bocchi. Washington,
DC: World Bank.
Bazeley, P. 2009. Analysing qualitative data: More than ‘identifying themes’. The Malaysian Journal of Qualitative
Research 2(2):6–22.
Bello, W., M. de Guzman, M.L. Malig, and H. Docena. 2004. The anti-development state: The political economy of
permanent crisis in the Philippines. London, UK: Zed Books.
Benedictos, A.S. 2019. Why we do free trade agreements: A Philippine perspective. Presented at the ITL 102:
Multilateral Trading System, June 19, DTI Academy, Makati City, Philippines.
Berggren, H. 2019. Is GSP+ a plus? A mixed method review of trade preference scheme GSP+. Bachelor’s thesis.
Lund University, Lund, Sweden.
Briones, R.M. and I.M. Galang. 2014. Prospects for a Philippines-European Union free trade agreement:
Implications for agriculture. PIDS Discussion Paper Series 2014-05. Makati City, Philippines:
Philippine Institute for Development Studies. https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/
pidsdps1405.pdf (accessed on February 15, 2020).
Cahiles-Magkilat, B. 2020. EU not keen on FTA talks with PH. Manila Bulletin. January 27.
Caraway, T.L. 2009. Labor rights in East Asia: Progress or regress? Journal of East Asian Studies 9(2):153–186.
Center for the Promotion of Imports (CBI). 2016. CBI product factsheet: Coconut oil in the Netherlands.
The Hague, Netherlands: CBI.
Commission on Filipinos Overseas (CFO). 2014. Statistics. Philippine migration at a glance. Manila, Philippines:
CFO. https://cfo.gov.ph/statistics-2/ (accessed on May 28, 2020).
Corong, E.L., R.C. Reyes, and A.B. Taningco. 2010. Poverty impacts of preferential and multilateral trade
liberalization on the Philippines: A computable general equilibrium analysis. MPIA Working Paper
2010-06. Nairobi, Kenya: Poverty and Economic Policy Research Network.
Cristobal, M.A. and E.I. Resurreccion. 2014. De-confusing contractualization: Defining employees engaged
in precarious work in the Philippines. Philippine Law Journal 88(2):342–374.
Cruz, M.N. 2018. PHL takes offense at resolution by European Parliament on GSP+, drug war. BusinessWorld.
April 21.
42
Julia
Department of Trade and Industry (DTI). 2017. Philippines-European Union (EU) free trade agreement
(FTA). Makati City, Philippines: DTI. https://www.dti.gov.ph/international-commitments/bilateral-
engagements/eu-fta (accessed on October 16, 2019).
Desiderio, L. 2019. Special report: Exporters urged to increase EU GSP+ utilization. Philippine Star. March 23.
———. 2020. Philippines open to FTA, higher GSP+ with EU. Philippine Star. February 21.
Dito, B.B. 2019. Introduction to quantitative methods. Presented at the GDS 4002: Research Methods in
Globalisation and Development, October 3, Maastricht University, Netherlands.
EU Delegation and EU-Philippines Business Network (EUPBN). 2018. EU-Philippines Trade & Investment
2018/2019. Makati City, Philippines: EU Delegation and EPBN.
European Commission. 2016a. Report on the Generalised Scheme of Preferences covering the period
2014–2015. Brussels, Belgium: European Commission.
———. 2016b. The EU special incentive arrangement for sustainable development and good governance
(‘GSP+’) covering the period 2014–2015. High Representative of the Union for Foreign Affairs and
Security Policy. Brussels, Belgium: European Commission.
———. 2018a. Report on the Generalised Scheme of Preferences covering the period 2016–2017.
Brussels, Belgium: European Commission.
———. 2018b. The EU special incentive arrangement for sustainable development and good governance
(‘GSP+’) assessment of the Philippines covering the period 2016–2017. High Representative of the
Union for Foreign Affairs and Security Policy. Brussels, Belgium: European Commission.
———. 2019. Generalised Scheme of Preferences (GSP). Brussels, Belgium: European Commission.
https://ec.europa.eu/trade/policy/countries-and-regions/development/generalised-scheme-of-
preferences/ (accessed on January 6, 2020).
———. 2020a. GSP Statistics (13 February 2020). Directorate-General for Trade. Brussels, Belgium:
European Commission.
———. 2020b. Report on the Generalised Scheme of Preferences covering the period 2018–2019.
High Representative of the Union for Foreign Affairs and Security Policy. Brussels, Belgium:
European Commission.
———. 2020c. Statistics. Brussels, Belgium: European Commission. https://madb.europa.eu/madb/
statistical_form.htm (accessed on February 15, 2020).
———. 2020d. The EU special incentive arrangement for sustainable development and good governance
(‘GSP+’) assessment of the Philippines covering the period 2018–2019. High Representative of the
Union for Foreign Affairs and Security Policy. Brussels, Belgium: European Commission.
Export Development Council (EDC). 2019. Philippine Export Development Plan 2018–2022. Makati City,
Philippines: EDC.
Export Marketing Bureau (EMB). 2019. Export intelligence. Tradeline Philippines. https://drive.google.com/
file/d/1Yex0rjGc6ddILwkiYLG1dySw9hkedz_a/view (accessed on October 15, 2019).
———. 2020. List of Philippine exporters to European Union. Makati City, Philippines: DTI.
———. 2021. Philippine merchandise exports to the world historical trend. Tradeline Philippines.
http://www.tradelinephilippines.dti.gov.ph:8080/exports (accessed on December 20, 2021).
Fatima, Z. 2018. A brief overview of GSP+ for Pakistan. Journal of European Studies 34(2):81–100.
Felipe, J., U. Kumar, A. Abdon, and M. Bacate. 2012. Product complexity and economic development.
Structural Change and Economic Dynamics 23(1):36–68.
Focus on the Global South. 2019. Trade Justice Pilipinas calls for withdrawal of EU trade preferences to the
Philippines under GSP+. https://focusweb.org/withdraw-eu-trade-preferences-to-the-philippines-
under-gsp-trade-justice-pilipinas/# (accessed on February 11, 2020).
Fugazza, M. 2004. Export performance and its determinants: Supply and demand constraints. Policy Issues
in International Trade and Commodities Study Series No. 26. Geneva, Switzerland: United Nations
Conference on Trade and Development.
Galace, U. 2018. Does the Philippines need the EU’s GSP+? CIRSS Commentaries, Volume 5, No. 3. Pasay City,
Philippines: Foreign Service Institute.
43
Hau, C.S. 2016. What is “crony capitalism”? Emerging State Project. National Graduate Institute for Policy
Studies. https://www3.grips.ac.jp/~esp/en/event/2016/ (accessed on June 28, 2020).
Hutchcroft, P.D. 1998. Booty capitalism: The politics of banking in the Philippines. Ithaca, New York: Cornell
University Press.
Ibañez, J.P. 2020. European Commission says administration’s drug war, death penalty are ‘serious concerns’.
BusinessWorld. February 12.
Intharacks, J.V. 2016. The influence of ethnicity on consumer behaviour: A study of inter-generational and
inter-group differences. PhD thesis. Western Sydney University, Australia.
Isip, I. 2017. Losses from GSP plus ‘not as much as imagined’. Malaya Business Insight. October 23.
Kahn, C. 2014. The trade effects of GSP+. Master essay. Lund University, Sweden.
Kelegama, S. 2016. EU-Sri Lanka trade and investment: Regaining GSP+. Presented at the ECCSL, EU,
and SLAEA seminar, January 22, Colombo, Sri Lanka.
Kleibert, J.M. 2018. Exclusive development(s): Special economic zones and enclave urbanism in the
Philippines. Critical Sociology 44(3):471–485.
Kondo, M. 2014. The Philippines: Inequality-trapped capitalism. In The Oxford Handbook of Asian Business
Systems, edited by M.A. Witt and G. Redding. Oxford, UK: Oxford University Press.
Lebzelter, T. and A. Marx. 2020. Is EU GSP+ fostering good governance? Results from a new GSP+ compliance
index. Journal of World Trade 54(1):1–30.
Legaspi, A.P. 2015. Maximizing EU GSP+ for PH exports. Presented at the Industry Roadmaps and the ASEAN
Economic Community Regional Localization for Competitiveness, May 28, Baguio City, Philippines.
Lim, J.C. 2019. Germany cites concerns over PHL’s compliance with GSP+ terms. BusinessWorld. May 9.
Mabayo, R.P. 2017. Online decision-making styles and modes of acculturation: Influences on the
Filipino-American consumers’ pre-purchase behavior. PhD dissertation. Northcentral University,
San Diego, California, US.
Maca, M. and P. Morris. 2012. The Philippines, the East Asian ‘developmental states’ and education:
A comparative analysis of why the Philippines failed to develop. Compare: A Journal of Comparative
and International Education 42(3):461–484.
Makabenta, M.P. 2002. FDI location and special economic zones in the Philippines. Review of Urban
& Regional Development Studies 14(1):59–77.
McCoy, A.W. (editor). 1994. An anarchy of families: State and family in the Philippines. Madison, Wisconsin:
University of Wisconsin Press.
Medalla, E.M. 2012. Managing the ASEAN economic integration process in the Philippines: An assessment
of progress in trade liberalization and facilitation. PIDS Discussion Paper Series 2012-41.
Makati City, Philippines: Philippine Institute for Development Studies. https://dirp4.pids.gov.ph/
ris/dps/pidsdps1241.pdf (accessed on February 26, 2020).
Mendoza, R.U. and J. Ocampo. 2017. Caught between imperial Manila and the provincial dynasties:
Towards a new fiscal federalism. Ateneo School of Government Working Paper 17-004. Quezon City,
Philippines: Ateneo School of Government.
Mina, C.S. 2017. Strengthening relations with EU through EU-Philippines free trade agreement. Economics
and Management Matters. College of Economics and Management Technical Bulletin.
Los Baños, Laguna: University of the Philippines Los Baños.
Ochave, R.M. 2020. PHL fourth-largest remittance destination in 2019. BusinessWorld. February 10.
Öniş, Z. 1991. The logic of the developmental state. Comparative Politics 24(1):109–126.
O’Reilly, C. 2020. Spotlight on Pakistan and Philippines in EU trade report. EUobserver.
https://euobserver.com/opinion/147292 (accessed on February 11, 2020).
Patalinghug, E.E. 2015. Supply chain connectivity: Enhancing participation in the global supply chain.
PIDS Discussion Paper Series 2015-14. Makati City, Philippines: Philippine Institute for
Development Studies. https://dirp4.pids.gov.ph/webportal/CDN/PUBLICATIONS/pidsdps1514.
pdf (accessed on June 4, 2020).
44
Julia
Philippine Statistics Authority (PSA). 2019. Gross regional domestic product by year published.
Tables and thematic maps. http://www.psa.gov.ph/grdp/tables (accessed on June 8, 2020).
Prasanna, R. 2018. Impact of GSP+ scheme on Sri Lankan apparel industry in post MFA world.
Proceedings of the 4th International Symposium on Agricultural Research in Asia. Anuradhapura,
Sri Lanka: Rajarata University of Sri Lanka.
Ravitch, S.M. and N.M. Carl. 2016. Qualitative Research: Bridging the Conceptual, Theoretical, and
Methodological. 2nd ed. Los Angeles, CA: SAGE Publications.
Rosales, E.F. 2018. Farmers, fisherman among top recipients of EU trade perks. Business Mirror. January 22.
———. 2019. Despite ‘positive’ feedback from GSP+ review team, PHL human rights issues bother
Germany. BusinessMirror. May 14.
Sarvananthan, M. and H. Sanjeewanie. 2008. Has GSP+ contributed to poverty reduction and fostered
‘sustainable development’ in Sri Lanka? In GSP+ and Sri Lanka: Economic, Labour and Human Rights
Issues. Colombo, Sri Lanka: Centre for Policy Alternatives and Friedrich Ebert Stiftung.
Serrano, M.R. 2007. Of jobs lost and wages depressed: The impact of trade liberalization on employment
and wage levels in the Philippines, 1980–2000. Paper presented at the International Conference on
Labour and the Challenges of Development, April 1–3, University of Witwatersrand, Johannesburg,
South Africa.
Shiraishi, T. 2014. Changing fortunes: Comparing state building and economic development in Indonesia,
the Philippines, Thailand, and Malaysia. In State Building and Development, edited by K. Otsuka and
T. Shiraishi. London, UK: Routledge.
Sidel, J.T. 1999. Capital, coercion and crime: Bossism in the Philippines. Stanford, California: Stanford
University Press.
Słok-Wódkowska, M. and P. Folfas. 2012. Export from developing countries to the EU member states
under GSP+ scheme. Paper presented at the ETSG 2012 Leuven Fourteenth Annual Conference,
September 13–15, Katholieke Universiteit Leuven, Belgium.
Thomas, G. 2017. How to do your research project: A guide for students. 3rd ed. London, UK: SAGE
Publications Ltd.
Tomacruz, S. 2018. PH’s EU-GSP+ preferential status ‘stays’ – Malacañang. Rappler. https://www.rappler.com/
business/194132-ph-retains-gsp-status-european-union (accessed on February 11, 2020).
Tombe, T. 2015. The missing food problem: Trade, agriculture, and international productivity differences.
American Economic Journal: Macroeconomics 7(3):226–258.
Usui, N. 2012. Taking the right road to inclusive growth: Industrial upgrading and diversification in the
Philippines. Mandaluyong City, Philippines: Asian Development Bank.
Vera, C.A. and Z. Hipolito. 2006. The Philippines tuna industry: A profile. International Collective in
Support of Fishworkers. https://aquadocs.org/bitstream/handle/1834/18208/The_Philippines_
tuna_industry,_a_profile.pdf ?sequence=1&isAllowed=y (accessed on June 11, 2020).
Wacziarg, R. and K.H. Welch. 2008. Trade liberalization and growth: New evidence. The World Bank
Economic Review 22(2):187–231.
Wong, S. 2010. Negotiating a trade agreement with the EU: Estimated poverty impacts in Ecuador.
International Agricultural Trade Research Consortium. https://ageconsearch.umn.edu/
record/97462?ln=en (accessed on January 15, 2020).
World Bank. 2020. Population, total - Philippines. https://data.worldbank.org/indicator/SP.POP.
TOTL?end=2018&locations=PH&start=1960&view=chart (accessed on June 23, 2020).
Yoshihara, K. 1988. The rise of erstaz capitalism in South-East Asia. Oxford, UK: Oxford University Press.
45
APPENDICES
Appendix A. Value of Philippine GSP+ exports to the EU, 2016–2018 (expanded table)
Value (in EUR millions)
GSP+ export
2016 Rank 2017 Rank 2018 Rank
Animal or vegetable fats 462.86 1 570.91 1 466.26 1
Prepared foodstuffs 264.08 2 355.58 2 375.46 2
Machinery and mechanical appliances 226.92 3 298.96 3 356.99 3
Chemical products 174.34 4 124.30 4 131.96 4
Plastics and rubber 120.54 5 82.67 7 84.55 6
Measuring and musical instruments 90.83 6 83.45 6 76.71 8
Textiles and textile articles 85.47 7 94.73 5 84.60 5
Miscellaneous 56.46 8 65.05 9 65.84 9
Transportation equipment 42.49 9 55.22 10 50.68 10
Footwear and headgear 40.79 10 73.46 8 83.64 7
Hides, skins, and leather 40.64 11 52.90 11 46.02 11
Base metals and articles thereof 27.10 12 23.31 13 30.14 13
Animals and animal products 22.17 13 34.64 12 40.34 12
Pearls, (semi-)precious stones,
10.98 14 9.29 14 11.19 14
and metals
Vegetable products 7.08 15 7.88 15 6.03 15
Wood and wood products 6.01 16 3.31 16 2.35 16
Articles of stone, plaster, cement,
2.80 17 1.95 17 2.04 17
and asbestos
GSP+ exports total 1,681.54 1,937.61 1,914.78
GSP+ = Generalised Scheme of Preferences Plus; EU = European Union; EUR = Euro
Appendix B. HHI of Philippine GSP+ exports to the EU, 2016-2018

Share
2016 2017 2018
GSP+ export
Percentage Percentage Percentage
HHI HHI HHI
of total of total of total
Animal or vegetable fats 27.53 0.0758 29.46 0.0868 24.35 0.0593
Prepared foodstuffs 15.70 0.0247 18.35 0.0337 19.61 0.0384
Machinery and
13.49 0.0182 15.43 0.0238 18.64 0.0348
mechanical appliances
Chemical products 10.37 0.0107 6.42 0.0041 6.89 0.0047
Plastics and rubber 7.17 0.0051 4.27 0.0018 4.42 0.0019
Measuring and musical
5.40 0.0029 4.31 0.0019 4.01 0.0016
instruments
Textiles and textile articles 5.08 0.0026 4.89 0.0024 4.42 0.0020
46
Julia
Appendix B. (continuation)
Share
2016 2017 2018
GSP+ export
Percentage Percentage Percentage
HHI HHI HHI
of total of total of total
Footwear and headgear 2.43 0.0006 3.79 0.0014 4.37 0.0019
Hides, skins, and leather 2.42 0.0006 2.73 0.0007 2.40 0.0006
Base metals and articles
1.61 0.0003 1.20 0.0001 1.57 0.0002
thereof
Animals and animal
1.32 0.0002 1.79 0.0003 2.11 0.0004
products
Pearls, (semi-)precious
0.65 0.0000 0.48 0.0000 0.58 0.0000
stones, and metals
Vegetable products 0.42 0.0000 0.41 0.0000 0.32 0.0000
Wood and wood products 0.36 0.0000 0.17 0.0000 0.12 0.0000
Articles of stone, plaster,
0.17 0.0000 0.10 0.0000 0.11 0.0000
cement, and asbestos
HHI total 0.1435 0.1591 0.1479
HHI = Herfindahl-Hirschman index; GSP+ = Generalised Scheme of Preferences Plus; EU = European Union
47
Rural Physicians’ Experiences

with Diagnosis, Treatment,
and Management of Pediatric
Tuberculosis Before and After
Disasters in Bohol
Nina T. Castillo-Carandang1*, Lauren M. Leining2,
Anna Maria Mandalakas2, Kristy O. Murray2,
Jo Anne Claire M. Liao3, Maureen Mae Cabatos-Riña4,
and Salvacion R. Gatchalian†
ABSTRACT
Tuberculosis (TB) is the sixth leading cause of death in the Philippines,

a country that accounts for 7 percent of the world TB case detection gap.
Achieving TB elimination milestones is contingent on strong national
surveillance and healthcare delivery. This paper highlights the experiences of
rural physicians from Bohol in managing pediatric TB cases before and after
disasters. The participants are physicians from public and private healthcare
systems in municipalities heavily affected and less affected by an earthquake
and the super typhoon that struck the province in 2013. The discussions focus
on the burden, diagnosis, treatment, management, and referral of pediatric
TB cases and how their circumstances changed before, during, and after the
1 Department of Clinical Epidemiology, College of Medicine, University of the Philippines (UP) Manila. Email for correspondence:
ntcastillocarandang@up.edu.ph.
2 Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
3 Governor Celestino Gallares Memorial Hospital, Tagbilaran City, Bohol
4 Tagbilaran Community Hospital and Tagbilaran City Health Office
* On behalf of the Partnerships for Enhanced Engagement in Research (PEER) Health Bohol Pediatric Study Team
† Deceased (The author used to be with the Department of Pediatrics, College of Medicine, and the Philippine General Hospital,
UP Manila, and was the president of the Philippine Pediatric Society at the time of her demise.)
Rural Physicians’ Experiences with Diagnosis, Treatment, and Management of Pediatric TB
recovery period in 2016. This study found that the situation of pediatric TB
before and after the disasters was almost unchanged. Both healthcare sectors
still struggled with stockouts of diagnostic supplies and medications, which
resulted in the disruption of TB diagnosis and treatment and loss to follow-up
among patients. The disasters further exacerbated these challenges.
Clinicians primarily rely on signs and symptoms for pediatric TB diagnosis.
However, some of them have not received training in the past years. There was
also a shortage of trained personnel across all levels of the healthcare system.
The rural physicians recognize the value of developing protocols for managing
TB patients during emergencies and disasters, conducting regular training
of staff, formalizing partnerships between the public and private healthcare
systems, and continuously orienting and soliciting the assistance of local
government officials on health concerns and funding to prevent stockouts.
The goals outlined by the World Health Organization’s End TB Strategy can
be achieved by increasing stewardship through stakeholder collaboration,
eliminating stockouts, and ensuring better diagnostics and treatment options.
The results from the group discussions provide an opportunity to examine the
strengths, weaknesses, opportunities, and threats in the diagnosis, control, and
treatment of TB among children in an island province with a high TB burden.
INTRODUCTION
Tuberculosis (TB) remains as one of the top causes of death worldwide (WHO 2020a). Out of
the estimated 9.9 million people globally who fell ill with TB in 2020, 56 percent of the reported
TB cases were among males aged ≥15 years, 33 percent were among women aged ≥15 years,
and 11 percent were among children aged <15 years (WHO 2021).
In their surveillance report, Snow et al. (2018, p. 1) stated that, “the Philippines, a country
with a young population, is currently experiencing an intense and persistent TB epidemic”, and it
seems that “TB in children aged 0–4 is being underdiagnosed or underreported”. TB in children
signifies the spread of the disease and is thus a “sentinel event that requires improved TB control”
(Aldaba et al. 2018, p. 317). Likewise, the success of TB control efforts in the Philippines demands
that adequate attention be given to the younger age groups.
In 2019, respiratory infections and TB were the second leading causes of death among
Filipino children less than 15 years old. The top causes of death were maternal and neonatal
disorders for children less than 5 years old and unintentional injuries for children 5 to 14 years
old (IHME 2020). Globally, there were 419,034 children (aged 15 years old and below) with any
form of TB in 2019, according to the World Health Organization (WHO). Out of this number,
16 percent (69,000) were in the Philippines. Thirteen percent of children worldwide (26,331 out
of 206,021) who missed receiving care for TB were in the Philippines, and 8 percent of notified
pediatric TB cases (42,669 out of the 523,819 cases globally) were reported among Filipino children.
Out of the global pediatric (<15 years age) TB notifications target of 677,603 in the same year, the
target for the Philippines was 51,000 children (<15 years old) (WHO 2020b).
Even if the disease is highly curable, 31,000 people in the Philippines died because of TB in
2020 (WHO 2021). Among the 591,000 Filipinos projected to have developed TB in 2020, 12 percent
or 73,000 were children. In addition, 16 percent or 54,551 of the 334,459 missing people with TB
50
Castillo-Carandang et al.
were children. Among Filipino children aged 0–4 years old, the notified TB cases (developed TB
and with started treatment) were 9 percent among female children, or 3,240 of 35,000 estimated
females, and 11 percent for male children, or 4,087 of 38,000 estimated males. The notified TB cases
for Filipino children aged 5–14 years old were 26 percent for females (4,926 of 19,000 estimated
females) and 34 percent for males (6,176 of 18,000 estimated males). The global target to place
on preventive therapy 90 percent of eligible children who are TB contacts has remained elusive,
with the global average of 54 percent (vs. the 90% target) and the Philippines’ average of 6 percent
in 2020 (Stop TB Partnership 2021). In 2019, only 3.4 percent of Filipino children aged <5 who
were household contacts of bacteriologically confirmed TB cases received preventive treatment
(WHO 2020b).
The core objectives of the WHO’s End TB Strategy and the Philippines’ National TB Control
Program (NTP) for reducing TB burden include promoting healthcare seeking behavior and
healthcare utilization, improving the quality of patient-centered TB care and prevention services,
and enhancing TB political stewardship and commitment among international organizations,
national and local governments, and private or commercial sectors (DOH 2020; WHO 2020a).
A whole-of-society approach and intensive cross-sectoral engagements are needed for successful
TB control programs. As described by the WHO (2022, par. 1), engagements for TB care and
prevention can be implemented through a “public-public” mix, which entails “engagement by a
country’s NTP with public health sector providers of TB care that are not under the direct purview
of the NTP” (e.g., public hospitals, state-funded medical schools, prisons), or a “public-private”
mix, wherein “NTP engages with private sector providers of TB care” (e.g., private individual
and institutional providers, the corporate or business sector, mission hospitals, nongovernmental
organizations, faith-based organizations) (WHO 2022).
It is not uncommon in highly urbanized areas in the Philippines to have a strong private
sector, which leads in the delivery of healthcare services. However, many private healthcare
providers in the country are not linked with the NTP. The passage of Republic Act 10767 in
2016 (Comprehensive TB Elimination Plan Act, otherwise referred to as the TB law) stipulated
mandatory notification for TB and increased notification rates. It further stipulated that TB
services, (e.g., prevention, screening, diagnosis, treatment, completion of treatment) should follow
the NTP policies and guidelines.
TB in the province of Bohol: Focus on children

Access to healthcare services in island provinces like the study site, Bohol, is challenging,
especially in geographically isolated and disadvantaged areas (GIDAs). Only the public sector,
as represented by rural health units (RHUs) in each municipality, receives technical support and
supplies for TB diagnosis and treatment from the Bohol Provincial Health Office. RHUs then
offer free drugs to TB patients (Murray et al. 2019; Leining et al. 2020). Most residents in Bohol
rely on public health services in RHUs, because the services offered by private healthcare providers
are costly. Patients need to pay for diagnostics and medicines in the private sector and for other
costs, such as transportation, since private practitioners are usually located in the población
(town center). The barangay (village) health stations are unable to provide specialized TB services,
such as for diagnosis (Leining et al. 2020). Similar findings were reported in the 2016 National
TB Prevalence Survey, wherein only 19 percent of symptomatic survey participants consulted a
healthcare worker. In this group, there were twice more who went to public facilities, compared
with private providers (Lansang et al. 2021).
51
The authors previously reported about the prevalence of tuberculin skin test (TST) positivity
(weighted prevalence=6.4%) among children (<15 years old) in a large community-based
study (n=5,476 children from 200 barangay in 14 municipalities) after disasters in Bohol. TST
positivity rate was almost 30 percent in some villages. TST prevalence for Filipino children
(in general) was not known at the time of the study. Based on the weighted prevalence of
6.4 percent TST positivity and the 2010 estimates of the number of children in Bohol (422,148),
about 27,000 children were probably TST positive in the province (Murray et al. 2019). Geospatial
and hot spot analysis showed that the travel time of more than one hour from the Bohol Provincial
Health Office was associated with increased risk for TST positivity. This was a particular concern for
GIDAs, especially island villages (Leining et al. 2020).
The authors identified factors that increased the risk of TB infection among study participants,
such as being five years old or older, having a known TB contact (internal or external to the
household), and residence in a municipality with a high TB burden. These factors were considered
in the development of risk assessment scoring tools to identify children with TB or at risk of TB
infection and guided the provision of TB preventive therapy (TPT) (Gatchalian et al. 2020).
Evaluating the country’s healthcare delivery programs is crucial to achieve TB control and
elimination milestones. The disruption of health services following disasters can impede the
progress made toward reducing pediatric morbidity and mortality.
In 2013, Bohol was struck by a 7.2-magnitude earthquake, followed within weeks by super
typhoon Haiyan (locally named Yolanda), one of the strongest typhoons on record (WHO 2017;
Reid 2018). In January 2014, it was reported that in the heavily affected areas (HAA), “patients
were treated in alternative sites or tents, because 17 health stations, 1 hospital, and 8 rural health
units and their accompanying birthing units were destroyed”, and there was a need to repair
or reconstruct damaged health facilities (Philippine Humanitarian Country Team 2014, p. 1).
In the post-disaster recovery setting in 2016, the researchers organized small group
discussions with physicians to discuss the burden, treatment, and management of pediatric TB
in Bohol. The group discussions aim to describe—from the rural physicians’ perspectives and
experiences—(1) the epidemiology, diagnosis, management, and treatment of TB and the resources
and medicines for pediatric TB in both public and private healthcare sectors; and (2) how the
healthcare system was disrupted as a result of the disasters that hit the province in 2013.
METHODS
Before the conduct of the project titled “Diagnosis, treatment, and management of pediatric
tuberculosis in disasters and emergencies: Focus on Bohol in the post-disaster period”, the team met
with the then provincial governor and coordinated with his staff and other provincial government
offices (i.e., Department of Health [DOH], Department of Education [DepEd], Department of Social
Welfare and Development, and Department of the Interior and Local Government). The team
oriented the provincial officials about the community-based epidemiological study on pediatric TB
(Murray et al. 2019; Gatchalian et al. 2020; Leining et al. 2020) and the qualitative study with rural
physicians, which are part of the project.
The study team discussed with provincial officials which municipalities would be included
in the project, and which of them would be classified as HAAs—based on the extent of damage
to infrastructures (particularly health facilities), displacement of residents, and relocation of
residents (especially children) to temporary shelters—and as less affected areas (LAAs), which
were not severely damaged by the disasters but nevertheless were indirectly impacted, given the
52
extent of damage in other parts of the island province. The HAAs include the seven municipalities
of Calape, Catigbian, Clarin, Inabanga, Loon, Sagbayan, and Tubigon, on the northwest side of
Bohol. The seven municipalities in the LAAs are Anda, Alicia, Bien Unido, Candijay, Mabini,
President Carlos P. Garcia, and Ubay, which are located on the northeast side of the province.
Practicing physicians were recruited for the group discussions in March 2016 through the
Bohol Provincial Health Office for the public healthcare sector and the Bohol Medical Society for
the private sector. For physicians from the public sector (e.g., municipal health officers), letters
introducing the project were sent to the local chief executives or mayors, whose permission was
sought to allow the municipal health officers to join if the health officers consented to do so.
The study team invited and recruited municipal health officers and private physicians from each
of the towns in HAAs and LAAs. They all agreed to participate, but only 16 physicians joined
the discussions (3 public physicians and 2 private physicians in HAAs; 7 public physicians and
4 private physicians in LAAs), which took place four weeks after informed consent was obtained.
The discussions with HAA physicians are the smallest in terms of the number of participants
(3 public physicians and 2 private physicians). From a conceptual point of view, the interactive
discussion with two HAA private physicians and three HAA public physicians could be considered
dyadic and triadic interviews, respectively. From a pragmatic viewpoint, the discussions
(even with a limited number of participants) were complex and even emotional, as the participants
recalled their professional and personal experiences during the 2013 earthquake. The discussions
provided detailed information and allowed the team to elicit the experiences of rural physicians
with pediatric TB and the provision of health services in the post-disaster period.
All physicians provided written informed consent to participate in the group discussions.
They were given a questionnaire, which they could answer either by themselves or as an
interviewer-administered questionnaire. All participants preferred the self-administered option.
Requests and reminders to answer the questionnaire were sent via phone calls, text messages, and
follow-up letters. The participants were busy with their clinical duties, had heavy workloads,
and patients were waiting in the health facilities for clinical consultations when they were briefed
about the project and invited to give consent.
The health sociologist in the study team developed the physician profile questionnaire
and the questions for the group discussions, which were then reviewed by the team members.
The questionnaire was pretested among three physicians (1 female Boholano pediatrician,
1 female Boholano general practitioner, and 1 male Ilonggo general practitioner), and appropriate
revisions were made. The self-administered questionnaire covered topics like the participants’
sociodemographic background (i.e., age, sex, civil status, and educational attainment),
characteristics of clinical practice (i.e., years in practice, accreditation with the Philippine Health
Insurance Corporation [PhilHealth], location of practice, and patient load before and after
the 2013 disasters). The physicians were asked about their perceptions on the current state and
adequacy of private and government health services in Bohol in the post-disaster period.
During the group discussions, the study team asked the participants what they thought were
the five most important diseases among Boholano children. They were given five cards each to
write their answers (one disease per card). Cards of similar or related diseases were grouped
together, followed by a discussion on the responses of their fellow participants and the groupings
of diseases. The research team reviewed the initial groupings and did further regroupings when the
discussions were concluded.
53
The health sociologist in the team and three other members in attendance (1 Boholana
pediatrician, 1 Boholana general practitioner, and 1 American veterinarian-epidemiologist)
conducted all the group discussions, primarily focusing on pediatric TB and the disruption of
healthcare services due to the 2013 disasters. Since the participants are physicians, and there was
an American in the study team, the discussions were generally done in English but with a mixture
of Bisaya (lingua franca in the Visayas and Mindanao regions) and Tagalog (widely spoken in
Luzon). The small group discussions and accompanying questionnaires captured the participants’
demographic data and perceptions on various aspects of pediatric TB (Box 1).
Box 1. Topics covered in the physician profile questionnaire and group discussions
1. Physicians’ education and training background*
2. Physicians’ clinical practice*
a. Patient load (inpatients and outpatients)
b. Top five medical conditions the physician saw in his/her practice among children (≤14 years)
3. Pediatric TB+
a. Perceived importance of pediatric TB compared with other childhood diseases
b. Characteristics of pediatric TB patients
4. Experiences and perceptions+ on:
a. Ability of healthcare workers to recognize the signs and symptoms of pediatric TB
b. How TB is diagnosed and how its diagnosis differs in the public and private healthcare sector
c. How TB cases are referred between sectors
d. How TB cases are treated and managed
e. Availability of anti-TB medications
f. Challenges and factors in the diagnosis, treatment, and management of pediatric TB cases
after the 2013 disasters
g. Perceived burden of TB before and after the disasters
h. State of health services and challenges in the post-disaster setting
i. Strengths, weaknesses, and suggestions to improve the pediatric TB control program in Bohol
TB = tuberculosis
* Questionnaire; + group discussions
Source: Authors’ compilation
A discussion was first conducted among public health physicians in LAAs, followed by
a separate discussion with private physicians from the same areas. A similar sequence of
discussions was done on the following day with public health physicians in HAAs, followed by a
another discussion with private physicians. The two group discussions in LAAs were conducted
at the Don Emilio Del Valle Memorial Hospital, a government district hospital in the town of Ubay
(124 km northeast from the provincial capital of Tagbilaran City). The two group discussions with
HAA particpants were done in Tubigon (54 km from Tagbilaran City). On average, the group
discussions took almost two hours, with the shortest duration of 98 minutes for discussions with
private physicians in both HAAs and LAAs. Meanwhile, the group discussions with public
physicians were lengthier (111 minutes for LAA physicians and 134 minutes for HAA physicians).
All responses were recorded and transcribed, with Bisaya and Tagalog responses initially
translated by one of the team members who is a native Boholano speaker and general practitioner.
Jointly with the health sociologist, the physician research associate prepared the notes and
summaries of the group discussions. The data underwent iterative review and analysis to identify
common themes until a point of theoretical saturation (Saunders et al. 2018).
54
The iterative review (i.e., via face-to-face meetings, email exchanges, and document reviews)
was done by the study team members who were based in the Philippines (i.e., in Bohol, Manila,
and Laguna) and in Texas, USA. The all-female Filipino-American study team who reviewed
and analyzed the data and reviewed the reports was composed of eight members. Four of them
were present in all group discussions, including a Tagalog-Boholana health sociologist-clinical
epidemiologist, a Boholana pediatrician, a Boholana general practitioner, and an American
veterinarian-epidemiologist who is a professor of pediatric tropical medicine and US principal
investigator for the study.
Three other team members were not present during the discussions but participated in the
review of data and subsequent reports, including a Filipino pediatric infectious disease specialist
(the principal investigator for the project wherein the qualitative study was one of the component
studies), an American pediatrician with specialization in global and immigrant health and global
TB, and an American infectious disease epidemiologist. Seven team members (except for the
pediatrician-global TB expert) spent time in the study area, were residents of Bohol, or had family
ties in the province. Another colleague (an American with specializations in pediatric emergency
medicine and infectious diseases, particularly pediatric TB) provided input to the draft reports.
The data collected were descriptive and qualitative, and the data collection proceeded until
a point of data saturation was achieved. The researchers aimed to have at least four group
discussions: two group discussions in LAAs (1 with public physicians and 1 with private physicians)
and two group discussions in HAAs (1 with public physicians and 1 with private physicians).
However, they were cognizant of the possible need for additional information, organization, and
group discussions. After the group discussions and when the participants had left the venue, the
onsite team assessed how the discussions went, the emerging common themes, and other topics
that could be further probed. The debriefing session allowed the researchers to reach a consensus on
whether data saturation had been achieved, and if they needed to organize and conduct additional
group discussions. The authors conducted four group discussions as had been originally planned.
Secondary data from the provincial government of Bohol on the leading causes of morbidity
and mortality, as well as the challenges faced by the national TB program in Bohol, were reviewed
to contextualize TB as a disease in the province and provide a background on issues that surfaced
from the group discussions (Provincial Government of Bohol 2017). The Institutional Review
Boards of the University of the Philippines Manila and the Baylor College of Medicine, Houston,
Texas approved the study.
LIMITATIONS
It is important to discuss the limitations of this study. The study team members encouraged all
participants to answer all items in the questionnaire, but they were not successful for some
participants. The small number of physicians who participated in the group discussions may have
resulted in selection and respondent bias. The participants were aware, at the onset, that the study
was about pediatric TB. This could have resulted in some social desirability bias, particularly the
question on perceived importance of TB in children. The length of time that passed between the
disasters and the group discussions may have also contributed to recall bias. To minimize the
possibility of these biases, the researchers checked the available health data in the province and
benchmarked them with local health personnel and the local government officials who were in
Bohol during the disasters and responsible for the province’s relief and rehabilitation efforts.
As responses were given in English, Tagalog, and local Boholano language, misrepresentation
55
or translation errors are possible. To mitigate these issues, the discussions were transcribed by a
physician who was fluent in all three languages. She was present during the group discussions and
later went through the recordings of the discussions to create a consistent transcript between what
was said and what was intended in meaning.
RESULTS
Demographic profile of physician participants and their rural clinical practice

Four group discussions were done for the study. Three government physicians and two private
sector physicians from HAAs participated in two group discussions. In LAAs, seven government
physicians and four private physicians took part in two separate discussions (Table 1). The ages of
participants ranged from 29 to 76 years (mean: 44 years), and most of them were females (10/16).
Half of the 16 physicians were general practitioners (no residency training), 6 had completed
residency training, and 3 had graduate degrees. The participants practiced medicine for an average
of 14.2 years (with a range of 2–30 years). The locations of their rural practice before and after
the 2013 natural disasters were the same, except for one participant. Government physicians
reported practicing medicine in public facilities during office hours on weekdays and transition
to their private practices after office hours and on weekends. All physicians were accredited by
PhilHealth, ranging from 2 to 30 years, and 9.25 years on average.
Table 1. Demographic profile and selected characteristics of clinical practice of participants (n=16#)
HAAs (n=5) LAAs (n=11) All participants
Public (n=3) Private (n=2) Public (n=7) Private (n=4) Total = 16
Age* (ave. = 44 yrs.) 29–52 36–39 37–59 38–76 29–76
Sex (F) 2 1 1 2 10
Level of training
General practitioner 1 1 5 1 8
(no residency
training)
Some residency
training
Surgery 1 1
Completed residency
training
Pediatrics 1 2 3
Surgery 1 1
Internal medicine 1 1
Anatomic and clinical 1 1
pathology
Master’s degree 3
Public 1 1
administration
56
HAAs (n=5) LAAs (n=11) All participants
Public (n=3) Private (n=2) Public (n=7) Private (n=4) Total = 16
Hospital 1
management
No. of years accredited 2, 6, 10 2, 5 3–27* 8–30* 2–30*
by PhilHealth (and its (ave. = 6 yrs.) (ave. = 3.5 yrs) (ave.= 9 yrs.) (ave.= 19.7 yrs.) (ave. = 9.25 yrs.)
predecessor Medicare)
Estimated average number of patients per week (min-max)
Inpatient 0*** 20–60 3–20 50–70 0–70
Outpatient 150–300 40–400 150–400 10–200 10–400
Current patients 3 2 7 4 16
are mostly children
≤17 years old
Current patient
load (in patient and
outpatients) compared
with patient load before
the 2013 disasters****
Same 2 4 1 7
Different (increase 2 3 1 6
in patients)
No response 1 2 3
HAAs = heavily affected areas; LAAs = less affected areas; ave. = average; F= female; PhilHealth = Philippine
Health Insurance Corporation; min = minimum; max = maximum
# Data are from physician profile questionnaires
* Range in years
** Question: What is the estimated average number of patients (inpatients and outpatients) per week in the
facilities where you are practicing?
*** Public physicians in HAAs who participated in the study did not have any inpatients.
**** Question: How would you compare your current patient load (inpatients and outpatients) per week in
the facilities where you are currently practicing vs. your former patient load before the 2013 disasters?
Source: Authors’ computation
LAA government physicians reported seeing double the number of outpatients (a range of 150
to 400 outpatients per week), compared with private doctors (a range of 10 to 200 outpatients).
A range of 3 to 20 inpatients were seen per week by government physicians, and 50 to 70 inpatients
by private physicians in LAAs. Government physicians in LAAs reported no inpatients and a range
of 150 to 300 outpatients per week, compared with 20 to 60 inpatients and 40 to 400 outpatients
weekly among private physicians. Most physicians in both HAAs and LAAs stated that their
patients were mostly children (≤17 years).
Physicians were asked to compare their patient load before and after the disasters. Thirteen of the
16 participants answered this question. Overall, 7 of the 13 participants (2 HAA private physicians,
4 LAA public physicians, and 1 LAA private physician) said that their case load was the same after
the disasters. Six of the 13 participants (2 HAA public physicians, 3 LAA public physicians, and
57
1 LAA private physician) who responded to this question saw an increase in the number of patients.
Three of the four private physicians who responded said that their patient load was the same after
the disasters, while one private physician reported an increase in outpatient visits to their clinic.
Out of the nine public physicians who gave responses, five noted an increase in patients, and
four said their patient load was unchanged.
Public physicians in Bohol attended to more patient consultations, compared with private
physicians. Patients in GIDAs, especially island villages, usually had access only to public
physicians who visit a few times a year, depending on the schedule and patient load in RHUs,
which are located in the generally more populated poblacion. Other factors affecting the frequency
of visits of public physicians in GIDAs were weather and travel conditions and the availability
of transportation. Private physicians rarely rendered healthcare services in remote villages,
whether they be mountainous or on an island. The major themes discussed in the four group
discussions are presented in Figure 1.
Figure 1. Major themes in the group discussions with Bohol physicians from public and private
sectors, March 2016
TB prevalence is believed to be higher in remote villages, coastal villages,

and on islands and among impoverished and malnourished families.
Procurement and supply chain issues delay TB testing and treatment

and result in loss to follow-up and non-adherence of patients to treatments.
The lack of regular and consistent training of public and private healthcare
workers impedes knowledge to correctly recognize the signs, symptoms, and
radiologic findings of TB, which are paramount for pediatric TB diagnosis.
There is a need for local leaders to (1) spearhead initiatives to fund TB control
programs and (2) strengthen the partnership between the public and private
healthcare sectors for critical support during stockouts.
Barriers to TB control are further amplified during emergencies and disasters.

There should be standard operating procedures to ensure the adequate
supplies of medicines and also to protect the supply chain during normal
and disaster affected times.
TB = tuberculosis
Source: Authors’ rendition
Leading causes of morbidity and mortality in Bohol and challenges in the NTP
Secondary data from the provincial government of Bohol give context on the leading causes of
illness and death in the area and the importance of TB and provide background on issues that
surfaced from the group discussions. These data were not discussed with the participants so as not
to influence their responses.
Based on the 2016 Annual Report of the Provincial Government of Bohol, the number one cause
of morbidity across all age groups and sexes was upper respiratory tract infections. Pneumonia
(all types) was the primary cause of mortality in 2015 and for the preceding five-year period
(2010–2015). Respiratory tract infections were also the leading cause of morbidity. Meanwhile,
fetal death or stillbirth was the leading cause of mortality among infants and children <5 years old.
58
In 2015, the leading causes of morbidity among Boholano children <5 years old were
respiratory tract infections, bronchitis, gastrointestinal/diarrheal diseases, skin disorders
(all types), infection, fever (unknown origin), influenza/coryza, cough, and neoplasms/malignancies.
The leading causes of mortality among children <5 years old were fetal death/stillbirth, pneumonia
(all types), sepsis/septicemia, asphyxiation, cardiorespiratory disease, electrolyte imbalance,
congenital abnormalities, infections, respiratory distress syndrome, prematurity, and upper
respiratory tract infections. The Provincial Government of Bohol (2017, p. 570) noted that “in the
province of Bohol… TB is not among the top 10 causes of mortality, but it remains to be a public
health burden”. The same report listed the major development issues and challenges of the NTP
in Bohol (Table 2).
Table 2. Major development issues and challenges of the NTP in Bohol

Major development issues and challenges of the NTP in Bohol Priority number of issue
Lack of medical technologists to operate microscopy centers 1
Continuous increase of drug-resistant TB cases 2
Stockout of anti-TB drugs, laboratory supplies, and other commodities 3
Inactive TB task forces and community partners 4
Overloading of programs handled by the local NTP coordinators 5
Absence of a half-way house for Programmatic Management for 6
Drug-Resistant TB Satellite Treatment Centers
Sustainability of the enhanced hospital DOTS initiative 7
Need for strengthened and more sustainable TB DOTS referral system 8
TB = tuberculosis; NTP = National Tuberculosis Control Program; DOTS = Directly Observed Treatment
Short-course
Source: Provincial Government of Bohol (2017, p. 591–592)
Most important diseases among children in Bohol as perceived by physicians

The participants were asked what they thought were the five most important diseases among
Boholano children (Table 3). Each of the physicians had his own perception of these diseases. Thus,
more than five diseases are presented in Table 3. Acute gastroenteritis was the most frequently
reported disease. Respiratory diseases, including TB in children, were rated of high importance.
TB was mentioned as an important disease in Bohol among children by two physicians in HAAs
(2/5) and five physicians in LAA (5/11).
Table 3. Most important diseases among Boholano children* as perceived by participants

and regrouped by theme
Physicians’ preceived most important
HAA LAA Total
diseases among Boholano children
Public Private Public Private

Acute gastroenteritis (e.g., diarrhea/dehydration,
acute infectious diarrhea, water/food transmitted 1 2 5 4 12
infections, amoebiasis)
59
Physicians’ perceived most important
HAA LAA Total
diseases among Boholano children
Public Private Public Private
Pneumonia 3 4 2 9
TB 1 1 4 1 7
Dengue/arboviruses 2 1 1 1 5
Urinary tract infection 3 2 5
Skin diseases including impetigo 3 2 5
Malnutrition 1 3 4
Accidents, injuries, wounds 1 2 1 4
Acute tonsillitis 1 1 2
Cancer 1 1 2
Acute febrile illness and other viral infections 1 1 2
Congenital anomalies 2 2
Acute bronchitis 1 1
Bronchial asthma 1 1
Allergies 1 1
HAA = heavily affected area; LAA = less affected area; TB = tuberculosis
*Question: What do you think are the five most important diseases among children in Bohol?
Importance of pediatric TB compared with other childhood diseases

Almost all physicians perceived that TB was important, with only one physician in the LAA
public sector saying that TB was not as important as other diseases. When asked to rank the
importance of TB in children compared with other childhood diseases (10–lowest importance;
1–highest importance), TB was ranked of highest importance by five participants (3 in HAAs
and 2 in LAAs). None of the physicians thought that TB was of lowest importance, but it was
ranked 8th by one LAA government physician. From a methodological perspective, the perceived
importance of TB vis-à-vis other diseases in children could be influenced by the fact that the study
focuses on pediatric TB. But this might be the same situation for other disease specific studies,
wherein the topic is already disclosed in the informed consent form.
Perceived differences in the prevalence of TB by sex, place of residence, and socioeconomic status
There was no perceived sex difference in the prevalence of pediatric TB across all groups.
Government physicians in HAAs were the only ones who did not see any difference in the TB
prevalence across various geographical locations (e.g., upland, lowland, coastal areas). Although
in a follow-up question, they agreed that TB was more prevalent in congested areas. HAA private
physicians said that TB was more common in coastal areas and less common in upland areas,
which they attributed to better ventilation. LAA government physicians expressed similar views
but pointed out that there were more TB cases on isolated islands. An LAA private physician
said that remote villages had poor access to health services, which accounted for the geographic
60
differences in TB prevalence. LAA government physicians reported more TB cases in large

households. The disease was thought to be more prevalent among low-income families because of
poor nutrition, sanitation, and bed sharing. For wealthier families, the participants believed that
paid caregivers could be a source of TB.
Perceived capability to recognize the signs and symptoms of pediatric TB

Participants were asked to assess the capability of parents and/or caregivers and health workers to
recognize the signs and symptoms of pediatric TB. HAA physicians said that symptoms were usually
treated first as common respiratory infections, and TB was only considered later if all options had
been exhausted and the symptoms persisted. For them, TB was harder to diagnose in children than
in adult patients. A private practitioner pointed out having extensive training in medical school,
but their latest training on pediatric TB had occurred several years before the conduct of the small
group discussion. The participants believed that all medical staff could benefit from a refresher
training on the signs and symptoms of TB. They were asked if they had a checklist in their minds
pertaining to diagnosing pediatric TB when having a clinical consultation with a child with
suspected TB. An LAA private physician said that their hospital staff were aware of the signs and
symptoms of TB, because they received instructions and guidelines on TB diagnosis and treatment.
Doctors should not immediately conclude that a patient is negative for TB based on diagnostic
tests alone. The correlation of test results with the patient’s clinical exam, signs and symptoms,
and medical history is needed for a diagnosis.
Diagnosis of pediatric TB in Bohol’s public and private healthcare systems

All participants used TSTs. However, they had difficulty accessing tuberculin purified protein
derivatives (PPDs) for the patients. Among the barriers to the routine use of TST in clinical
practice are the erratic supply of PPDs in health centers, cost of PPDs, and cost of transportation
from the patients’ home to the provincial or district hospital. During the few instances that PPDs
were available in government health centers, there were concerns in opening a vial, if there were
not enough patients to be tested. Patients are scheduled to return on the same day to maximize the
available tests from an open vial. Unfortunately, this could lead to loss to follow-up due to financial,
time, and travel constraints.
HAA participants mentioned that while they had facilities and diagnostic tests for TB, the
erratic availability of supplies was a problem. In LAAs, a participant said that supplies were
available at the provincial health office, but the physicians must travel for about four hours to
obtain these supplies. In the absence of TST, diagnosis is typically made based on clinical
observation of TB compatible signs and symptoms of cough for two weeks, loss of appetite,
weight loss, reduced drive to play, back pain, chest pain, enlarged lymph nodes, fever, and chest
radiography. Physicians consider TB if a child had reported TB exposures or failed to respond
to antibiotic treatment. Sputum is requested for microscopy if the patient can expectorate.
One physician said that children are referred to the RHU for testing, if they live in a household
with a diagnosed adult TB patient.
Across both LAAs and HAAs, the physicians believed that TST was more available in the
private sector. Most private practitioners can buy their own TST kits and include the cost in their
consultation charges. Government physicians rely on the procurement and supply of PPD from
the local government units (LGUs), because TST services are at no cost to the patient when
available. Patients are occasionally referred to private pediatricians or at the provincial hospital in
61
Tagbilaran City for TST if it is not available at the RHU. One private physician believed that the
recognition of TB was better and more expedient in the private healthcare system but at a higher
cost to the patient. The private practitioner can quickly follow up if the patient does not respond
to antibiotics, allowing prompter and more aggressive patient care. Only one private practitioner
believed that the diagnosis of TB in children in both healthcare sectors was the same.
When asked whether it was better for pediatric TB to be diagnosed in private healthcare
facilities than in the public ones, the responses varied, with pros and cons to both. Those who believed
that pediatric TB was best diagnosed in private healthcare system cited the faster TB diagnosis
and wider availability of TST and anti-TB medications, which are out-of-pocket expenses. Those
who believed that pediatric TB was better diagnosed in the public healthcare system mentioned
that government physicians have more consistent training on TB, and they diagnose and treat
TB cases according to the NTP guidelines if the resources (e.g., TST, pediatric TB medicines)
are available. Barangay health workers (BHWs) who work closely with health professionals
(e.g., rural health physicians and midwives, public health nurses) in the public sector (who are
in charge of the patients) can administer directly observed therapy (DOT) to a child if there is
no treatment partner available in the patient’s household. BHWs can also monitor the patient’s
response to the medication and report on his progress to other members of the healthcare team.
They can also motivate patients (or their caregivers) to regularly take their TB medicines and visit
their doctors for checkups.
Bohol’s referral system for pediatric TB

The referral system from private to public healthcare sector was facilitative of diagnosing and
treating pediatric TB. However, participants pointed out the gaps between public and private
practitioners in the diagnosis, treatment, and management of TB in children, such as the
perceived noncompliance of private practitioners with the NTP policies and guidelines. An HAA
government physician said that they usually receive a referral to initiate the first line of anti-TB
medications and/or to test the patient’s sputum for direct sputum smear microscopy (DSSM).
Getting an adequate sputum sample from children is difficult, and the preference—as far as ease
of testing is concerned and if the child cannot produce sputum—is to use the Mantoux TST if it
is available. Public physicians and their teams gather a specified number of children (usually 8 to
10 children) during a common schedule for testing before they can open a vial of PPDs to avoid
wastage. However, they often lose patients who are unable to come back on the designated schedule.
At the time of the study, GeneXpert testing was being rolled out in the province, but access to
testing was limited to the provincial health office and the district hospital in Ubay.
The child starts treatment if the DSSM results are positive and the medicines are available.
If DSSM was done previously based on information from the patient and/or caregiver, but
the results are not documented in the patient’s medical record, the physicians request a chest
radiograph to aid in the diagnosis. The participants consider chest X-rays as a tool in TB
diagnosis among children, if DSSM and/or TST are not available and/or they are uncertain of
the patient’s clinical presentation (e.g., sign and symptoms, clinical history). However, the
physicians are cognizant of the difficulty of accessing services to have X-rays due to costs involved
(e.g., payment for X-ray and transportation, opportunity costs). An LAA private physician noted
the shortage of licensed radiologic technologists in Bohol.
Sometimes, patients come to RHUs without formal referral or arrive with just a radiograph.
In this case, the physician contacts the referring doctor about treatment plans. The participants
initiate treatment only upon a written referral. One of them agreed that if a patient comes in
62
without a referral, they look at the patient’s previous TB tests, including the laboratory results,
DSSM, radiographs, and request to run any additional tests. However, an HAA private practitioner
said that patients who go to RHUs without referrals are lost to follow-up with private physicians
and shift to a public facility. The switch from private to public sector most likely happens
because of cost constraints, since the NTP services in the public sector are at no cost to patients.
This leaves government physicians frustrated at times, because they believe private physicians are
aware of the NTP and its prescribing guidelines, but ask patients to pay for medications instead
of referring them to RHUs for free treatment. Some patients are unaware of their treatment
options. Private practitioners in HAAs refer private patients to RHUs for free treatment.
Treatment of pediatric TB in Bohol

Medicine supply was seen as erratic and sometimes lacking in Bohol. HAA public physicians
prescribed pediatric formulations for isoniazid and rifampicin. Vitamins were added to the treatment
regimen of patients if they were available. Among the private practitioners in HAAs, a physician said
that they would combine rifampicin, isoniazid, and pyrazinamide for treatment with two months
of acute intensive phase and a four-month maintenance period. Private practitioners in LAAs also
prescribed pyrazinamide, isoniazid, and rifampicin. An LAA physician said that they performed
TB skin test, and if the patient was positive for pulmonary TB, they would prescribe isoniazid.
If TB was extrapulmonary, they would add streptomycin to the regimen. Another participant said
that he did not treat TB in his private practice, because patients would stop their treatment if
they would pay for it. He believed that it was better for patients to attend the RHUs, because they
were monitored and have continuity of care. Public physicians in HAAs pointed out that isoniazid
preventive therapy (IPT) was not available for household contacts of TB patients, even though they
were instructed to give IPT to exposed contacts. Another physician said that they had isoniazid
stockouts for two years. Three physicians who commented on the lack of supplies were unsure
about the condition of exposed patients. The question of whether IPT really made a difference in
the transmission of TB came up in the discussion. They suggested to conduct a study comparing
the probability of contracting TB between exposed household contacts who were given IPT and
those who were not given IPT.
Management of pediatric TB in Bohol

The importance of patients’ adherence to treatment and monitoring of pediatric TB cases were
stressed in the discussions. For example, contact tracing did not seem to be a standard practice in
HAAs and LAAs. An HAA government physician said that the proper scheduling of diagnostic
workup and checkups, consistent availability of medication, and contact tracing are essential in
managing pediatric TB. Contact tracing can be problematic if the exposed household members
refuse testing or deny any symptoms. There was a discussion on the differences in managing
childhood TB in the public and private healthcare sectors. Government physicians said they
have to comply with the NTP guidelines and procedures and the strict TB-DOTS recordkeeping
because of the funding by the United States Agency for International Development (USAID).
However, not all patients who consulted with or treated by private practitioners were identified
or officially recorded as TB cases.
An HAA government physician believed that the healthcare system management for
TB was the same in public and private healthcare centers, since patients are followed up and
monitored in both sectors. In the office of one LAA private physician, a nurse did patient
follow-up and asked the RHU if the private patients referred to them had actually consulted the
63
RHU. An LAA private physician followed up with patients for six months and tracked their
progress by determining who continued to buy medicines from the clinic (even if physicians were
not supposed to dispense medicines). The private physicians attempt to follow up pediatric TB
patients and/or their parents or caregivers if the patient stops treatment. If the patient and/or his
family or caregiver happened to consult again for another cause, whether for pediatric TB of the
patient himself or for another family member, the physician would inquire about the pediatric TB
patient’s disrupted treatment.
Availability of medicines for treatment of TB in children

Ensuring a consistent supply of pediatric TB medicines remains to be a logistical challenge
in Bohol. All participants mentioned the stockout of pediatric TB medicines, which lasted for
many months. HAA government physicians had supplies of anti-TB medicines at the time of the
group discussions but had gone a year without these medicines. On one occasion, they had to ask
the LGU to purchase pediatric TB drugs using the municipal funds. The HAA private physicians
reported the erratic supply of medications, such as having no supply of drugs or having them in
very small quantities due to rationing of the provincial health office to accommodate more patients
and give them equal access to treatment, even if this resulted in having inadequate allocation of
drugs for each patient.
In times of stockouts, one of the physicians would ask the patients to buy their medications,
but they would eventually fail treatment because of the high costs of medicines. A physician felt
like they were giving the patients empty promises during stockouts. As a result, they would delay
starting treatment. The same physician disclosed that when they resume treatment after stockouts,
which could last for many months, they no longer reevaluate the patient and just resume the
medication instead.
Physicians from LAAs also reported stockouts. The supply of pediatric TB medicines,
whether for free in RHUs or for purchase in drugstores, was problematic. A physician who
practiced in both public and private healthcare sector reported going a year without a supply
of TB medications. The initial stock they were provided was consumed in the first month after it
was delivered, since some of the anti-TB drugs were given to inpatients. Released inpatients are
given one-week supply of anti-TB medications before they are referred to RHUs for the rest of the
treatment. This process helps conserve stocks at the RHUs. Hospital nurses and physicians do
follow-ups to ensure that the patients complete the treatment. A physician expressed concern
about the stockouts and its impact on their patients’ health outcomes. Secondary data from the
provincial government of Bohol corroborated the observations of participants.
Perceived burden of disease due to TB before and after the 2013 disasters in Bohol
The participants had varied opinions on whether the number of TB cases were the same or
increased, following the disasters in 2013. Only two physicians believed that TB cases
had decreased in the province. Half of the participants thought that the number of cases had
increased, while six believed that it remained. Another participant agreed that the burden of
disease was the same, but that there had been improvements in the health seeking behaviors of
patients (Table 5).
64
Table 5. Perceived burden of disease due to TB in Bohol before and after disasters
Perceived burden of disease due to TB HAA-Public HAA-Private LAA-Public LAA-Private Total
in Bohol before and after disasters (n=3) (n=2) (n=7) (n=4) (n=16)
Number of TB cases was the same/unchanged 1 2 3 6
Number of TB cases has gone down/improved 1 1 2
Number of TB cases has worsened/more cases 2 3 3 8
TB = tuberculosis; HAA = heavily affected area; LAA = less affected area
Source: Authors’ computations
Changes in the diagnosis, treatment, and management of pediatric TB after the 2013 disasters
HAA participants believed that the disasters resulted in slight improvements in health facilities
and resources. One participant agreed that healthcare facilities were improved and the medicines
became more available and were continuously supplied after the disasters. Despite the influx of
patients, their needs were attended to and the capacity of healthcare facilities was increased.
Another participant expressed reservations about the sustainability of using GeneXpert for
TB diagnosis even in the post-disaster setting, because the training of staff was not sustained.
This participant expressed concern on the return of TB medication stockouts because of the
unreliability of the supply of diagnostics and drugs for pediatric TB. They attributed the decline of
these items to the focus given by the DOH on Leyte, another province in Visayas that was severely
hit by the super typhoon. The LAA participants did not notice any changes in the way pediatric
TB was diagnosed, treated, or managed since the 2013 disasters. One participant believed that the
situation was the same, because their side of the province was less affected by the disasters.
Strengths and weaknesses of the pediatric TB program in Bohol: Suggestions for improvement
An HAA government physician believed that the monitoring of TB in children and the availability
of PPD reagents were some of the strengths of the pediatric TB control program in Bohol.
Other strengths were the active TB monitoring system (mainly through BHWs who follow up
with patients) for adults and children, along with the strong PPD screening program for TB
case-finding in private hospitals. A weakness mentioned by the participants was the lack of medical
technologists and radiology technicians to aid in the diagnosis of TB. A private LAA physician said
that they had an X-ray machine but did not have a licensed radiology technician to operate it.
Participants were asked for their suggestions to improve the pediatric TB control program in
Bohol. They cited the crucial role of the local chief executives in health planning, procurement,
and mitigation of stockouts and the enactment of ordinances for pediatric TB. Officials must
increase the number of adequately and regularly trained health personnel to focus on pediatric TB
and do active case finding (including for latent TB infections [LTBI]). The erratic and inadequate
supply of diagnostics and medicines and the lack of funding should be addressed. In addition,
social mobilization and partnerships between community stakeholders and agencies (e.g., DepEd)
to improve TB education must be intensified (Table 6).
65
Table 6. Suggestions of rural physicians to improve the pediatric TB control program in Bohol
For local chief executives
Suggestions from HAA participants:
• Health should be a priority of the local chief executives. Mayors should be involved in health planning,
since they control the budget and resources for health programs.
• Local ordinances for the pediatric TB program should be passed and implemented with the cooperation
of other stakeholders (e.g., DepEd).
Suggestion from LAA participants:
• LGUs should have a local NTP representative to help procure supplies and mitigate stockouts of
anti-TB medications.
For healthcare personnel
Suggestions from HAA and LAA participants:
• Increase the number of health personnel who can focus on TB in children.
• Address the lack of personnel in both public and private sectors and the shortage of medical
technologists and radiologic technologists in the area.
• Ease the heavy workload of frontline health workers, which hampers their focus on treating pediatric TB.
• Tap the staff of Nurse Deployment Program to conduct house-to-house case investigations.
For trained healthcare workers and other stakeholders
Suggestions from HAA and LAA participants:
• Conduct frequent trainings, specifically on the diagnosis of pediatric TB. Many of the healthcare
workers’ trainings are outdated. For example, the last training of some healthcare workers in the area
was conducted seven years ago. This is problematic because they cannot identify TST positives or
recognize TB-compatible signs or symptoms.
• Increase funding for the NTP and the supply of medicines
• Intensify social mobilization and multisectoral campaigns to educate community members and school
personnel on pediatric TB. Boholanos need more information and awareness on TB, especially in children.
For active TB case-finding
Suggestions from HAA participants:
• Actively look for undiagnosed TB cases instead of waiting for walk-in patients.
• Improve the structure of TB DOTS program by strengthening active case finding to identify LTBIs.
• Improve resources to conduct active case finding through house-to-house case finding.
• Provide free PPD skin test for all children and adults aside from free BCG vaccine.
TB = tuberculosis; HAA = heavily affected area; LAA = less affected area; DepEd = Department of Education;
LGUs = local government units; NTP = National Tuberculosis Control Program; TST = tuberculin skin test;
DOTS = Directly Observed Treatment Short-course; LTBIs = latent TB infections; PPD = purified protein
derivative; BCG = Bacillus Calmette-Guerin
Source: Authors’ summary
DISCUSSION
The results of the group discussions highlight the need for equitable and efficient delivery of
accessible and quality TB healthcare services even before the series of disasters and emergencies.
Pediatric TB in Bohol is affected by multiple factors, such as poverty, lack of healthcare seeking
behavior, low TB education, and limited healthcare access of patients, and supply chain issues,
limited resources, and lack of funding at the system level. The already-fragile health infrastructure
66
is further strained when emergencies occur, which is a common concern for a disaster-prone
country like the Philippines (UNICEF 2022). Issues in the patients’ health seeking behaviors,
as well as the stockouts and limited resources for TB diagnosis and treatment, remained after the
occurrence of disasters in 2013. Participants had mixed responses on whether there was a higher
TB burden before or after the earthquake and the super typhoon. In both healthcare sectors in
LAAs and HAAs, the participants saw improvements in health facilities in the late post-disaster
period, because of the renovation and building of new clinics, increase in bed capacity, and
provision of new equipment. Stockouts were still a concern in both areas, as aid was directed by
the provincial health office and relief organizations for other post-disaster emergencies. Similar
challenges (i.e., stockouts, lack of personnel and active community partnerships, and overloaded
NTP coordinators) were mentioned in the provincial government of Bohol’s assessment of the NTP.
Following the small group discussions, the researchers conducted a household-based cluster
survey in Bohol and found a province-wide TST-positive prevalence of 6.4 percent among
children <15 years old (Murray et al. 2019), which was much higher than expected. Villages with
high TST positive prevalence were farther away from the provincial health office. Geographically
isolated villages were especially vulnerable to TB, with TST positive prevalence in children as high
as 29 percent. Remote islands are also more likely to suffer from poverty, creating an even greater
risk for TB infection (Leining et al. 2020). The findings from the two parallel studies further
corroborated what the rural physicians had earlier described: TB was more prevalent in coastal
towns, remote villages, on remote islands and among large and impoverished families with poor
sanitation and malnutrition.
In 2015, Snow et al. (2018) found that children (<15 years old) in the Philippines accounted
for almost 13 percent of diagnosed incident of TB, and older adolescents and young adults
(15–24 years old) accounted for 14.5 percent of reported TB cases. It emphasizes the importance
of heightened focus on TB prevention, treatment, and control programs among children.
Greater distance to healthcare facilities also negatively impacts access to health care, thereby
impeding diagnosis and treatment of TB. According to the WHO (2020b), healthcare seeking
behavior and deficiencies in diagnosing TB are responsible for the global gap between estimated
and notified TB cases. In 2020, the Philippines contributed to 7 percent of the global gap in TB
cases. Notified cases varied geographically and by age group (WHO 2021).
Similarly, the 2015 National TB Surveillance Survey showed that TB cases demonstrated a
high degree of geographic variability in incidence by age group and highlighted the gaps in
the disease’s diagnosis, particularly among children (Snow et al. 2018). These findings support
perceptions of participants that the patients’ healthcare seeking behaviors are critical for TB
diagnosis, and the lack thereof contributes to underdiagnosis and underreporting of pediatric
TB cases in the country. TB diagnosis is reliant on caregivers persistently seeking health care and
providers being able to recognize pediatric TB. The population in general should also be made
more aware of the typical signs and symptoms of pediatric TB. Rural physicians push to educate
communities and healthcare personnel on the signs and symptoms of TB to improve its diagnosis.
Physicians in Bohol primarily rely on signs and symptoms for TB diagnosis, but their training was
out of date.
The participants consistently reported challenges in diagnosing and treating pediatric TB due
to procurement and supply chain issues, similar to what was reported at the national level by
the NTP in 2016 (Lansang et al. 2021). Diagnostic supplies, equipment, and even personnel,
particularly medical and radiologic technologists, were in short supply in Bohol (Provincial
Government of Bohol 2017). The participants perceived that stockouts of PPDs in Bohol had
67
resulted in delayed diagnosis, and, consequently, delayed initiation of treatment. This common
perception among the physicians highlights the reliance on tests of Mycobacterium tuberculosis
infection despite the WHO diagnostic guidelines including the tests of infection as optional.
Loss to follow-up happens in the private sector because of the financial burden on the patient to
cover out-of-pocket costs for travel, consultation, tests, and treatment.
Stockouts of pediatric TB medicines and diagnostics have implications for (1) sick children
being turned away from clinics, the possibility of interrupted treatment, and the concomitant
problem of drug resistance, such as what was reported in India (Anand et al. 2013); and (2) greater
socioeconomic inequalities like more stockouts and worse TB treatment outcomes in poorer
areas and the different abilities of provinces to deal with stockouts and monitor supply chains, as
documented in South Africa (Hwang et al. 2019; Koomen et al. 2019).
The participants suggested to ensure the stricter adherence to the NTP guidelines of all
sectors. The supply of TB diagnostic equipment, medicines, and personnel must be improved.
They recommend strengthening the collaboration of the public and private healthcare sectors and
the LGUs and to prioritize health programs and secure funding for medical supplies and equipment.
These are critical for TB control, patient referrals, and surge capacity of healthcare facilities during
emergencies. As outlined in the End TB strategy, eliminating TB requires enhanced multisectoral
collaboration and the persistence of local governments to ensure enough funding for TB screening,
diagnosis, and treatment. More responsive local policies and active support from local officials
(and other provinces with similar remote communities) are also needed to identify and implement
setting-specific strategies. Policies must be appropriate and feasible to address the frequently
unrecognized burden of TB in children.
In conclusion, this study provides insights on the perceived impacts of disasters on the
diagnosis, treatment, and management of pediatric TB in a remote province in the Philippines.
Already existing weaknesses in the country’s health system are exacerbated by disasters.
Physical infrastructure repairs conducted in the late disaster period afforded improvements.
Nevertheless, the impact of physical improvements is hampered by a dearth of education on TB
in general and pediatric TB and the continued supply chain disruptions, which are common in the
predisaster period. This study highlights opportunities to improve the diagnosis, treatment, and
control of TB in children in a high-risk setting. Achieving TB elimination goals outlined by the
WHO’s End TB Strategy is contingent on increasing stewardship through improved stakeholder
collaboration and zero stockouts, better diagnostics, and treatment options. Social science research
is also critical in identifying the strengths, weaknesses, opportunities, and threats to eliminating
TB in vulnerable populations, especially among children in disaster-stricken communities.
ACKNOWLEDGMENTS
The authors would like to thank the families and children who participated in this study.
They extend their gratitude to the physicians, nurses, and other health workers at the Bohol
Provincial Health Office, municipal rural health units, and barangay health stations.
The invaluable work of the PEER Health Bohol Pediatric Study Team (Hazel M. Remolador,
Zarah Jane H. Tubiano, Rhea Annvi H. Lofranco, Ellen D. Lague, Riovi May S. Salmasan,
Caya R. Estoque, Fernando B. Lopos, Diozele Hazel M. Sanvictores, Carmelita D. Amora,
Maureen Mae C. Riña, Catherine O. Calipes, Jeia Pondoc, Marlo Tampon, and Myra Riccil Estose;
Katherine Ngo and Andrea Tania Cruz; and the study team’s partners, Reymoses Cabagnot, Polizena
Rances, Mutya Kismet T. Macuno, Crisanta Estomago, and Nelson Elle) is gratefully acknowledged.
68
The authors dedicate this publication to honor Dr. Salvacion Rodriguez-Gatchalian, the study’s
Philippine principal investigator. Dr. Gatchalian was a pediatric infectious disease specialist and
staunch advocate of child health in the Philippines. COVID-19 might have “silenced her voice”,
but the authors continue with Dr. Gatchalian’s advocacies for Filipino children, especially those
with TB. Manang Sally will be forever missed but never forgotten.
This study was funded in part by the USAID and the US National Academy of Sciences
through the PEER Health Program.
REFERENCES
Aldaba, J.G., M.C.G. Ama, A.M. Salonga, P.G. Sylim, J.N. Sarol Jr., and A.L. Lopez. 2018. Diagnosis and
management of childhood tuberculosis in public health clinics in a rural area in the Philippines:
Results from a community surveillance. Acta Medica Philippina 52:4.
Anand, G., S. Shah, and B. McKay. 2013. Shortages of drugs threaten TB fight. The Wall Street Journal.
June 6. https://online.wsj.com/article/SB10001424127887323469804578523262257381332.
html?reflink=desktopwebshare_permalink (accessed on April 13, 2022).
Department of Health (DOH). 2020. Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020–2023.
Manila, Philippines: DOH. https://ntp.doh.gov.ph/download/updated-philippine-strategic-tb-
elimination-plan-2020-2023/# (accessed on April 9, 2022).
Gatchalian, S.R., N.T. Agathis, N.T. Castillo-Carandang, S.M. Gunter, K.O. Murray, and A.M. Mandalakas.
2020. Design and evaluation of risk assessment tools to identify pediatric tuberculosis infection in
Bohol, Philippines, a low-HIV- and high-TB-Burden setting. American Journal of Tropical Medicine
and Hygiene 103(5):1818–1826.
Hwang, B., A. Shroufi, T. Gils, S.J. Steele, A. Grimsrud, A. Boulle, A. Yawa, S. Stevenson, L. Jankelowitz,
M. Versteeg-Mojanaga, I. Govender, J. Stephens, J. Hill, K. Duncan, and G. van Cutse. 2019.
Stock-outs of antiretroviral and tuberculosis medicines in South Africa: A national cross-sectional
survey. PLoS ONE 14(3):e0212405.
Institute for Health Metrics and Evaluation (IHME). 2020. Global burden of disease 2019: Cause and risk
summary. Seattle, WA: IHME. http://ihmeuw.org/5qd4 (accessed on April 8, 2022).
Koomen, L.E.M., R. Burger, and E.K.A. van Doorslaer. 2019. Effects and determinants of tuberculosis drug
stockouts in South Africa. BMC Health Services Research 19:213.
Lansang, M.A.D, M.M. Alejandria, I. Law, N.R. Juban, M.L.E Amarillo, O.T. Sison, J.R.B. Cruz, C.F Ang,
J.A.L Buensalido, J.P.A. Cañal, N.T. Castillo-Carandang, C.P. Cordero, D.M.G. Gaviola, M.A.J. Ladia,
J.B.V. Mantaring, M.T. Mendoza, M.S.S. Salamat, H.Y. Lam, M. Tadolini, and A.M.C.G. Garfin. 2021.
High TB burden and low notification rates in the Philippines: The 2016 national TB prevalence
survey. PLoS ONE 16(6):e0252240.
Leining, L., S. Gatchalian, S. Gunter, N.T. Castillo-Carandang, A. Mandalakas, A. Cruz, J.B. McCormick, and
K.O. Murray. 2020. Geospatial and hot spot analysis of paediatric tuberculosis infection in Bohol,
Philippines. Epidemiology and Infection 148:E89.
Murray, K.O., N.T. Castillo-Carandang, A.M. Mandalakas, A.T. Cruz, L.M. Leining, and S.R. Gatchalian. 2019.
Prevalence of tuberculosis in children after natural disasters, Bohol, Philippines. Emerging Infectious
Diseases 25(10):1884–1892.
Philippine Humanitarian Country Team. 2014. Philippines: Bohol earthquake action plan (Revised).
https://reliefweb.int/sites/reliefweb.int/files/resources/Bohol%20Earthquake%20Action%20Plan%20
%28BEAP%29%20Revision%20FINAL.pdf (accessed on April 13, 2022).
Provincial Government of Bohol. 2017. Annual Report for CY 2016. https://ppdo.bohol.gov.ph/ppdofiles/
AnnualReport_2016.pdf (accessed on April 20, 2022).
Reid, K. 2018. 2013. Typhoon Haiyan: Facts, FAQs, and how to help. World Vision. https://www.worldvision.
org/disaster-relief-news-stories/2013-typhoon-haiyan-facts (accessed on December 26, 2020).
69
Saunders, B., J. Sim, T. Kingstone, S. Baker, J. Waterfield, B. Bartlam, H. Burroughs, and C. Jinks. 2018.
Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality
and Quantity 52:1893–1907.
Snow, K., R. Yadav, J. Denholm, S. Sawyer, and S. Graham. 2018. Tuberculosis among children, adolescents
and young adults in the Philippines: A surveillance report. Western Pacific Surveillance and Response
Journal 9(4):6–20.
Stop TB Partnership. 2021. Tuberculosis situation in 2020: Philippines. https://www.stoptb.org/static_pages/
PHL_Dashboard.html (accessed on April 8, 2022).
World Health Organization (WHO). 2017. Bohol earthquake: Six months on. Manila, Philippines: WHO
Representative Office for the Philippines. https://www.who.int/philippines/news/feature-stories/
detail/bohol-earthquake-six-months-on (accessed on February 4, 2021).
———. 2020a. The END TB Strategy. Geneva, Switzerland: WHO. https://www.who.int/teams/global-
tuberculosis-programme/the-end-tb-strategy (accessed on June 16, 2022).
———. 2020b. Global tuberculosis report 2020. Geneva, Switzerland: WHO. https://apps.who.int/iris/rest/
bitstreams/1312164/retrieve (accessed on April 9, 2022).
———. 2021. Global tuberculosis report 2021. Geneva, Switzerland: WHO. https://apps.who.int/iris/rest/
bitstreams/1379788/retrieve (accessed on April 9, 2022).
———. 2022. Public-Private Mix (PPM) for TB care and prevention. https://www.who.int/activities/public-
private-mix-(ppm)-for-tb-care-and-prevention (accessed on June 17, 2022).
70
Learning from Stories Behind

Unexpected Results: A Qualitative
Follow-up Study on the Third
Impact Evaluation of 4Ps
Nina Victoria V. Araos, Kris Ann M. Melad,
and Aniceto C. Orbeta Jr.1
ABSTRACT
Consistent with previous evaluations, the third wave impact evaluation (IE3)
of the Pantawid Pamilyang Pilipino Program (4Ps) provided evidence that the
program was able to achieve its main goal to keep children healthy and in school.
However, the evaluation highlighted unexpected results on some outcomes,
particularly child nutrition, maternal health, and labor market outcomes.
To gain insights on the IE3’s unexpected findings, this study conducted focus
group discussions with 4Ps beneficiaries and nonbeneficiaries from identified
areas and key informant interviews with program stakeholders. It used thematic
analysis to examine the interview transcripts and tease out relevant discussion
themes. The results show that the lack of proper understanding of the importance
of postnatal checkups could be the reason for its low utilization even if prenatal
checkup utilization was high. In the case of nutrition, there was no difference in
the knowledge, attitudes, and practices or supply-side factors of 4Ps beneficiaries
and nonbeneficiaries. Other factors may explain the program’s perverse impact
on stunting. Meanwhile, the perverse employment outcomes may have resulted
from low educational attainment and seasonality or lack of job opportunities.
Beneficiaries prefer livelihood over employment because it is compatible with
housework. This paper recommends reinforcing knowledge on maternal care and
strengthening the Sustainable Livelihood Program. It calls for a more in-depth
assessment of the source of perverse impact on stunting. Employment barriers
among 4Ps beneficiaries must also be addressed.
1 The authors are former research analyst, supervising research specialist, and president at PIDS. This article is a
condensed and revised version of the PIDS discussion paper titled “Deepening the narrative: A qualitative follow-up
study on the third impact evaluation of Pantawid Pamilya”. Email for correspondence: KMelad@pids.gov.ph.
Learning from Stories Behind Unexpected Results
INTRODUCTION
The Pantawid Pamilyang Pilipino Program (4Ps) is the Philippines’ largest social protection
program, covering more than 4 million beneficiary households across the country (DSWD 2019c).
It aims to “reduce poverty by investing in the health and education of children ages 0–18 years
in poor households, thereby helping break the intergenerational cycle of poverty among them”
(DSWD 2021, p. 24).
Three impact evaluations have been conducted since the program’s inception in 2008. The
evaluations found that 4Ps has made gains toward its main objective to instigate improvements
in the education, health, and sociobehavioral outcomes of beneficiaries (DSWD 2014;
DSWD and World Bank 2014). The findings were mostly confirmed in the program’s most recent
evaluation, the 4Ps third wave impact evaluation (IE3). However, the IE3 presented some unexpected
and confounding results.
This follow-up study delves into the unexpected results of the IE3. Using qualitative
methodology, it collected information on the knowledge, attitudes, and practices (KAP) and
other characteristics of 4Ps beneficiaries and nonbeneficiaries, supply conditions of health facilities,
and program implementation. It intends to understand the IE3 quantitative evaluation results
and identify the factors explaining the deviations from expected impacts on selected outcomes.
Unlike the quantitative evaluation, the differences between beneficiaries and nonbeneficiaries
are illustrative and based on the respondents’ narrative accounts. The study acknowledges the
limitations of the qualitative thematic analysis. Interventions are implemented in the research
process to minimize validity and reliability issues (Nowell et al. 2017).
The IE3 results show that 4Ps has only partially achieved its goal to increase maternal
health services utilization. Consistent with the global literature on prenatal care uptake
(Barber and Gertler 2008b; DSWD and World Bank 2014), prenatal care utilization among
4Ps beneficiary mothers increased. In contrast, there was no significant impact on postnatal care
attendance. The study aims to identify the factors resulting in the discrepancy in maternal
healthcare services utilization and the pathways to address this issue.
The evaluations show that 4Ps has positively affected several outcomes, particularly
those corresponding to its conditions. A review of studies on the impact of conditional cash
transfers (CCTs) on nutrition found that in sum, CCTs have a nominally positive but insignificant
impact on children’s nutritional status (Manley et al. 2013). Contrary to this and the previous
findings, severe stunting was found to have a higher prevalence among 4Ps beneficiary children
in the IE3. Although the accompanying IE3 randomized control trial (RCT) cohort study partly
explains this, further investigation is needed.
The IE3 RCT cohort study, which focuses on children who received program inputs during
the critical period of the first 1,000 days of their lives found a significant decrease in the number
of severely underweight children and positive although insignificant impacts on other nutrition
outcomes. It suggests that the timing of inputs is crucial to instigate impacts on children’s nutrition
outcomes. This was further explored by looking at the supply-side factors, reevaluating the program’s
grant amount, and assessing the monitoring of program conditionalities.
Given that health outcomes, specifically of maternal and child health, depend on inputs not just
from 4Ps but also other stakeholders like local health centers, several factors can explain the results.
Interpretation may not be as straightforward as other outcomes. The positive child nutrition impact
was commonly attributed to the availability and accessibility of health services and the length and
timing of program benefits, maternal education, and workshops and counseling for beneficiary
72
Araos et al.
households (Gertler 2004; Lagarde et al. 2009; Manley et al. 2013). Other pathways through
which CCTs instigate a positive impact on health services utilization are program conditionalities,
additional resources to avail of health care, and supply-side improvements through increased
demand for services (Tesluic and Walker 2007; Barber and Gertler 2008a).
With conflicting findings in the previous evaluations, it is important to understand supply-side
conditions and the community knowledge, attitudes, and health-seeking practices of beneficiaries
for a more rounded analysis. Finally, although the previous impact evaluations have established that
4Ps does not foster dependency, beneficiaries are observed to have a lower employment likelihood
in the IE3. The international literature on CCTs and adult labor outcomes found no significant
impact on adult work incentives (Skoufias and di Maro 2006; ECLAC and ILO 2014).
In the urban-rural subgroup analysis of labor outcomes, the difference was primarily found
among beneficiaries from rural areas. The same was observed in other studies. Less access to
schools and health facilities and fewer transportation options require parents to spend more time
on child care to comply with program conditions (Ferro and Nicollela 2007). Given this, the study
investigated possible shifts in employment types and productivity and compared the employment
and job-seeking experiences of beneficiaries from urban and rural areas.
RESEARCH DESIGN AND METHODOLOGY
Conceptual framework
The analysis was conducted based on the theory of change detailed in the IE3 and the conceptual
framework of Peters et al. (2008), who noted three factors that contribute to the health outcomes
and access to health services of individuals: policy environment, individual factors, and healthcare
system factors. Policy environment refers to programs and services affecting the supply and
demand of health services in a community. Individual factors pertain to qualities describing an
individual’s knowledge, practices, health-seeking behavior, socioeconomic background, and source
of information. Lastly, healthcare system factors, such as geographic and financial accessibility
of health facilities, availability of services and supplies, and acceptability to the community, are
considered as mediating factors to overall health care access.
Figure 1 shows the conceptual framework following this idea in the context of 4Ps. Before
receiving program inputs, poor households get trapped in a cycle of poverty due to low investment
in the human capital of its members, especially children. Low-income households tend to have
poor health due to inadequate nutrition and limited knowledge, attitude, and health practices.
Inputs from 4Ps are expected to affect individual factors and health-seeking behaviors through
cash grants; monitoring and enforcement of program conditions, including monthly attendance to
learning sessions (i.e., family development sessions [FDS]) and availing of recommended health
interventions; and linkages to other government programs and services. FDS can help beneficiaries
gain knowledge and encourage them to adopt ideal family development and health practices.
Additional income from the cash grants can ease the household’s spending constraints
and lead to increased food consumption and better provision of basic needs. Factors that
determine the availability of healthcare services for a particular community overlap with individual
outcomes and affect how the program influences individual health-seeking behaviors. Increased
demand for health services and the program’s linkages to the Philippine Health Insurance
Corporation (PhilHealth) and other government services can stimulate investments in the
healthcare system (Tesluic and Walker 2007; Barber and Gertler 2008a).
73
Figure 1. Framework analysis for the impact of 4Ps on health outcomes
Low investment in
• Low productivity
human capital
Poor • Low income
• Low schooling
households • Vulnerability
• Poor health
to shocks
• High malnutrition
4Ps
Program
conditions and Linkages to
Cash grants enforcement of PhilHealth and
compliance other programs
monitoring
Healthcare
system
factors
Household financial Beneficiaries Improved capacity - Geographic
Increased
attend FDS and investment in
resource increases, to access and avail accessibility
income augmented
visit health centers the healthcare
of health services
system due to
- Financial
linkages and
accessibility
higher
demand for
Parents improve - Availability
Increased services
knowledge and Increased
consumption of practices in family - Acceptability
availment of
food and other basic development and child
healthcare services
needs and maternal health
Improved health and nutrition outcomes
4Ps = Pantawid Pamilyang Pilipino Program; KAP = knowledge, attitude, and practices; PhilHealth = Philippine
Health Insurance Corporation; FDS = family development sessions
Source: Authors’ interpretation
This framework guides the health component analysis of the study, which assesses the
program’s policy environment or implementation, including its linkages to other government
programs. In addition, individual factors (e.g., KAP) and healthcare system factors (e.g., availability,
access, acceptability) were examined to encompass the three categories of the elements illustrated
above. On labor market outcomes, the IE3 results suggested lower employment rates among 4Ps
beneficiaries relative to nonbeneficiaries. The study aims to investigate if this was driven by the lack
of available jobs, a shift in the types of employment, or other factors that discourage employment.
It looked into the labor market and the decisionmaking of households in urban and rural areas to
identify possible explanations for the quantitative survey findings.
The analysis refers to the framework of Banerjee et al. (2017), which suggests that cash transfers
can positively or negatively impact labor supply and demand (Figure 2). Treated as a pure income
effect, cash transfers can increase the purchase of leisure and lower labor hours. It can be considered
as some form of a tax that discourages beneficiaries from working and earning more, if it means
becoming ineligible to the program. It can provide enough sustenance and make beneficiaries
productive for work or unlock productive economic activities and opportunities for those facing
credit constraints. Finally, cash transfers may have spillover effects on local markets that can
increase the overall labor demand. Theoretically, it is not clear which of these effects will dominate.
74
Araos et al.
Figure 2. Framework analysis for the impact of cash transfers on labor market outcomes
Pure income
effect
Labor supply
hours
“Tax” on labor ________________
earnings
Productive
Income to capacity
become
productive
Labor
market
Cash transfer Reduce credit outcomes
constraints
Financially risky Labor market

but profitable demand
investments
Spillover effects
increasing sales of
local businesses
Source: Adapted from Banerjee et al. (2017)
The framework shows acare

Prenatal list of the potential effects
text of cash
Postnatal transfers
care related to labor outcomes.
text references
The interplay and difference
referencesin the magnitude 45 of the program’s positive and negative effects
determine the labor market outcomes from cash40transfer. These factors are explored to see whether
50 35
41
the negative effects outweigh the positive ones,30resulting in lower employment rates in the IE3.
40
25
30
20
Data sources
20 16 15
The data sources
10
are focus group discussions10(FGDs) with 7 beneficiaries and nonbeneficiaries,
5implementers and partners, 1
key informant
0
interviews (KII) with program and supplementary
0
secondary data sources.
FGD with FGD with non- FGD with beneficiaries FGD with non-
beneficiaries beneficiaries beneficiaries
FGDs
Two FGDs were conducted (1 with beneficiaries; 1 with nonbeneficiaries) in 16 barangays (villages)
from eight municipalities (2 barangay per municipality) nationwide. The sampling of municipalities
and barangays was based on areas in the IE3. The target respondents were mothers/main caregivers
or guardians of children. The study sites were identified based on the IE3 nutrition outcomes.
Areas with high prevalence of stunting relative to the control group were selected among the
treatment group and vice versa. The team considered urban and rural classifications in the selection
of sites to allow comparison given the urban-rural heterogeneities observed in the IE3, especially
on labor outcomes. The selection of target FGD sites was guided by the need to cover a range of
experience to reveal the issues identified in the evaluation questions.
Beneficiaries were asked questions on their KAP on maternal health services utilization and
child health and nutrition as well as their main sources of information on these topics. They were
surveyed on their access to and assessment of health facilities and services in their communities.
For the analysis on labor outcomes, questions on household welfare were asked, specifically on
75
the participants’ main source of information and sufficiency of their household income, coping
mechanisms, employment, and needed livelihood interventions.
The FGDs aim to provide qualitative information not captured by the IE3 survey.
The respondents’ experiences and relevant household or community contexts were discussed to
identify potential explanations for the quantitative data results. Most of the information collected
were related to their KAP, access to services, and decisionmaking.
KIIs
The KIIs were conducted with the DSWD city/municipal links (C/MLs) assigned to the
sampled areas and heads or staff of community health facilities. The top three health facilities
per municipality visited by the IE3 respondents were selected. At least one barangay health
station (BHS) and one rural health unit (RHU) were chosen per municipality when applicable.
The KIIs aim to gain insights on the assessment of the beneficiaries’ health-seeking behaviors and
find out how compliance monitoring and updating are conducted in their area of assignment.
Two DSWD C/MLs were interviewed per municipality (1 for each sampled barangay) about
compliance with program conditionalities; supply-side conditions in their area; beneficiaries’ access
to health services; topics in FDS, particularly about maternal and child health; and their opinions on
whether these issues were sufficiently discussed. C/MLs were asked about the updating of beneficiary
information and compliance monitoring. The questions focused on whether new pregnancies or
newborns were monitored for compliance with program conditions. The KIIs primarily provide
information on the status of program implementation, including unique challenges and difficulties
in specific areas and how the program achieved the outcomes based on its effectivity and delivery.
KIIs with health facilities gave crucial information on healthcare system factors influencing the
respondents’ health-seeking behaviors.
Method of analysis
The study employed thematic analysis for the qualitative data collected from FGDs and KIIs.
Summarized in Box 1, the steps involve the qualitative coding of interview transcripts to organize
the data and identify themes that emerged during the interviews (Maguire and Delahunt 2017).
Computer-assisted qualitative data analysis software (CAQDAS), particularly NVivo, was used
in the thematic analysis of interview transcripts, which were coded into predetermined themes
based on the interview questionnaire. Data was explored using the query command of NVivo.
The themes were further refined in the succeeding rounds of coding.
Box 1. Data analysis procedure

1. Cleaning of interview transcripts
2. Import of interview transcripts to NVivo
3. Generation of cases and import of classification sheets to NVivo
4. Coding of data into predetermined themes
5. Exploration of data using query command
6. Refinement of themes
Source: Authors’ summary
Patterns were identified within respondent groups and a comparison of subgroups, which
were analyzed based on the urban-rural characterization and groupings of municipalities in
accordance to the IE3 nutrition outcomes. Triangulation was done through a comparison of the
76
Araos et al.
responses of beneficiaries, nonbeneficiaries, program staff, and health facility staff. Measures were
taken in the analytic process to ensure credibility of the study results. Analytic memos were taken
using the CAQDAS features during thematic coding to record the coding decisions. Observations
were detailed using thick descriptions to capture the appropriate context of responses.
FINDINGS
This section presents findings based on the thematic analysis of FGDs and KIIs, which were
discussed with relevant IE3 findings. The discussion focused on the beneficiaries’ maternal and
child health KAP. It was supported by observations in supply-side conditions based on KIIs with
health facility personnel and the program implementation, particularly monitoring and updating
of compliance with program conditions. Findings on labor participation, employment, and
household welfare are detailed in this section. It covers the beneficiaries’ opinions on grants, food
security, coping mechanisms, type and nature of employment, productivity, opportunities, and
employment barriers. It discusses the problems in implementing the program and the solutions
forwarded by program beneficiaries, DSWD C/MLs, and health facility staff.
Maternal health KAP

This section focuses on the maternal health KAP of 4Ps beneficiaries and their peers based on
FGDs with 295 respondents through 32 sessions. The majority (87%) of the respondents were
female. The observations supplement the responses during the FGDs with 4Ps program staff,
implementers, and health facility staff. In terms of checkups during and after pregnancy, knowledge
and awareness of postnatal care were lower compared with prenatal care (Figure 3). In some
FGDs, the participants neglected to mention postnatal checkups for mothers when asked about
proper health practices after pregnancy. The knowledge of FGD respondents on the appropriate
number and timing of prenatal and postnatal checkups was inconsistent. One doctor stressed
that it was a challenge to get beneficiaries to follow the proper timing of checkups, particularly first
trimester checkups.
Figure 3. Number of references in text for prenatal and postnatal care by beneficiary status
Prenatal care text references Postnatal care text references

50 50
40 40
30 30
20 20
10 10
0 0
FGD with beneficiaries FGD with nonbeneficiaries FGD with beneficiaries FGD with nonbeneficiaries
FGD = focus group discussion

High compliance was observed in the attendance for prenatal checkups during FGDs,
as validated in the KIIs with health facility personnel and 4Ps staff. However, compliance was
inconsistent in postnatal checkups for beneficiaries and nonbeneficiaries. This may be due to
lower provision of postnatal checkups in health centers compared with prenatal checkups (Figure 4).
77
4Ps staff (i.e., C/MLs) implied that achieving the program objectives depends on the quality of health
facilities and services that key stakeholders, such as the Department of Health (DOH), provide.
Figure 4. Proportion of health facilities providing maternal health checkups by urban/rural

classification
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
All Urban Rural
Prenatal checkup Postnatal checkup

45%
The slightly lower postnatal care compliance among 4Ps beneficiaries may mean that
40%
knowledge of being monitored for conditionalities plays a significant role in availing of maternal
35%
health services. Awareness of prenatal care as one of the program conditions was high. Postnatal care
30%
was not explicitly mentioned as a program condition in any of the FGDs. There were variations in
25%
the timing and venue for the administration of postnatal checkups, making it difficult to evaluate the
20%
beneficiaries’ health-seeking behaviors in this aspect.
In terms of childbirth,
15% FGD respondents place importance on facility-based delivery attended
by skilled health professionals,
10% even though most of them were not aware that these were conditions
of the program. Among the reasons for this was compliance with local ordinances prohibiting home
5%
birth deliveries for0%health and safety reasons (e.g., hospitals being better equipped to deal with
emergencies or complications All Urban
during childbirth). Rural
While some FGD participants reported home births, most of the recent pregnancies were
delivered in health facilities by skilled health personnel. Based on the KIIs with health facility
staff, these services were more available in health facilities in rural areas compared with urban
areas (Figure 5). This is likely due to higher demand for delivery services in these facilities, which
have become an alternative to hospitals because they are rarely available in rural areas, especially
in remote villages.
The levels of knowledge of 4Ps and non-4Ps respondents on maternal health are comparable.
This refers to the importance of adequate nutrition and proper care for pregnant women, prenatal
checkups, facility delivery, and monitoring of complications. However, 4Ps beneficiaries were
more confident and thorough in their knowledge on pregnancy and childbirth compared with
non-4Ps respondents. This is likely due to their mastery and exposure to maternal health topics
during FDS. The learning sessions and seminars provided by health facilities, local governments,
and civil society organizations (CSOs) are crucial in informing beneficiaries and nonbeneficiaries.
However, they must be made be more stringent and consistent to achieve mastery of topics,
especially postnatal care. The updating of pregnancy status and deliveries (i.e., newborn in the
family), needs to be strengthened to effectively monitor the health of 4Ps beneficiary households.
78
20%
10%
0%
All Araos Urban
et al. Rural
Prenatal checkup Postnatal checkup
Figure 5. Provision of normal delivery services by urban/rural classification

45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
All Urban Rural
Child health and nutrition

The study further investigated the mixed results on child nutrition in the IE3. The FGDs with
4Ps beneficiaries and their peers as well as the interviews with 4Ps program staff, implementers,
and health facility staff revealed gaps in the KAP of parents, supply-side conditions, and program
implementation, which hinder the achievement of program goals on child health and nutrition.
Parents were knowledgeable about proper feeding practices and the importance of proper
nutrition for children. 4Ps beneficiaries demonstrated high awareness of the program conditions
for child health. In fact, they could recite most of the conditions during the FGDs, as depicted in
the word cloud of the qualitative data analysis on the beneficiaries’ awareness of 4Ps conditions
(Figure 6). When asked whether they had difficulty fulfilling the program conditions, 4Ps
beneficiaries recognized the conditions as part of their responsibilities toward their children.
Figure 6. Beneficiaries’ awareness of 4Ps conditions
4Ps = Pantawid Pamilyang Pilipino Program

The accounts of C/MLs who reported that noncompliance was rare among children monitored
in the program confirmed the high compliance with program conditions related to child health.
79
In terms of the availability of health services, the health facilities in urban study sites provided
most child health services. Meanwhile, health facilities in rural areas are lagging (Figure 7).
Weight monitoring and deworming are provided in all surveyed BHS. This means that the availability
of service was not a major concern for 4Ps beneficiaries in fulfilling the growth monitoring condition
of the program (Figure 8).
Figure 7
Figure 7
Figure 7. Child health services by urban/rural classification
100%
100%
80%
80%
60%
60%
40%
40%
20%
20%
0%
0%
All Urban
All Urban
OPD = outpatient department
Figure 8
Figure 8. Child
Figurehealth
8 services by health facility type
100%
100%
80%
80%
60%
60%
40%
40%
20%
20%
0%
0%
All RHU BHS

OPD = outpatient department; RHU = rural health unit; BHS = BHS
All RHU barangay health station
The respondents’ awareness of other child health and nutrition aspects, particularly those
not related to the program conditions, was extremely low. For example, hardly any of the FGD
participants was aware of the First 1,000 Days program. Although many stressed the importance
80
Araos et al.
of breastfeeding, there was no agreement on the appropriate period for exclusive breastfeeding
and timing to introduce other food items to infants.
Most of the FGD participants were aware of the importance of immunization and followed
the immunization schedule in health centers. However, 4Ps beneficiaries were more conscious
of following the vaccination schedule due to program conditions. Although nonbeneficiaries
reported immunizing their children, a few participants recalled refusing to have vaccines
administered to their children because they were not familiar with the vaccine brand. Beneficiaries
and nonbeneficiaries differed in their sources of information about vaccines. For example, 4Ps
beneficiaries have additional sources of information through FDS, where the importance of
vaccination is explained and fears of its side effects are allayed.
Deworming incidence was high among program beneficiaries and nonbeneficiaries, but the
main barrier to the full compliance of both groups was misconceptions on deworming. Deworming
is administered at school by health facilities. Some respondents have the impression that it can
be dangerous for children when not administered properly and are afraid of the possible side
effects. In terms of supply-side conditions, all health facilities reported having sufficient stocks of
deworming pills.
FGD participants reported bringing their children to the local health centers (i.e., BHS or
RHUs) for regular weight monitoring, vaccination, and preventive checkups. 4Ps respondents often
cited the program’s health conditionality as one of the main reasons for bringing their children to
health facilities. Consistent with the IE3 regression discontinuity design results, more 4Ps children
visited health facilities for this reason. However, knowledge on the proper timing of checkups for
weight monitoring once children are past the age of receiving vaccination must be strengthened.
Non-4Ps respondents reported bringing their children for regular checkups until they are one year
old. After this, most visits to the health facilities are for instances of illness. Health facility staff
confirmed that instances of illness and vaccination were the primary reason for children’s health
visits. They reported that regular weight monitoring visits were usually done only by 4Ps members
in fulfillment of the program requirements. The weight and height measurements were included in
the routine checkup when children were brought to health facilities and during house-to-house visits
for Operation Timbang.2
The growth monitoring visits usually end with the collection of children’s weight and height.
Parents rarely receive nutrition counseling after the visit. Caregivers reported keeping record of
the children’s weight while most rely on records from health facilities or daycare. Children do not
receive preventive health checkups in facilities where health personnel are scarce because checkups
are dependent on the availability of skilled health personnel. For example, in a case when only the
barangay health worker or nutrition scholar is present in a health facility, the health visit will consist
only of weight and height measurements. This often happens in health facilities in rural areas with
fewer skilled health professionals on average (Figure 9).
It was hypothesized in previous evaluations and studies that supply-side factors, such as
accessibility and quality of health facilities, influenced the mixed findings on the program ’s impact
on child health. Based on earlier spot checks and studies commissioned by the DSWD, health
center resources, particularly infrastructures, are lacking. The data collected in the KIIs with health
facility staff confirmed these gaps.
2 Operation Timbang is an “annual weighing and height measurement of all preschoolers 0–59 months old or under
five years old in a community to identify and locate the malnourished children” led by the National Nutrition Council.
81
Figure 9. Average number of health facility staff by urban/rural classification
1.00
Barangay nutrition scholars 2.30
2.00
7.33
Barangay health workers 7.50
7.46
3.00
Full-time midwives 3.36
3.22
0.86
Full-time nurses 2.00
1.56
0.29
Full-time doctors 0.82
0.61
Rural Urban All

However, instead of infrastructures, there is primary shortage in the number of available

professional or skilled health workers in barangay facilities. This limits the heath services
available in communities. The variations in providing and implementing health services may be
one of the factors behind inconsistencies in health outcomes. During the KIIs, the health facility
staff acknowledged these issues as barriers to parents caring for their children. To achieve child
health and nutrition objectives, these gaps must be addressed by the program staff and other key
stakeholders like the DOH and local government units (LGUs).
Another issue was the underreporting of succeeding pregnancies and newborns in the family
roster of 4Ps beneficiaries. This results in pregnant women and newborn children escaping the
monitoring and enforcement of program conditions. In the 2019 quarterly status reports for 4Ps,
records of pregnancy status and newborn children consistently had the fewest number of updates
on beneficiary information (DSWD 2019a, 2019b, 2019c). According to KII respondents at the 4Ps
National Program Management Office, this gap had been recognized in the program management.
Households were encouraged to report succeeding pregnancies and births so that the household
roster could be updated continuously. It may be useful to provide an incentive structure for the
regular updating of the household roster for succeeding pregnancies and newborns. The FDS and
learning seminars in the communities help educate beneficiaries and nonbeneficiaries on proper
child-rearing and other health practices. However, some topics must be strongly advocated
because not all health services are availed according to the health department’s recommendations.
In addition, the active involvement of health facility staff is crucial in improving health service
delivery and the health-seeking behaviors of benecifiaries.
Program implementation
Understanding the program goal
The FGD and KII respondents consistently understood the goals of 4Ps. The program’s objective to
improve the wellbeing of beneficiaries through investments in education and health of children
from poor households was clear among the program beneficiaries, 4Ps program staff (i.e., C/MLs),
82
2.00
7.33
7.46
Araos et al. 3.00
3.22
0.86
and health facility staff. For 4Ps beneficiaries, awareness was1.56 manifested in how they spend
the grant, which they use primarily for the education0.29
and health of their children (Figure 10).
Full-time doctors 0.82
For C/MLs, besides improving the beneficiaries’ material 0.61
wellbeing through the grant, FDS were a
crucial component of the program to initiate behavior change and empower beneficiaries.
Rural Urban All
Figure 10. Knowledge of 4Ps beneficiaries on the program objectives

Most respondents believed that the program was on track to achieve its goals given the
changes in the behavior and welfare of beneficiaries. C/MLs cited the success stories of graduated
beneficiaries and observed that they were better off because of their 4Ps membership, although
most health facility staff believed that the success of the program depends on how beneficiaries
utilize the grant and comply with the program conditions.
Knowledge on program design

One of the important procedures in implementing 4Ps is the Beneficiary Updating System,
which ensures that relevant beneficiary information is correct and up-to-date. This requires
the submission of updates by beneficiaries to the program implementers to reflect correct or
new information in the program registry. The 4Ps respondents and C/MLs from most study
sites were aware of education-related updates like enrollment or change of school of children
and rarely mentioned the submission of updates for succeeding pregnancies and newborns.
Program beneficiaries do not submit updates voluntarily. Not all C/MLs require beneficiaries to
file updates for newborns and subsequent pregnancies when the household has already met the
maximum number of child beneficiaries. This is not consistent with the actual program policies.
Based on the Pantawid Operations Manual (DSWD 2021), updates should be filed for newborns
of any household member and for succeeding pregnancies of members related to the household
head (Table 1). However, the common understanding is that updates are filed only when the
household has less than two children as active beneficiaries of the education grant.
83
Barangay nutrition scholars 2.30
2.00
7.33
7.46
3.00
3.22
Table 1. Criteria for the updating of newborns and succeeding
0.86
pregnancies
Type of update Description
1.56
Newborn • Children born from the pregnancy
0.29
of any member of the household at
the Full-time doctors
time of assessment 0.82 the program period.
and during
0.61
• Children born out of the pregnancy of the household member during

Rural Urban All
program implementation.
Succeeding pregnancy Includes the updating of pregnancy of a household member while under the
program. The following are household members eligible for this update:
a. Head (female)
b. Wife of the household head
c. Daughter of the household head
d. Granddaughter of the household head
e. Daughter-in-law of household head
Source: DSWD 2015
Grants, food security, coping mechanism

When asked about their opinions on the grant amount, most beneficiaries in the FGDs were satisfied
and appreciated the grant’s contribution to their budget for household expenses. The grants were
described as a big help in getting beneficiaries through various life situations (Figure 11).
Figure 11. Common expenses using cash grant as reported by beneficiaries
The sufficiency of the grant amount was further probed. Although it helps supplement
household budget, the grant is not enough to cover the education and clothing expenses of children
of some FGD participants. Some suggest adjusting other program benefits, such as providing an
allowance for additional children as beneficiaries or extending the program to cover students
in college. Most respondents, however, are firm on their opinion that beneficiaries should not be
84
Araos et al.
demanding on the amount of grants provided to them and that the purpose of the cash grant is to
supplement expenses for children’s education and health.
In terms of how the grants are spent, it helps beneficiary households purchase their daily
needs and the schooling needs of their children. 4Ps beneficiaries also prioritize food expenses.
Some of them disclosed that part of the grant was apportioned for rice. A few respondents spend
leftover money from the grant as capital for their business.
Lastly, there was no apparent difference between the two groups in terms of budget constraints.
They both find their household budget insufficient to cover their basic needs because of the rising
prices of basic commodities, low and/or seasonal income, and school expenses. A common coping
mechanism was taking out informal loans from relatives, neighbors, or loan sharks. However, this
was more common among non-4Ps beneficiaries (Figure 12).
Figure 12. Economic coping mechanisms by beneficiary status
4Ps beneficiaries Non-4Ps beneficiaries

100% adjust their household spending and consumption (e.g., limiting food portions or
Both groups
the number of 80%meals and buying cheaper food items like vegetables instead of meat). Respondents
earn additional income by taking additional work, such as washing laundry or hawking food.
60%
In rural communities, respondents take seasonal jobs like planting or harvesting to supplement their
household income.
40% Backyard gardening is commonly practiced to supplement meals, particularly
in rural areas. The 4Ps beneficiaries consistently reported this and even cited backyard gardening
as part of the20%
program’s conditions. While the program does not require backyard gardening, it is
encouraged through
0% FDS and collaboration of the DSWD, Department of Agriculture, and civil
society organizations (DSWD4Ps Non-4Ps
4Ps Social Marketing Division 2018).
Non-SLP 97 151
SLP 36 3
Labor participation
SLP benefits and feedback
About one-quarter of FGD participants reported being beneficiaries of the DSWD’s SLP.
Consistent with the observation in the IE3, the proportion of SLP beneficiaries among non-4Ps
beneficiaries was only 2 percent (Figure 13). Many SLP beneficiaries were under the microenterprise
development track, which provides assistance for entrepreneurial activities. Only one respondent
was under the employment facilitation track, which gives employment assistance.
85
4Ps beneficiaries Non-4Ps beneficiaries
Figure 13. Proportion of SLP beneficiaries among FGD respondents

100%
80%
60%
40%
20%
0%
4Ps Non-4Ps
Non-SLP 97 151
SLP 36 3
SLP = Sustainable Livelihood Program; FDG = focus group discussion; 4Ps = Pantawid Pamilyang
Pilipino Program
The livelihood support under the microenterprise track are assistance in-kind, such as provision
of livestock and tricycle units and capital for businesses like community sari-sari (variety) stores
or food vending. Many of the respondents under the microenterprise development track reported
issues in their membership like business failure, problems in association management, and lack of
support from the SLP staff.
Criticism of dependency
4Ps beneficiaries are aware of the criticism from nonbeneficiaries and politicians
(Office of Rep. Susan Yap 2014) that they are dependent on cash grants, and they disagree with this
characterization. Household cannot rely on the grant as their only source of income because its
amount is insufficient. Thus, they still need to work to fulfill their household needs. Beneficiaries
are aware that the grant is meant for children’s education and health expenses. On the other hand,
nonbeneficiaries believe that 4Ps beneficiaries are not dependent on the grant because they are
aware of the program’s aim to aid in the health and education needs of children and the grant alone
is not enough to cover all of their household expenses. A small number of 4Ps and non-4Ps members
agreed that some of the beneficiaries have become dependent on the grants, but this pertains only
to a small number of beneficiaries perceived as delinquents. FGD participants associated it with
other delinquent behaviors, such as cash card pawning or engagement in vices like drinking or
gambling. Some participants from urban areas have the perception that dependence on the grant
are more frequent in rural areas, where they believe cash card pawning is more prevalent.
Challenges in labor market participation and suggested programs

Both 4Ps and non-4Ps respondents reported construction, agriculture, freight transport, and trade
jobs in electricity or plumbing as their usual work opportunities. In rural areas, many are engaged
in fishing and agriculture. The grantee or mother is usually not in the labor force, since they serve as
caretakers of children. Employed females are usually working part-time in the informal sector, such
as doing domestic work like caregiving, or as seasonal farm laborers. Some are self-employed or
have small businesses like wholesale/retail trade (Figure 14).
86
Araos et al.
Figure
Figure 14
14. Primary occupation of 4Ps members by urban/rural characteristics
Figure 14
Urban Rural

Source: Authors’
Figure 15 compilation
Breadwinners of 4Ps household respondents held casual or contractual employment and found
it difficult to find regular work. They enumerated
Urban the following barriers to their regular employment:
Rural
(1) qualifications (i.e., education, age), (2) lack of available jobs in communities, (3) seasonality
of jobs, and (4) end-of-contract employment practices by employers (Figure 15). In rural areas,
seasonality of work and Figure
lack15of available jobs are the main hindrances to employment.
Figure 15. Barriers to permanent employment of 4Ps beneficiaries

When asked about possible livelihood programs, most participants preferred microenterprise
development programs over employment facilitation. This includes the provision of financial
assistance and training to open small businesses, such as sari-sari stores or food vending business.
Most of the respondents are women who are household caretakers and may think that livelihood
programs are compatible with housework. They also have limited qualifications for employment
and are constrained by childcare duties.
87
SUMMARY AND RECOMMENDATIONS
Summary
Maternal health service utilization
• There is no noticeable difference between the KAP of beneficiaries and nonbeneficiaries on
maternal health and the First 1,000 Days of Life program. Besides FDS, health facilities provide
information on maternal and child health to non-4Ps members in the community.
• Respondents must be made more aware of the appropriate number and timing of prenatal
and postnatal checkups. Most respondents believed that the appropriate timing of postnatal
checkups was seven days after delivery, but the recommended time was within 24 hours after
childbirth (WHO 2013). Both 4Ps and non-4Ps mothers know the importance of prenatal care,
but their knowledge and awareness of postnatal care are mixed. Some believe that checkups
are necessary only for complicated cases or for newborns. 4Ps beneficiaries do not mention
postnatal care when asked about the program conditions.
• 4Ps beneficiaries and nonbeneficiaries complete, if not exceed, the minimum number of prenatal
visits that the DOH recommend. They cited prenatal care as a program condition. In general, the
BHS bolstered the compliance with prenatal checkups in communities.
• Newborn updates are not filed when the limit for child beneficiaries has been met. 4Ps beneficiaries
and DSWD C/MLs reported that newborn updates were filed only when registering new
children beneficiaries. Children exceeding the three-child beneficiary limit were often no
longer included in the roster. Updates on new pregnancies were seldom processed because
program beneficiaries have no incentive to report them, which means being monitored for
additional conditions.
• Respondents are more likely to deliver at their local RHU if it is a PhilHealth-accredited maternity
care package provider. This bolsters support to expand the coverage of RHUs with delivery
capabilities, especially in urban areas, and improved facilitation and staffing of RHUs.
Child health and nutrition

• There is no consensus on the appropriate period for exclusive breastfeeding, although many of
the interviewed participants stressed its importance. Most respondents cannot practice exclusive
breastfeeding for six months for various reasons, such as lack of milk supply or mothers
needing to return to work.
• 4Ps parents are more diligent in bringing their children to the health facilities for preventive
checkups compared with non-4Ps parents who usually bring their child only during instances
of illness or for vaccination. This is done in compliance with program conditions for regular
weight monitoring.
• Barriers hinder parents from properly implementing knowledge on recommended child health
practices. Respondents commonly reported insufficient household budget for their daily needs.
This is a concern given the interrelatedness of wealth with childcare practices and height for age
measure (Amugsi et al. 2014). The provision of cash grants for education and health may not be
enough to address food insecurity among 4Ps households. These concerns must be addressed
in the program and by other key stakeholders, such as the DOH and LGUs, to achieve the
objectives on child health and nutrition.
• The health facilities in rural areas are lagging in providing adequate child health services. RHUs
and barangay health centers are less likely to provide services like weight monitoring and
88
Araos et al.
pediatric outpatient consultations primarily due to the lack of skilled personnel and medical
supplies. Vaccine provision is also lower among rural health facilities. However, vaccines are
well-stocked if the health facilities can offer them.
• There was no perverse program incentive effect on child nutrition. 4Ps parents do not have an
impression that 4Ps membership is related to their children’s nutritional status. They are aware of
the program’s objective to support child health through grants and FDS. Moreover, discussions
with the 4Ps beneficiaries and nonbeneficiaries did not suggest any undesirable health or
feeding practices among 4Ps beneficiaries that may result in perverse nutrition effect. Overall,
there was no evidence from the FGDs that the negative impact on severe stunting observed in
the IE3 was linked with the difference in health KAP or supply-side factors between 4Ps and
non-4Ps beneficiaries. Raitzer et al. (2021) suggest that the limit in the number of children
beneficiaries may have driven these effects. The intrahousehold allocation of resources favors
children who are monitored by the program at the expense of those who are not. However, this
cannot be confirmed in the FGDs with beneficiaries and requires a more detailed account of
household expenditure patterns and resource allocation.
Labor market outcomes

• Both 4Ps beneficiaries and nonbeneficiaries are often in casual or informal employment.
Respondents mentioned the lack of qualifications, particularly education, as a barrier to
permanent employment. Rural respondents specified the lack of available jobs and the
seasonality of jobs in their areas as a hindrance to employment.
• The provision of capital is preferred to employment facilitation for livelihood assistance.
Most of the respondents are women who are caretakers of the households. Because of
this, they may think that livelihood is compatible with housework and may have limited
employment qualifications.
• Compliance with program conditions does have an impact on time spent working. Program
beneficiaries have no difficulty complying with program conditions in terms of time and other
expenses. For FDS, where compliance is usually the lowest, beneficiaries are allowed to have a
proxy or take make-up sessions should they have conflicts in their schedule. However, similar
to the findings of Laigo (2016), there were instances when beneficiaries have to miss work to
attend the sessions.
Recommendations
• Update the program conditions of 4Ps on maternal health. Given the program’s success in
instigating a positive impact on attendance to prenatal checkups, updating the condition on
prenatal visits and increasing its minimum number can reflect the number recommended by
the World Health Organization (WHO 2013).3
• Harness the potentials of FDS to reinforce knowledge on maternal health. FDS and other
similar parenting lectures are important sources of information for both beneficiaries and
nonbeneficiaries and should be utilized to capacitate identified areas where knowledge and
awareness are still lacking, particularly on the timing and importance of postnatal care.
Further study can be conducted to evaluate and quantify the effectiveness of FDS in relaying
information to beneficiaries.
3 WHO (2013) recommends eight prenatal contacts in the duration of a woman’s pregnancy.
89
• Provide additional support for FDS, which has proven to be a significant factor in initiating
positive change among program beneficiaries. Provide appropriate venue and presentation
materials for the sessions. The program must engage resource persons, especially for specialized
topics, and delegate the conduct of FDS to other program staff to reduce the responsibilities of
C/MLs. Similar to the recommendation of EPRI (2019), a rigorous study measuring the FDS
outcomes should be conducted.
• Strengthen the information campaign and implementation of the First 1,000 Days Law.
Low awareness of the First 1,000 Days Law was observed among FGD and KII respondents.
Since the previous IE3 RCT study identified this period as a relevant factor influencing the
nutrition outcomes of children, efforts to raise the beneficiaries’ awareness must be more
aggressive. The DOH should strengthen the law’s implementation and maximize its benefits.
• Bolster health service delivery in rural areas. Improvements in staffing, facilities, and
equipment must be given attention. The number of health facility staff, particularly doctors and
nurses, should be increased to improve the quality and accessibility of health services. Support
staff like barangay health workers and nutrition scholars are crucial in community outreach.
Providing basic health services for mothers and children must be enhanced to approximate
those in urban areas. The DOH should aim to make laboratory and diagnostic services more
accessible for households in remote areas to reduce patient transportation costs and other fees.
• Assess the updating of 4Ps beneficiary information. Beneficiaries and program staff
respondents gave conflicting responses when asked about the filing of updates, particularly
for household members who were supposed to be monitored for the program’s health
conditionalities. The criteria should be clarified at the C/ML level to ensure that the family
roster is continuously updated even when households have met the beneficiary limit. This
ensures that all pregnant women and the children are captured in the compliance monitoring.
• Strengthen the collaboration of the DOH, Department of Education, LGUs, and other
stakeholders. The broad range of outcomes that 4Ps aims to address and the program’s success
need the strong ties of concerned agencies. Anecdotes from program staff demonstrate the
effectiveness of active support from the health facility staff in learning interventions and
monitoring to improve the health-seeking behaviors of community members. 4Ps provides
beneficiaries with excellent links to various social services. LGUs should utilize the program to
mobilize potential beneficiaries for other special programs. The program may harness venues,
such as city/municipal inter-agency committees, to foster cooperation among agencies.
• Continuously evaluate and increase the grant amount. The finding that households often lack
budget for basic needs and children’s education expenses highlights the need to increase the
grant amount to meet inflation. However, the field work was conducted before the increase was
implemented in 2020 under Republic Act 10931. Further studies should evaluate the impact of
this increase on the grant amount and whether it is sufficient to make up for the scarcity that
households experienced, particularly on food expenses and children’s education and health.
• Address the barriers to regular employment in rural areas. On the part of the DSWD, the
existing SLP mechanism must be strengthened to improve outcomes on labor participation
and employment. However, this needs to be investigated by other concerned agencies, such as
the Department of Labor and Employment and LGUs, particularly for job creation and regional
economic development.
90
Araos et al.
REFERENCES
Amugsi, D., M. Mittelmark, A. Lartey, D. Matanda, and H. Urke. 2014. Influence of childcare practices on
nutritional status of Ghanaian children: A regression analysis of the Ghana Demographic and
Health Surveys. BMJ Open 2014(4):e005340.
Banerjee, A., R. Hanna, G. Kreindler, and B. Olken. 2017. Debunking the stereotype of the lazy welfare
recipient: Evidence from cash transfer programs. The World Bank Research Observer 32(2):155–184.
Barber, S. and P. Gertler. 2008a. Empowering women to obtain high quality care: Evidence from an evaluation
of Mexico’s conditional cash transfer programme.” Health Policy and Planning 24(1):18–25.
———. 2008b. The impact of Mexico’s conditional cash transfer programme, oportunidades, on birthweight.
Tropical Medicine and International Health 13(11):1405–1414.
Department of Social Welfare Development (DSWD). 2014. Keeping children healthy and in school:
Evaluating the Pantawid Pamilya using regression discontinuity design. https://pantawid.dswd.gov.
ph/wp-content/uploads/2018/07/Pantawid-Pamilya-Impact-Evaluation-2014-Report-Final.pdf
(accessed on May 25, 2020).
———. 2015. Impact of time-critical household investments in Pantawid Pamilyang Pilipino Program:
Evaluating the Pantawid Pamilya using RCT-cohort analysis. Quezon City, Philippines: DSWD.
———. 2019a. 4Ps program implementation status report: First quarter of 2019. Quezon City,
Philippines: DSWD.
———. 2019b. 4Ps program implementation status report: Fourth quarter of 2019. Quezon City,
Philippines: DSWD.
———. 2019c. 4Ps program implementation status report: Second quarter of 2019. Quezon City,
Philippines: DSWD.
———. 2021. Pantawid Pamilyang Pilipino Program (4Ps) operations manual. Quezon City,
Philippines: DSWD. https://pantawid.dswd.gov.ph/wp-content/uploads/2022/08/08152022_4ps_
OM_print.pdf. (accessed on November 25, 2021).
Department of Social Welfare Development 4Ps Social Marketing Division. 2018. DSWD, East-West
Seed Foundation formalize partnership on sustainable community gardening. August 6.
https://pantawid.dswd.gov.ph/2018/08/dswd-east-west-seed-foundation-formalize-partnership-on-
sustainable-community-gardening/ (accessed on November 5, 2020).
Department of Social Welfare Development and World Bank. 2014. Philippines conditional cash transfer
program impact evaluation 2012. Report Number 75533-PH. Quezon City, Philippines: DSWD.
Dervisevic, E., E. Perova, and A. Sahay. 2022. Conditional cash transfers and gender-based violence:
Does the type of violence matter? World Bank Policy Research Working Paper 10122. Washington,
DC: World Bank. https://documents1.worldbank.org/curated/en/099856507072222123/pdf/
IDU09733c89b0f84e0492609f970a1b1fb55ce51.pdf (accessed on July 20, 2022).
Economic Commission for Latin America and the Caribbean (ECLAC) and International Labour
Organization (ILO). 2014. The employment situation in Latin America and the Caribbean:
Conditional transfer programmes and the labour market. Santiago, Chile: United Nations.
Economic Policy Research Institute (EPRI). 2019. Rapid qualitative assessment of the impact of Pantawid
Pamilyang Pilipino Program (4Ps) on nutrition outcomes in beneficiary households in selected
municipalities. https://pantawid.dswd.gov.ph/wp-content/uploads/2020/02/4-Final-Report-Rapid-
Qualitative-Assessment-of-the-Impact-of-4Ps-on-Nutrition-Outcomes-in-Beneficiary-Households-
in-Selected-Municipalities.pdf (accessed on November 5, 2020).
Ferro, A. and A. Nicollela. 2007. The impact of conditional cash transfer programs on household
work decisions in Brazil. IZA-World Bank Conference on Employment and Development.
Bonn, Germany: Institute for the Study of Labour. https://www.iza.org/conference_files/
worldb2007/ferro_a3468.pdf (accessed December 10, 2018).
91
Gertler, P. 2004. Do conditional cash transfers improve child health? A randomized experiment.
The American Economic Review 94(2):336–341.
Lagarde, M., A. Haines, and N. Palmer. 2009. The impact of conditional cash transfers on health outcomes
and use of health services in low and middle income countries. Cochrane Database of Systematic
Reviews 2009(4).
Maguire, M. and B. Delahunt. 2017. Doing a thematic analysis: A practical, step-by-step guide for learning and
teaching scholars. All Ireland Journal of Higher Education 9(3):3314–3351.
Manley, J., S. Gitter, and V. Slavchevska. 2013. How effective are cash transfer programmes at improving
nutritional status? World Development 48:133–155.
Nowell, L., J. Norris, D. White, and N. Moules. 2017. Thematic analysis: Striving to meet the trustworthiness
criteria. International Journal of Qualitative Methods 16:1–13.
Office of Representative Susan Yap. 2014. House committee approves conditional cash transfer.
Quezon City, Philippines: Congress of the Philippines. https://www.congress.gov.ph/press/details.
php?pressid=8324 (accessed on December 2, 2019).
Peters, D., A. Garg, G. Bloom, D. Walker, W. Brieger, and M. Rahman. 2008. Poverty and access to health care in
developing countries. Annals of the New York Academy of Sciences 161–171.
Raitzer, D., O. Batmunkh, and D. Yarcia. 2021. Intrahousehold responses to imbalanced human
capital subsidies: Evidence from the Philippine conditional cash transfer. ADB Economics
Working Paper Series. https://www.adb.org/publications/human-capital-subsidies-philippine-cct
Skoufias, E. and V. di Maro. 2006. Conditional cash trans fers, adult work incentives, and poverty.
Washington, DC: World Bank.
Tesluic, C.M. and I. Walker. 2007. Peru: Social safety nets in Peru. Washington, DC: World Bank.
http://hdl.handle.net/10986/7693 (accessed on August 25, 2022).
World Health Organization (WHO). 2013. WHO recommendations on postnatal care of the mother and
newborn. Geneva, Switzerland: WHO. https://www.ncbi.nlm.nih.gov/books/n/whopostnat/pdf/
(accessed on December 18, 2019).
92
The Philippine Journal of Development is a
multidisciplinary social science journal
published twice a year. As a policy-oriented
journal, it features papers that have strong
policy implications on national or
international concerns, particularly
View publication stats

Cloa 2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cloa 2

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Rural Physicians' Experiences with Diagnosis, Treatment, and

Article · January 2022

Nina Castillo-Carandang Lauren Leining

SEE PROFILE SEE PROFILE

Anna Mandalakas Kristy O Murray

SEE PROFILE SEE PROFILE

The user has requested enhancement of the downloaded file.

Analyzing the Diversity and Inclusivity of Philippine

Rural Physicians’ Experiences with Diagnosis,

Learning from Stories Behind Unexpected Results:

Editorial and Production Team

Printed in the Philippines, 2022

Boosting the Productivity of Agrarian Reform Beneficiaries through

Analyzing the Diversity and Inclusivity of Philippine

Rural Physicians’ Experiences with Diagnosis, Treatment, and Management

Learning from Stories Behind Unexpected Results: A Qualitative

Boosting the Productivity of Agrarian

COMPREHENSIVE AGRARIAN REFORM PROGRAM

COLLECTIVE CERTIFICATE OF LAND OWNERSHIP AWARDS

Related statistics on CCLOA

Table 2. Number of ARBs by region and type of CLOA

5 This estimate includes all lands under various modes of acquisition.

Box 1. Is collective farming a viable strategy?

Issues that farmers encounter under CCLOAs

Figure 1. General process flow of parcelization

Step 1: Inventory Step 2: Prioritization Step 3: Field

Figure 2. Step 4: Firming up of the list of collective owners of awarded lands

ARBs = agrarian reform beneficiaries; ARBOs = agrarian reform beneficiary organizations

Figure 3. Step 5: Process of parcelization

Pathway 3: Land registration/titling  increased access to credit  greater agricultural investment

Transferability of property rights is an important factor in increasing investments

EMPIRICAL ANALYSIS FOR PATHWAY 2

Table 3. Project ConVERGE land tenure services, 2017–2018

PIDS baseline survey

Table 4. CLOA parcels owned by sampled households

Table 5. CLOA parcels owned and cultivated by sampled households

Table 7. CLOA parcels with crop yield and sales information

Household-level analysis: Sales per ha

Table 9. Average annual sales per ha by types of crops and CLOAs

Table 10. (continuation)

Parcel-level analysis: Yield per ha

Table 11. Number of parcels by types of crops planted and CLOA

Table 12. Average yield of copra and banana by type of CLOA

Table 13. Average yield of palay and corn by type of CLOA

Why pursue a more secure and individualized form of tenure?

Plantation crops and contract farming

Farm ownership vs. farm management

CONCLUSION AND RECOMMENDATION

Analyzing the Diversity

REVIEW OF RELATED LITERATURE

Philippine compliance with the EU’s GSP+

Table 1. Highlights of the Philippines’ compliance with EU-GSP+ obligations, 2018–2019

- Bills were introduced in Congress to include death penalty for drug-related

Economic impact of EU’s GSP+ on other beneficiary countries

Figure 1. Conceptual framework of the study

Opening of Political economy of

(Limited) Economic impact

EU = European Union; GSP+ = Generalised Scheme of Preferences Plus

Data collection procedures

Data analysis procedures

RESULTS AND DISCUSSION

Table 2. Relative importance of Philippine GSP+ exports, 2016–2018