INEQUALITY IN THE PHILIPPINES IN REPRODUCTIVE, MATERNAL, AND CHILD HEALTH. A Post-Workshop Report. November 2012

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1 INEQUALITY IN REPRODUCTIVE, MATERNAL, AND CHILD HEALTH IN THE PHILIPPINES A Post-Workshop Report November 2012 This report is intended to document the participants collective efforts during a workshop held in June 2012 that aimed to assess the status, dimensions and trends in inequality in key reproductive, maternal and child health indicators in the Philippines and identify priorities for action. The report was written by a sub-group of the workshop participants and cleared for dissemination by the Government of the Philippines. Inputs from other workshop participants, namely, Ms Zeny Recidoro and Dr Genesis Samonte (Department of Health), Mr Valerie Ulep (Philippines Institute of Development Studies), Ms Gilda Diaz from PhilHealth (the Philippines Health Insurance Corporation), and Ms Leslie Escalada (RTI-HealthGov) are gratefully acknowledged. Technical support and guidance from WHO is also gratefully acknowledged: Dr Ahmad Reza Hosseinpoor and Mr Kyle Ragins (WHO headquarters), Ms Anjana Bhushan and Ms Anita Liu (WHO Regional Office for the Western Pacific) and Ms Lucille F Nievera (WHO Country Office for the Philippines).

2 Table of Contents Introduction... 4 EQUITY IN HEALTH: THE PHILIPPINE CONTEXT... 4 PHILIPPINE COMMITMENT TO THE GLOBAL STRATEGY FOR WOMEN S AND CHILDREN S HEALTH... 4 Methodology... 6 Trends and Latest Status in Maternal and Child Health Indicators... 9 NATIONAL COVERAGE OF HEALTH SERVICES NATIONAL CHILD HEALTH OUTCOMES INEQUALITY IN HEALTH SERVICES BY WEALTH FIGURE 1. WEALTH-BASED INEQUALITY IN ANTENATAL CARE COVERAGE (FOUR OR MORE VISITS) FIGURE 2. WEALTH-BASED INEQUALITY IN SKILLED BIRTH ATTENDANT COVERAGE INEQUALITY IN CHILD HEALTH OUTCOMES BY WEALTH FIGURE 3. WEALTH-BASED INEQUALITY IN UNDER-FIVE MORTALITY RATE FIGURE 4. EDUCATION-BASED INEQUALITY IN FAMILY PLANNING FIGURE 5. EDUCATION-BASED INEQUALITY IN SKILLED BIRTH ATTENDANT COVERAGE INEQUALITY IN CHILD HEALTH OUTCOMES BY EDUCATION INEQUALITY IN HEALTH SERVICES BY AREA FIGURE 6. AREA-BASED INEQUALITY IN VITAMIN A SUPPLEMENTATION INEQUALITY IN CHILD HEALTH OUTCOMES BY AREA INEQUALITY IN HEALTH SERVICES BY REGION FIGURE 7. REGION-BASED INEQUALITY IN THE PRESENCE OF A SKILLED BIRTH ATTENDANT INEQUALITY IN HEALTH SERVICES BY SEX INEQUALITY IN CHILD HEALTH OUTCOMES BY SEX FIGURE 8. SEX-BASED INEQUALITY IN UNDER-FIVE MORTALITY RATE Benchmarking of the Philippines against other Countries NATIONAL COVERAGE ABSOLUTE AND RELATIVE INEQUALITY FIGURE 9. BENCHMARKING OF SKILLED BIRTH ATTENDANT COVERAGE Situation Analysis PRIORITY HEALTH SERVICES INDICATORS PRIORITY EQUITY STRATIFIERS IN HEALTH SERVICES PRIORITY INEQUALITIES IN CHILD HEALTH OUTCOMES Data tables TABLE 1. SITUATION ANALYSIS OF LATEST STATUS

3 TABLE 2. SITUATION ANALYSIS OF TIME TRENDS TABLE 3. SITUATION ANALYSIS OF BENCHMARKING LATEST STATUS TABLE 4. PHILIPPINES NATIONAL COVERAGE TABLE 5. WEALTH-BASED INEQUALITY TABLE 6. EDUCATION-BASED INEQUALITY TABLE 7. AREA-BASED INEQUALITY TABLE 8. REGION-BASED INEQUALITY TABLE 9. SEX-BASED INEQUALITY TABLE 10. NATIONAL COVERAGE OF HEALTH SERVICES BENCHMARKING AGAINST COMPARABLE COUNTRIES Appendix APPENDIX 1. DEFINITIONS OF INDICATORS AND CODING KEY APPENDIX 2. LIST OF WORKSHOP PARTICIPANTS APPENDIX 3. WORKSHOP AGENDA References

4 Introduction EQUITY IN HEALTH: THE PHILIPPINE CONTEXT The Philippine health sector has implemented reform initiatives meant to apply the advances of medicine and progressive public health approaches and consequently affect substantial improvement in health status indicators. Despite certain successes and important progress in some areas, large disparities remain among geographic areas and income groups. The challenges of the health system are characterized by the dominance of an independent private health sector, a disconnect between national and local authorities, and the absence of an integrated curative and preventive network. These challenges together have resulted in slower progress in expansion of access to health services in underserved populations from geographic and socioeconomic perspectives. The current health sector leadership seeks to implement Universal Health Care to address the inequities in the current health system. Universal Health Care, dubbed as Kalusugan Pangkalahatan (KP), is defined as the provision to every Filipino of the highest possible quality of health care that is accessible, efficient, equitably distributed, adequately funded, fairly financed and appropriately used by an informed and empowered public. KP is envisioned to ensure health as a right to ALL Filipinos regardless of ability to pay. The Department of Health (DOH) aims to achieve this goal through the following three strategies: 1) rapid expansion in social health insurance enrolment and benefit delivery using national subsidies for the poorest families; 2) improved access to quality hospitals and health care facilities through accelerated upgrading of public facilities; and 3) attainment of healthrelated Millennium Development Goals (MDGs) by applying additional effort and resources to localities with a high concentration of families currently in need. In working towards covering the poorest, DOH and the Philippines Health Insurance Corporation (PhilHealth) have enrolled the poorest households for social health insurance based on the national targeting household system for poverty reduction (NHTS-PR) developed by the Department of Social Welfare and Development. In addition to being enrolled in the social health insurance program (PhilHealth), these households will be: 1) informed and guided about their national health insurance entitlements; and 2) assigned to primary health service providers as well as a network of hospitals which can provide them necessary inpatient services. Moreover, a no-balance billing policy for such services is being implemented and applied to these identified poorest households. PHILIPPINE COMMITMENT TO THE GLOBAL STRATEGY FOR WOMEN S AND CHILDREN S HEALTH The DOH is committed to championing the cause of women s and children s health, specifically to achieving substantial reductions in maternal mortality ratios and under-five mortality by 2015 through the implementation of Universal Health Care and other efforts. Through quality emergency obstetrics and newborn care to the 279 tertiary and secondary level facilities and 1,482 primary level facilities, the Philippines will move towards making pregnancy and childbirth 4

5 safer, while changing the fundamental societal dynamics that influence decision-making on matters related to pregnancy and childbirth. This move ensures easy access for those most in need of quality health care by competent doctors, nurses and midwives. With the implementation of major system reforms, and the consequent change in health service delivery, the Philippines has set the following targets for 2015: 80% of pregnant women will have at least 4 antenatal check-ups, deliver in a health care facility and have at least 2 post-natal check-ups; 63% of men and women of reproductive age will have access to contraceptives; 80% of pregnant women will have access to at least 2 doses of tetanus toxoid vaccine; and 90% of infants below 1 year will be fully immunized. To ensure that these targets are met, the government has committed to deploy Community Health Teams in every village as health advocates and to reduce the financial burden of health care by ensuring universal social health insurance coverage with a guaranteed 100% subsidized enrolment of poor families in the PhilHealth Sponsored Program. Two (MDGs 4 and 5) of the eight MDGs specifically deal with maternal and child health. These two MDGs are also the furthest from being achieved by In response to slow progress, the Secretary-General of the United Nations launched the Global Strategy for Women s and Children s Health in 2010, with the goal of saving 16 million lives in the world s poorest 49 countries and pledging $40 million in funding towards achieving MDGs 4 and 5. Following the announcement of the Global Strategy for Women s and Children s Health, the World Health Organization (WHO) created the Commission on Information and Accountability for Women s and Children s Health ( Accountability Commission ). The Accountability Commission was tasked with developing a global strategy for monitoring progress towards child and maternal health goals in a way that would facilitate progress. In 2011, the Accountability Commission produced their final report, Keeping Promises, Measuring Results, with ten recommendations. Among their recommendations was the use of eleven specific indicators on reproductive, child and maternal health for monitoring progress towards the goals of the Global Strategy. They also underlined the need to pay attention to inequalities when monitoring these indicators. 5

6 Methodology In order to assess inequality in reproductive, maternal and child health in the Philippines, we chose 13 health service indicators related to child and maternal health. Our health services indicators included the coverage of antenatal care (at least one visit by a skilled provider), antenatal care (four or more visits), the presence of a skilled birth attendant, modern contraceptive prevalence, modern and traditional contraceptive prevalence, family planning needs satisfied, DPT3 vaccination, measles vaccination, full immunization, care-seeking for pneumonia, oral rehydration therapy, early breastfeeding and vitamin A supplementation (Appendix 1). We chose these 13 indicators, because they are all either the same as, or strongly related to, the eight health services indicators recommended by the Accountability Commission. While the initial assessment and workshop included assessment of care-seeking for pneumonia and oral rehydration therapy, both indicators were excluded from all inequality and benchmarking assessments due to low sample sizes. When divided by equity stratifiers, this had led to high levels of uncertainty in point estimates in population subgroups which did not allow for meaningful conclusions about inequality levels or time trends. As a result, only the national coverage for these indicators was included in the post-workshop report. In addition to the 13 health services indicators assessed, we also looked at two child health outcomes indicators: the infant mortality rate, and the under-five mortality rate. The under-five mortality rate was chosen as it had been recommended in the Accountability Commission s report. Infant mortality is a closely related outcome indicator. The full definitions of all the indicators assessed are presented in Appendix 1. The health indicators selected were assessed by five different dimensions of inequality: wealth, education, sex, area, and region. These dimensions were chosen as they have been used widely in the literature previously. Notably, the specific indicator used to stratify individuals into wealth quintiles was an asset-based index derived from information on specific household asset ownership collected by Demographic and Health Surveys (DHS). Asset-based indices derived through principal component analyses had previously been shown to have a high correlation with other indicators of socioeconomic positions, such as income and expenditure, though they do have certain limitations, which have been explored in the literature (Howe, Hargreaves & Huttly, 2008; Howe et al., 2012; Vyas & Kumaranayake, 2006). The estimates used for our assessment of inequalities in the Philippines were extracted from the Equity Monitor database of the WHO Global Health Observatory (GHO). 1 These estimates are derived from the re-analysis of the publicly available DHS micro-data. Four rounds of DHS have been conducted in the Philippines in 1993, 1998, 2003, and 2008 allowing for assessment of progress on these indicators across four different time points, spanning over 15 years. 1 Data are derived from re-analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) micro-data, which are publicly available. The definitions of each indicator are the standard definitions published in DHS and UNICEF documentation. The analysis was done by the International Center for Analysis and Monitoring of Equity in Health and Nutrition based in the Federal University of Pelotas, Brazil and updated in December There may be slight differences between these results and those reported in DHS or MICS country reports in a few cases due to differences in calculation of indicators' numerators and/or denominators. 6

7 Calculations of summary measures of inequality for each indicator were conducted using HD*Calc, a publicly available software program specifically designed for the purpose of performing such calculations (see for more information). All calculations to estimate health indicators disaggregated by equity stratifiers were extracted directly from the WHO GHO Equity Monitor database. All visualizations were done using Microsoft Excel. The calculations of simple summary measures were double-checked using Excel. For each indicator, three aspects were assessed: 1) the latest status (from DHS 2008), 2) the time trend (going as far back as DHS 1993), and 3) benchmarking against other countries in the Asia Pacific Region. We selected eleven neighboring countries as comparison in the benchmarking assessment. We restricted our assessment to only the low- and middle-income countries in the Asia Pacific Region (26 countries), of which only 11 countries, other than the Philippines, had recent publicly available international household health data on the selected indicators (DHS or Multiple Indicator Cluster Survey (MICS) from 2005 to 2010). These countries included Bangladesh, Cambodia, India, Indonesia, Lao People s Democratic Republic, Maldives, Mongolia, Nepal, Thailand, Timor-Leste, and Vanuatu. In cases where recent data for a specific country was not available, that country was dropped from the assessment. These countries, and the Asia Pacific Region overall, are quite diverse. Nonetheless, by comparing the Philippines with these countries, we hoped to expand our understanding of the broader context with which to interpret information on health inequalities. Countries of the Asia Pacific Region may share many similar underlying causes of health inequalities, meaning that inequalities in certain health indicators may be challenging across the region (AP-HealthGAEN, 2011). Through a benchmarking comparison with other countries in the region, we can develop a greater understanding of the context with which to assess priority areas where action is warranted to reduce health inequalities in the Philippines. All assessments were conducted in group exercises during a three-day workshop on inequality monitoring from June 18 to 20, 2012 in Manila, Philippines. A full list of participants can be found in Appendix 2. Except for the situation analysis, participants were divided into three small groups for each assessment and exercise. In small groups, the participants discussed tables and graphs demonstrating the values of indicators by each equity stratifier and summary measures of inequality. During the plenary session, the best and worst health indicators were identified and discussed. The situation analysis was conducted in two small groups. Participants were asked to examine the national coverage, absolute inequality, and relative inequality for each indicator in terms of latest status, time trend, and benchmarking. Participants scored each indicator in these subcategories on a scale of one to three: 3 (red) indicated urgent need for action, 2 (yellow) indicated that action was needed, and 1 (green) indicated that no action was needed. When assessing the time trends for the situation analysis, many indicators that improved over time were not scored a 1," as participants felt that further action was still needed. It should be noted that there was some degree of subjectivity on the part of workshop participants in assigning these scores. 7

8 The final presentation of the situation analysis and priorities in maternal and child health was given by participants in the presence of national health policymakers. The situation analysis developed during the workshop was finalized by a small subset of workshop participants with assistance from WHO. This report is intended as a preliminary document assessing maternal and child health inequalities in the Philippines. Certain terminology related to health inequality monitoring, especially with regards to relative and absolute inequality, may not be familiar to all audiences. Existing publications describing the terminology and additional considerations for health inequality information can be reviewed for more information (Harper & Lynch, 2006; Braveman, 1998; O'Donnell et al., 2008-b; Keppel et al., 2005; Braveman, 2003). 8

9 Trends and Latest Status in Maternal and Child Health Indicators NATIONAL COVERAGE OF HEALTH SERVICES In the 15 years from DHS 1993 to DHS 2008, the Philippines achieved increases in national coverage for 10 of the 13 health services indicators assessed (Table 4). The indicators that have increased in coverage included: antenatal care (both one visit and four or more visits), modern and traditional contraceptive prevalence, modern contraceptive prevalence, DPT3 vaccination, early breastfeeding, family planning, full immunization, oral rehydration therapy, and presence of a skilled birth attendant. The largest increase in coverage was seen in four or more antenatal care visits, which went from 52.5% coverage in DHS 1993 to 77.8% coverage in DHS 2008 (an increase of 25.3 percentage points in coverage over the 15 years of DHS data). Oral rehydration therapy showed the second largest increase at 22.3 percentage points from DHS 1998 to DHS The remaining indicators had modest increases in coverage during this time period: five of them showed increases of less than 10 percentage points; and all others showed increases of less than 15 percentage points over the 15 years. From DHS 1993 to DHS 2008, three indicators showed no change in coverage: measles vaccination, pneumonia care-seeking, and vitamin A supplementation. 2 Measles vaccination and vitamin A supplementation coverage were fairly high at the beginning of the assessment period, starting at 81.4% and 76% respectively. Pneumonia care-seeking, however, started the assessment period at just 51.3% coverage. No health services indicators significantly decreased their coverage in the Philippines from DHS 1993 to DHS Latest Status: In DHS 2008, six of the 13 health services indicators showed high coverage at greater than 75%. These indicators included antenatal care (both one visit and four or more visits), DPT3 vaccination, full immunization, measles vaccination, and vitamin A supplementation. The coverage of one antenatal care visit was the highest of any health services indicator at 96%. Five of the 13 indicators showed moderate coverage between 50% and 75%. These indicators included modern and traditional contraceptive prevalence, early breastfeeding, family planning, oral rehydration therapy, and the presence of a skilled birth attendant. Only 2 For vitamin A supplementation only data points for 2003 to 2008 were assessed, and there was no change in this 5- year interval in national coverage. 9

10 two indicators (modern contraceptive prevalence, and pneumonia care-seeking) had coverage levels below 50%.. At 34%, modern contraceptive prevalence had the lowest coverage rate of all indicators. NATIONAL CHILD HEALTH OUTCOMES Both infant mortality and under-five mortality decreased from DHS 1993 to DHS Underfive mortality significantly decreased from 63.1 deaths per 1,000 live births down to 37.3, representing a 40.8% decrease in under-five mortality over the 15 years. In comparison, infant mortality went from 38.1 per 1,000 live births down to 28, a decrease of 26.5%. Latest Status: In DHS 2008, the infant mortality rate was 28 per 1,000 live births, while the under-five mortality rate was 37.3 per 1,000 live births. INEQUALITY IN HEALTH SERVICES BY WEALTH The Philippines achieved decreases in wealth-based inequality from DHS 1998 to DHS 2008 in four of the eleven health services indicators assessed (Table 5). The indicators that showed decreases in wealth-based inequality included the antenatal care indicators, family planning, and vitamin A supplementation. Of the indicators with decreasing wealth-based inequality, four or more antenatal care visits decreased greatly in both absolute and relative inequality over the 10-year period in DHS: the absolute gap between the wealthiest and poorest quintiles decreased from 52.1 percentage points in DHS 1998 to 32 percentage points in DHS 2008, while the relative ratio of these quintiles went from 2.4 to 1.5 in the same period (Figure 1). One antenatal care visit was the indicator with the second largest decrease in inequality, with the absolute difference between wealthiest and poorest quintiles decreasing from 24.7 to 6.9 percentage points over the same 10-year period, and the relative ratio of the quintiles decreasing from 1.3 to 1.1. FIGURE 1. WEALTH-BASED INEQUALITY IN ANTENATAL CARE COVERAGE (FOUR OR MORE VISITS). The large decrease in inequality in both antenatal care indicators occurred primarily in the fiveyear interval from DHS 2003 to DHS All lower quintiles improved coverage faster during this interval than the wealthiest quintile, which led to reduced inequality overall. With regards 10

11 to coverage of one antenatal care-visit, the drop in inequality was disproportionately driven by an improvement in the poorest quintile, as that group was an outlier from the other quintiles in coverage previously. In contrast, in family planning, the decrease in inequality was not driven by improvements in coverage, but primarily by a decrease in coverage in the upper three quintiles in the DHS 2003 to DHS 2008 period, leading to convergence among quintiles. This was similar in the case of vitamin A supplementation coverage: the poorest wealth quintile remained an outlier over the DHS 2003 to DHS 2008 period (1998 data was not available), and the drop in inequality was primarily driven by a decrease in coverage in the wealthiest quintile, coupled with a slight improvement in coverage of the second poorest quintile. From DHS 1998 to DHS 2008, seven of the eleven indicators assessed by wealth showed no substantial change in inequality. The indicators that showed little change in inequality over the 10-year period included: DPT3 vaccination, early breastfeeding, measles vaccination, full immunization, modern and traditional contraceptive prevalence, modern contraceptive prevalence, and presence of a skilled birth attendant. Of these seven indicators, three of them early breastfeeding, and the two contraceptive prevalence indicators showed low levels of inequality in DHS 1998, with absolute gaps between wealthiest and poorest quintiles at less than 15 percentage points. However, the other four unchanged indicators had higher levels of inequality at the start, with absolute gaps of over 20 percentage points in DHS 1998 that showed no substantial improvement in DHS Early breast-feeding was the only category in which inequality favored the poorest quintile, i.e. the poorest quintile achieved the highest coverage. In all other indicators, inequality favored more wealthy quintiles. Latest Status: In DHS 2008, five of the eleven child and maternal health indicators showed low levels of wealth-based inequality, with the absolute gap between wealthiest and poorest quintile at less than 10 percentage points. The indicators with absolute levels of inequality with less than a 10 percentage-point gap included: one antenatal care visit, modern and traditional contraceptive prevalence, modern contraceptive prevalence, early breastfeeding, and vitamin A supplementation. All of these indicators had relative ratios of inequality of less than 1.3. The lowest level of absolute and relative inequality was in the coverage of one antenatal care visit with a difference between poorest and wealthiest of 6.9 percentage points and a relative ratio of 1.1. In contrast, four of the eleven indicators saw high levels of wealth-based inequality in DHS 2008, with an absolute gap between wealthiest and poorest quintiles of over 20 percentage points. These indicators included: 11

12 four or more antenatal care visits, DPT3 vaccination, full immunization, and presence of a skilled birth attendant. Three of these four indicators had absolute gaps between 22 and 32 percentage points, with relative ratios between quintiles ranging from 1.3 to 1.5. The presence of a skilled birth attendant provided an outlier of extreme inequality. By far, the presence of a skilled birth attendant showed the greatest inequality by wealth of any indicator, with an absolute gap between wealthiest and poorest quintiles of 68.7 percentage points and a relative ratio of 3.7 (Figure 2). FIGURE 2. WEALTH-BASED INEQUALITY IN SKILLED BIRTH ATTENDANT COVERAGE. INEQUALITY IN CHILD HEALTH OUTCOMES BY WEALTH Wealth-based absolute and relative inequality in the infant and under-five mortality rates remained unchanged between DHS 1998 and DHS Both of these indicators began this 10- year period with high levels of inequality, with the mortality rates of the poorest quintile more than double the rates of the wealthiest quintile, and both indicators exceeding 45 per 1,000 live births in the poorest quintile (Figure 3). Latest Status: In DHS 2008, the infant under-five mortality rates in the poorest quintile were more than double the rates of the wealthiest quintile. Infant mortality in the poorest quintile stood at 40.3 per 1,000 live births compared to 14.9 per 1,000 live births in the wealthiest quintile. Under-five mortality in the poorest quintile stood at 58.6 per 1,000 live births compared to 17.1 per 1,000 live births in the wealthiest quintile. 12

13 FIGURE 3. WEALTH-BASED INEQUALITY IN UNDER-FIVE MORTALITY RATE. INEQUALITY IN HEALTH SERVICES BY EDUCATION Technical note on this section The population was stratified by education into three groups no education, primary school, and secondary school+. However, the population of women of reproductive age with no education in the Philippines was very small, at less than 5% of the total population of women in reproductive age who were used in the assessment throughout the period assessed. As a result, in examining education-based inequality, we will not speak about the simple difference in coverage between the most and least educated groups, as attempting to express the overall level of inequality in relation to a population grouping that is so small might be misleading. Rather, to describe the level of absolute inequality more accurately, we will talk about inequality for each indicator throughout the whole educational spectrum measured by slope index of inequality. The slope index of inequality is a means of measuring the gradient in coverage between those more educated and those less educated, including all 3 groups simultaneously. This measure also accounts for our no education group s low numbers by weighing each indicator s coverage by the proportion of the population in that group, so that the educational groups with more people in them are weighed more heavily in determining the slope index of inequality than the group with few people. From DHS 1993 to DHS 2008, the Philippines achieved decreases in education-based inequality (measured through the slope index of inequality) in just three of eleven child and maternal indicators assessed (Table 6). The indicators that showed decreases in inequality were one antenatal care visit, family planning, and vitamin A supplementation. One antenatal care visit saw the most dramatic decrease in inequality with the gradient in coverage by education showing a decrease of 25.9 percentage points over this period. The inequality in one antenatal care visit was virtually flat from DHS 1993 to DHS Most of this improvement occurred during the five-year interval from DHS 2003 to DHS 2008, with the lesser educated groups showing large gains in coverage of one antenatal care visit during that period, resulting in a drop in absolute inequality. Family planning and vitamin A supplementation saw more modest decreases in absolute inequality with decreases in the coverage gradient by education of 9-12 percentage points during the assessment period (Figure 4). 13

14 In contrast to one antenatal care visit coverage, where the drop in inequality was driven entirely by improvements in coverage in the lesser educated groups, the drop in inequality for family planning and vitamin A supplementation coverage was driven in part by decreases in coverage in the most educated group. FIGURE 4. EDUCATION-BASED INEQUALITY IN FAMILY PLANNING. For seven of the eleven health services indicators, education-based inequality remained essentially unchanged during the period assessed. The indicators that remained unchanged included: four or more antenatal care visits, early breastfeeding, full immunization, measles vaccination, modern and traditional contraceptive prevalence, modern contraceptive prevalence, and presence of a skilled birth attendant. For all of these indicators except early breastfeeding the gradient of coverage by education favored the most educated. In early breastfeeding, the gradient was reversed with coverage rates favoring the least educated. All other indicators showed high levels of absolute inequality in DHS 1993, with coverage gradients by education of over 15%, rising up to 71% in the case of skilled birth attendants. All of these had not improved by DHS Latest Status: In DHS 2008, five indicators of maternal and child health showed high levels of absolute inequality, with gradients in coverage by education exceeding 40%. The indicators with high levels of inequality included: four or more antenatal care visits, DPT3 vaccination, full immunization, measles vaccination, and 14

15 presence of a skilled birth attendant. The presence of a skilled birth attendant was the indicator showing the highest level of inequality, with a coverage gradient of 81.8% by education level (Figure 5). The remaining eight health services indicators showed lower levels of absolute inequality, all with gradients in coverage by education below 22%. Early breastfeeding showed the least absolute inequality in DHS 2008, with a coverage gradient of -8.2%. Early breastfeeding was also the only indicator in DHS 2008 where the gradient of inequality showed better coverage for those who were less educated. All other indicators showed better coverage for those who were more educated. FIGURE 5. EDUCATION-BASED INEQUALITY IN SKILLED BIRTH ATTENDANT COVERAGE. INEQUALITY IN CHILD HEALTH OUTCOMES BY EDUCATION There was no change in education-based absolute inequality in the infant mortality rate or the under-five mortality rate from DHS 1993 to DHS Both of these indicators began this 15- year period with high levels of inequality: the least educated group had nearly triple the mortality rates of the most educated group, and the middle (primary school) group had nearly double the rate. The gradient in mortality by education exceeded 70 per 1,000 live births in both indicators. Latest Status: In DHS 2008, the gradient in infant and under-five mortality rates by education exceeded 90 per 1,000 live births for both indicators. Infant mortality in the least educated group stood at 88.8 per 1,000 live births compared to 24.3 per 1,000 live births in the most educated group. While under-five mortality in the least educated quintile stood at 115 per 1,000 live births, it was at 30.1 per 1,000 live births in the most educated group. 15

16 INEQUALITY IN HEALTH SERVICES BY AREA The Philippines saw a decrease in area-based inequality from DHS 1993 to DHS 2008 in three of eleven health services indicators assessed (Table 7). Both antenatal care indicators and vitamin A supplementation (Figure 6) saw a decrease in both absolute and relative area-based inequality. For the antenatal care indicators, the decrease in inequality was driven by faster growth of coverage in rural areas compared to urban areas over this period. Coverage of four or more antenatal care visits was the indicator with the largest decrease in inequality between rural and urban areas. From DHS 1993 to DHS 2008, this indicator saw a decrease in the absolute gap in coverage by 11.8 percentage points, and the ratio of urban to rural coverage decreased from 1.5 to 1.1. For vitamin A supplementation, the decrease in inequality was largely due to a decrease in coverage in urban areas between DHS 2003 and DHS 2008 (data prior to DHS 2003 was not assessed for vitamin A supplementation). FIGURE 6. AREA-BASED INEQUALITY IN VITAMIN A SUPPLEMENTATION. Eight of the eleven assessed indicators showed no change in area-based inequality from DHS 1993 to DHS These indicators included: early breastfeeding, DPT3 vaccination, family planning, full immunization, measles vaccination, modern and traditional contraceptive prevalence, modern contraceptive prevalence, and presence of a skilled birth attendant. Of these eight indicators, all but the indicator on presence of a skilled birth attendant presented with low levels of inequality in DHS 1993, with the absolute gap between rural and urban at less than 10 percentage points and the relative ratio at less than 1.2. The presence of a skilled birth attendant showed a high level of absolute and relative inequality in DHS 1993, with an absolute gap of 34.5 percentage points and a relative ratio of 2.0, which had remained unchanged in DHS

17 Latest Status: In DHS 2008, ten of the eleven indicators had low levels of area-based inequality with absolute gaps in coverage between rural and urban areas at less than 11 percentage points and relative ratios of less than 1.2. One indicator, the presence of a skilled birth attendant, stood out in DHS 2008 as having a higher level of area-based inequality, with an absolute gap in coverage between urban and rural at 29.8 percentage points and a relative ratio of 1.6. INEQUALITY IN CHILD HEALTH OUTCOMES BY AREA There was no change in area-based relative or absolute inequality in the infant mortality rate or the under-five mortality rate from DHS 1993 to DHS Both of these indicators began this 15-year period with moderate levels of inequality, as rural mortality rates were almost 50% greater than urban mortality rates. In DHS 1993, the infant mortality rate in rural areas exceeded 40 per 1,000 live births for rural areas and the under-five morality exceed 70 per 1,000 live births. Latest Status: In DHS 2008, infant and under-five mortality showed moderate levels of areabased inequality, with the absolute gap between urban and rural populations at greater than 15 deaths per 1,000 live births for each, and both with urban-to-rural ratios greater than 1.6. The infant mortality rate in rural areas was 35.4 per 1,000 live births compared to 20.1 in urban areas, while the under-five mortality rates were 46.3 and 27.7 respectively. INEQUALITY IN HEALTH SERVICES BY REGION From DHS 2003 to DHS 2008, the Philippines saw a decrease in region-based absolute inequality in only one of eleven indicators assessed: coverage of one antenatal care visit (Table 8). Additionally, the indicator on coverage of four or more antenatal care visits saw a decrease in, relative inequality, but not in absolute inequality. For both antenatal care indicators, the decrease in inequality was driven primarily by a large increase in coverage in the ARMM region between DHS 2003 and DHS 2008, as coverage for each of these indicators nearly doubled in ARMM during that time. ARMM had previously been a regional outlier of low coverage in DHS With regards to coverage of four or more antenatal care visits, the large increase in ARMM did not result in a decrease in absolute inequality. This was because other regions with high coverage in DHS 2003 had also increased their coverage in DHS 2008, making ARMM s progress between DHS 2003 and DHS 2008 result only in a decrease in relative inequality. For nine of the assessed indicators, no change was seen in region-based absolute or relative inequality from DHS 2003 to DHS All of these indicators had high levels of inequality in DHS 2003, with absolute gaps between regions of highest coverage and of lowest coverage greater than 30 percentage points and relative ratios exceeding 1.5. Current Status: In DHS 2008, ten of the eleven indicators all except one antenatal care visit showed a high level of regional inequality with absolute gaps between regions in coverage greater than 30 percentage points. The relative ratio between regions in ten of these indicators exceeded 2. Only vitamin A supplementation and four antenatal care visits had lower relative ratios of 1.8. The highest level of region-based absolute and relative inequality was in skilled 17

18 birth attendant coverage, with an absolute gap of 67.6 percentage points and a ratio of 4.5 in DHS 2008 (Figure 7). The coverage of one antenatal care visit had the lowest level of inequality by region in DHS 2008, with an absolute gap between most and least covered regions of only 5.9 percentage points and a relative ratio of 1.1. In ten of the eleven indicators all except early breastfeeding ARMM was the region with the lowest level of coverage in DHS 2008, while regions with highest level of coverage varied. FIGURE 7. REGION-BASED INEQUALITY IN THE PRESENCE OF A SKILLED BIRTH ATTENDANT. INEQUALITY IN HEALTH SERVICES BY SEX From DHS 1993 to DHS 2008, there was virtually no change in sex-based inequality in any of the five health services indicators assessed (Table 9). For all five indicators, coverage in DHS 1993 showed no absolute or relative inequality by sex. Latest Status: In DHS 2008, there was no absolute or relative inequality by sex in any of the five indicators of child and maternal health assessed. INEQUALITY IN CHILD HEALTH OUTCOMES BY SEX There was no significant change in absolute or relative sex-based inequality in infant or underfive mortality rates between DHS 1993 and DHS Both indicators started the period with slightly increased ratios among boys compared to girls., Boys saw a difference of 10.4 more infant deaths per 1,000 live births and 11.3 more under-five deaths per 1,000 live births in DHS 1993 (Figure 8). 18

19 FIGURE 8. SEX-BASED INEQUALITY IN UNDER-FIVE MORTALITY RATE. Latest Status: In DHS 2008, infant and under-five mortality rates were slightly higher among boys than girls. The infant mortality rate was 30.9 per 1,000 live births among boys compared to 24.8 among girls, while the under-five mortality rates were 40.6 and 33.6 for boys and girls, respectively. 19

20 Benchmarking of the Philippines against other Countries NATIONAL COVERAGE The Philippines ranks in the midrange of countries in the Region in terms of overall national coverage in seven of the eleven indicators (Table 10): early breastfeeding, modern and traditional contraceptive prevalence, DPT3 vaccination, measles vaccination, full immunization, presence of a skilled birth attendant, and family planning The national coverage for three indicators the two antenatal care indicators, and vitamin A supplementation was among the best in the Region. National coverage for the remaining indicator modern contraceptive prevalence was in the bottom third of countries assessed. ABSOLUTE AND RELATIVE INEQUALITY When benchmarked against other similar countries in the Asia Pacific Region, the Philippines ranks in the midrange in wealth-based absolute inequality for eight of eleven child and maternal health services indicators assessed based on DHS These indicators included: antenatal care (one visit, and four or more visits), modern and traditional contraceptive prevalence, modern contraceptive prevalence, family planning, DPT3 vaccination, measles vaccination, and full immunization. For two of eleven indicators presence of a skilled birth attendant, and vitamin A supplementation the Philippines was among the one-third of countries with the highest wealth-based absolute inequality. Among the twelve countries assessed, the Philippines presented with the highest level of wealth-based absolute inequality for the presence of a skilled birth attendant indicator (Figure 9). The Philippines never reached a level of wealthbased absolute inequality that placed among the lowest one-third of countries assessed. For one of the indicators early breastfeeding the wealth-based absolute and relative inequality in the Philippines was such that the poorer population groups achieved better coverage than the wealthier groups. Five of the eleven neighboring countries showed similar trends in early breastfeeding coverage favoring poorer population groups. 20

21 FIGURE 9. BENCHMARKING OF SKILLED BIRTH ATTENDANT COVERAGE. Philippines Other Countries With regards to relative inequality, two health services indicators in the Philippines achieved levels of wealth-based relative inequality that put them among the one-third of countries with the lowest levels of wealth-based relative inequality in our assessment. The two antenatal care indicators, which were some of the only indicators to achieve comparably high levels of national coverage amongst countries assessed, were also the only two indicators in which the Philippines was among the one-third of countries with the least relative inequality. In contrast to the antenatal care indicators, the Philippines did not manage to reach such comparably low levels of relative inequality for any other indicator. Rather, eight of eleven indicators fell in the midrange of comparable countries: modern and traditional contraceptive prevalence, modern contraceptive prevalence, family planning, DPT3 vaccination, full immunization, measles vaccination, presence of a skilled birth attendant, and vitamin A supplementation. 21

22 Situation Analysis PRIORITY HEALTH SERVICES INDICATORS The single most inequitable health services indicator across all equity stratifiers assessed was the presence of a skilled birth attendant. This indicator had the highest level of absolute inequality of any indicator when assessed by wealth, education, area, and region (Table 1). The wealth-based absolute inequality was the greatest with an absolute gap in coverage between poorest and wealthiest quintiles at 68.7 percentage points in DHS When compared to other countries in the Asia Pacific Region, the Philippines had the greatest absolute wealthbased inequality of skilled birth attendant coverage of any country in our assessment (Table 3). Additionally, the inequality in coverage of skilled birth attendants showed no improvement by any equity stratifier from DHS 1993 to DHS 2008 (Table 2). Other high priority health services indicators that showed high levels of inequality across several equity stratifiers were four or more antenatal care visits, DPT3 vaccination, full immunization, and measles vaccination. These indicators showed high levels of absolute and relative inequality across wealth, education, and region. With regards to wealth, each of these indicators had an absolute gap between wealthiest and poorest groups of greater than 20 percentage points in coverage and relative ratios exceeding 1.3 in DHS The region-based inequality in DHS 2008 for each of these was greater than a 35 percentage point absolute gap between best and least covered regions with ratios exceeding 1.8 for all indicators. The education-based inequality for each of these indicators was the greatest of any stratifier, with a gradient in coverage by educational level that exceeded 40% for all indicators in DHS The trend over time for the inequality in four or more antenatal care visits, DPT3 vaccination, measles vaccination and full immunization was slightly more promising than the situation for skilled birth attendants. Wealth-based inequality in four or more antenatal care visits and education-based inequality for DPT3 vaccination decreased from DHS 1993 to DHS 2008, though the inequality by other stratifiers remained unchanged during this period. Full immunization and measles vaccination did not see a reduction in inequality by any stratifier. While the situation for these indicators four or more antenatal care visits, DPT3 vaccination, measles vaccination and full immunization proved to have some of the highest levels of inequality across a variety of stratifiers, the situation of the Philippines was similar to comparable countries in the types of inequality seen for these indicators. The Philippines placed in the midrange of comparable countries in wealth-based relative and absolute inequality for nearly all of these indicators. This was however not the case for four or more antenatal care visit coverage, where the Philippines actually achieved one of the lowest levels of relative inequality among comparable countries and one of the highest levels of overall national coverage. For DPT3 vaccination, measles vaccination and full immunization, wealth-based inequality for these indicators was not only in the midrange of comparable countries, but the Philippines also fell in the midrange of countries in terms of overall national coverage. Workshop participants identified family planning and modern contraceptive prevalence as additional areas of concern for the Philippines in terms of the latest status and time trend of 22

23 inequality across various stratifiers and when benchmarked against comparable countries. By region these indicators had absolute differences between most and least covered regions of over 35 percentage points with relative ratios of 2.5 or greater. Education-based inequality also had moderately high levels with an absolute gradient in coverage by education of 14-15% for both indicators. The situation by wealth was slightly better, with the absolute difference in contraceptive prevalence between poorest and wealthiest at only 7.2 percentage points, and family planning at 11.8 percentage points. For neither indicator did the relative ratio of wealth quintiles exceed 1.3, nor was there any significant inequality by either area or sex. In terms of time trends, family planning proved to have reductions in absolute and relative inequality from DHS 1993 to DHS 2008 by both wealth and education. Neither indicator managed an improvement in region-based inequality. While modern contraceptive prevalence did not show significant improvement over the assessment period, it is worth noting that modern contraceptive prevalence had one of the lowest levels of inequality of any indicator by wealth, region, and education at both the beginning and end of the assessment period. When benchmarked against comparable countries, the wealth-based relative and absolute inequality was typical for the region, as the Philippines ranked in the midrange of countries in inequality for both indicators. Family planning national coverage overall was also typical of the region, placing in the middle one-third of countries, though the modern contraceptive prevalence did fall below the median for the region, as prevalence was in the bottom one-third of comparable countries. Two indicators that stood out as having an especially favorable position in terms of inequality across multiple stratifiers were early breastfeeding and one antenatal care visit. By DHS 2008, these indicators showed low levels of absolute and relative inequality across wealth, education, area, region, and sex (for early breastfeeding). By wealth, area, and region, both indicators saw absolute coverage gaps of less than 10 percentage points and relative ratios at 1.1 or less. By education, both indicators saw absolute gradients in coverage of less than 15%. With regards to region-based inequality, the coverage of one antenatal care visit was the only indicator assessed (out of eleven) to achieve a low level of inequality by DHS 2008 with an absolute gap of 5.9 percentage points and a relative ratio of 1.1. The coverage of one antenatal care visit is a burgeoning success story for the Philippines, as the latest, low levels of inequality are the result of decreases by wealth, education, area, and region over the last 15 years of DHS data. Compared to other countries, the Philippines is doing well with regards to this indicator It falls in the top one-third of countries in terms of national coverage and is among the one-third of countries with the lowest relative inequality. Early breastfeeding was notable not just for its low levels of inequality, but also as the only health services indicator for which coverage consistently favored the less educated, poorer, and more underserved quintiles. When compared to other countries, this was common in the region, as five of the twelve countries assessed had wealth-based inequality that favored the poorer population groups with regards to early breastfeeding. The overall coverage for the Philippines in early breastfeeding fell into the midrange of comparable countries. 23

24 PRIORITY EQUITY STRATIFIERS IN HEALTH SERVICES Inequality by region and education proved to have the most wide-reaching inequalities of any equity stratifiers assessed (Table 1). In DHS 2008, ten out of eleven health services indicators had an absolute difference in coverage between most and least covered regions, exceeding 30 percentage points with relative ratios of 1.8 or greater. The high levels of region-based inequality were primarily due to low coverage levels in the ARMM. In all health services indicators, other than early breastfeeding, the ARMM region had the lowest level of coverage in DHS Between DHS 2003 and DHS 2008, there was little improvement in inequality for the ARMM region. Only the coverage of antenatal care (both one visit and four or more visits) improved in terms of region-based inequality during this time, with coverage of one visit seeing improvements in both relative and absolute inequality, and coverage of four visits seeing improvement in only relative inequality. All other inequalities in health services by region remained essentially unchanged. The DHS 2008 data showed gradients in coverage by education exceeded 20% in seven of the eleven health services indicators. With regards to only one indicator, early breastfeeding, there was a gradient of less than 10% in coverage by education. The indicator with the greatest level of education-based absolute inequality was the presence of a skilled birth attendant with a gradient of 81.8% in coverage by education (Figure 5). Similar to region-based inequality, there was hardly any chronological trend towards improvement in education-based inequality in most indicators. The only indicator with substantial improvements in education-based inequality from DHS 1993 to DHS 2008 was, again, the coverage of one antenatal care visit. While vitamin A supplementation and family planning also saw drops in absolute inequality, these were driven by decreases in coverage in the most educated group. In contrast to inequality by region and education, the Philippines proved to have little inequality by sex or area. None of the assessed health services indicators saw any substantial sex-based inequality during the DHS 1993 to DHS 2008 period. By DHS 2008, ten of eleven assessed indicators had very low levels of area-based inequality, with absolute gaps between urban and rural at 10 percentage points or less and relative ratios at less than 1.2. PRIORITY INEQUALITIES IN CHILD HEALTH OUTCOMES Infant and under-five mortality rates were assessed by wealth, education, sex, and area. Education proved to have the highest level of both absolute and relative inequality for both health outcome indicators, with gradients in mortality rates by education exceeding 90 deaths per 1,000 live births in DHS Wealth also had a high level of absolute and relative inequality with absolute differences between poorest and wealthiest exceeding 25 deaths per 1,000 and relative ratios over 2.5 for each indicator in DHS There were comparatively low levels of area or sex-based absolute and relative inequality in the child health outcomes indicators. 24

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