by Kaye Galler, Cedric Katigbak, and Sophia Romilla

Even before the coronavirus pandemic started to impact the Philippines, severe malnutrition continued to plague the country for decades. With still over a million cases annually since 2017, 95 children die from malnutrition in the country every day. Twenty-seven in every 1,000 children do not reach their fifth birthday due to lack of nutrition; if they do, they suffer from lifelong health and developmental effects.

Undernutrition in the country is measured in three types/categories by the National Nutrition Council (NNC): wasting (low weight-for-height), which is characterized by severe weight loss; stunting (low height-for-age), which can be caused by chronic or recurrent undernutrition; and underweight (low weight-for-age), which can be found in children who also suffer from stunting, wasting, or both.

A decline in the aggregate cases of undernutrition can be seen from 2018 to 2019, but a 15% surge occurred in 2020, the year the pandemic began. Headey et al. (2020) estimated a 14.3% increase in the global prevalence of child wasting due to poor diet quality, disruption of essential and nutrition-related services, and socioeconomic shocks caused by the pandemic. Aggregate cases fell again by 10% in 2021, the second-to-last year before the end of the Duterte administration.

Undernutrition in the country is measured in three types/categories by the National Nutrition Council (NNC): wasting (low weight-for-height), which is characterized by severe weight loss; stunting (low height-for-age), which can be caused by chronic or recurrent undernutrition; and underweight (low weight-for-age), which can be found in children who also suffer from stunting, wasting, or both.

Looking at the trend from 2017-2021, stunting is consistent as the top indicator of undernutrition in the country, which is a common phenomenon in many Asian countries. According to United Nations International Children’s Emergency Fund (UNICEF) data, one-third of Filipino children are stunted. This is concerning because stunting after the age of two can be ‘permanent, irreversible, and even fatal’.

Multiple studies reveal that external factors beyond health and wellness can cause and exacerbate malnutrition. In 2015, UNICEF data revealed that socioeconomic status reinforces the high prevalence of stunting among children, with a 34% difference in cases between the bottom 20% (poor) and top 20% (non-poor) of the population. This analogy holds true six years later, with World Bank data indicating that 42.4% of children from the poorest income households were stunted last year. Development agencies also attribute the country’s vulnerability to disasters and climate change to the high prevalence rates.

Case A: Regional variations

Weaved into the Philippine Development Plan (PDP) and Ambisyon 2040 of the Duterte administration is the Philippine Plan of Action for Nutrition (PPAN) 2017-2022, which contains eight nutrition-specific programs, ten nutrition-sensitive programs, and three enabling programs.

One of PPAN’s strategic thrusts is to intensify the mobilization of local government units (LGUs). Thus, 32 target areas were selected based on the National Nutrition Survey results in 2015. These areas are prioritized for nationally-funded programs such as Early Child Care and Development (ECCD) and the First 1,000 Days:

1. 5 provinces: Region V (Albay, Camarines Norte, Camarines Sur, Catanduanes, and Masbate)
2. 4 provinces: Region III (Aurora, Bataan, Bulacan and Nueva Ecija)
3. 3 provinces: Region VI (Aklan, Antique, and Ilo-ilo), Region VII (Bohol, Cebu, and Negros Oriental), and Region X (Bukidnon, Lanao Del Norte, and Misamis Oriental)

Navigate: Regional Distribution of Total Malnutrition Cases in 2017 and 2021 | Flourish

Region V has the most priority provinces and the highest recorded number of undernutrition cases in both 2017, the first year of PPAN implementation, and 2021, the final year. In contrast, CAR had the lowest number of cases in both years. The visualization highlights the magnitude differences between cases, displaying a significant difference between the Top 4 regions (dark reddish circles) and the lowest regions (whitish circles).

Though no studies have directly explained the cause of this, a cross-sectional study by Khaing et al. (2019) also found substantial variations in the prevalence of malnutrition in Myanmar. They see this pattern of regional variation among countries where universal health coverage has yet to be achieved. In the Philippines, though former President Duterte signed the Universal Health Act into law, systemic issues restrict some Filipinos’ access to healthcare.

We also know that in 2019, BARMM was not able to turn over the results of its Operation Timbang Plus (OTP), the primary monitoring and evaluation tool used to track malnourished children at the barangay level, to the NNC – revealing discrepancies in the record system.

Case B: Six years after, same malnutrition hotspots

A Cambridge University Press malnutrition study on the modifiable factors that cause malnutrition identified regional and geographic factors as one of the primary causes of malnutrition. To further zoom in to the Philippine context, the regional results of OTP from 2017-2021 were retrieved, containing the years of PPAN’s implementation.

Navigate: 2017, 2018, 2019, 2020, and 2021

The projection map shows that the undernutrition hotspots, or regions with the highest undernutrition cases, are concentrated in South Eastern Luzon and Central and Eastern Visayas. However, the map also shows that the number of undernutrition cases has decreased over time, with a maximum of 150,000 cases in 2021.

Case C: Some priority areas, priority again in the next administration

Region V – Bicol Region had the highest number of undernutrition cases at the start of the PPAN implementation in 2017, exceeding 200,000 undernutrition cases in the region alone. All provinces in Region V are Priority Areas for PPAN. In the same year, Region III – Central Luzon, Region VI – Western Visayas, and Region VII – Central Visayas fall within the 100,000-150,000 undernutrition case range. Among the priority regions, Region X – Northern Mindanao has the lowest undernutrition cases.

In 2018, Regions III, VI, and VII fell within the 70,000-120,000 case range. Region V also showed a decrease in their cases in the same year. All priority regions’ undernutrition cases started to exhibit a downward trend in 2019. When the pandemic hit the country in 2020, there was a significant increase in undernutrition cases for Regions III, VI, VII, and X. In 2021, the undernutrition cases in Region VII continued upward, while the rest of the priority regions exhibited a decrease in cases.

Data show that the prevalence rates of undernutrition across the country have improved over the last five years, despite the unanticipated global pandemic. However, Bicol Region constantly exhibited the highest prevalence rates of undernutrition cases in 2017, 2019, and 2020.

The verdict

If we are only to look at the outcome target of PPAN, which is merely to ‘reduce levels of child stunting and wasting’, then the aggregate decrease in undernutrition cases is ‘pass’-worthy. However, looking at the level decrease is another issue – as cases only decreased by 23% and the number is still over a million despite the budget and time allocated for the plan. Moreover, various insights on the Duterte administration’s fight against malnutrition can be generated by deconstructing OTP results into regions.

First, while the country’s aggregate undernutrition rates have improved since the implementation of PPAN in 2017, subnational variations can still be very much observed. With this, the government must seek out and target regional factors that contribute to the disparity of cases across regions.

Second, the saturation of undernutrition rates in specific parts of the country must also be explored. The consistency of this pattern over the years must be considered when understanding the delivery of nutrition services across regions, the structure and culture of governance, and their geographical targeting strategies.

Finally, all the regions with the most priority provinces, except Region X, have remained at the top for the past five years despite implementing the PPAN. Identification of what caused this lack of shift must be prioritized by the next administration.

Regional findings show that the next nutrition program blueprint must shift its focus from the national level to empowering LGUs, who manages the main site of implementation. Strengthening the capacity of the smallest political units to combat malnutrition results in more accurate monitoring and distribution of services. The PPAN Priority Areas for the years 2023 to 2027 have yet to be released, and if we see the same areas and results again, then the blueprint must be realigned and reexamined.