Health and Sanitation
Development in the Philippines:
Potential for Stakeholder Cooperation
and Education
Hayashi Seminar
Faculty of Economics
Faculty Linkage Program
Chuo University
February 2012
i
Preface
This volume is a collection of academic papers written by my third-year undergraduate
seminar students at Chuo University as a product of their one-year research project in the
2011 school year. In the process of this project, my students conducted their field survey
in the Philippines during two weeks from 28 August to 9 September 2011.
This one-year study project was staged for the seventh time this school year, and the
countries my students dealt with in the past were Laos, Indonesia and the Philippines. The
current third-year students decided to tackle the Philippines again and investigate its
poverty and development.
Similar to the previous four years, I commissioned almost all tasks to the participating
students wherever possible, because I would like to foster their initiatives and reflect their
wishes. In February 2011, my seminar students launched full preparations toward their
research project, starting with a series of discussions on the selection of the country and
academic fields to be investigated.
As in past years, the project team in this school year has consisted of two different
Hayashi seminars. Out of 21 members in total, 13 are from Hayashi seminar of the
Faculty of Economics and the remaining 8 from Hayashi seminar of Chuo-specific
Faculty Linkage Program (FLP). This combined team with the large number of
participants has carried out the student-led and tough study project.
In such challenging conditions, the economics-FLP joint team as a whole and four
individual study teams fully prepared their research project, actively executed their field
survey in Manila and the surrounding areas, and finally produced this thesis. For the first
time ever in my seminar, the current batch student set up a unified theme within a single
sector and investigated further detailed research topics by four teams. Specifically, in the
context of “health and development through cooperation among stakeholders and
education,” four research teams, respectively, examined: 1) improvement of adolescent's
knowledge on reproductive health through peer education; 2) development of sanitation
facilities and diffusion of its use through education and awareness activities; 3)
public-private partnership (PPP) in nutritional improvement; and 4) relationships among
stakeholders in the TB control programs.
Overall, I have highly appreciated representatives of economics/FLP seminars for
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their leadership and good management, team leaders for their academic initiatives and
good coordination, and all participating members for the quality of this study through
their hard work.
Finally, I would like to express my strong gratitude to all those who extended a
helping hand to my students when they worked for this research project. In particular, I
am so grateful to organizations/individuals that kindly received my students in Laos and
Japan and warmly provided them with valuable information/materials. Also, my deepest
appreciation goes to Mr. Toshifumi SUZUKI, Mr. Tsuyoshi MIYATA, and Chuo
University for their financial assistance.
Mitsuhiro HAYASHI
Faculty of Economics, Chuo University
Tokyo, Japan
28 January 2012
iii
Acknowledgements
This paper was written by the students of Hayashi seminar in Chuo University, Japan.
The main theme of our survey is “Health and Sanitation development in the
Philippines: potential of education and stakeholder cooperation” and we carried out our
on-the-spot survey for approximately two weeks from 28th of August to 9th of
September 2011.
It is a pleasure to thank those who made this thesis possible for the warmest
understandings and supports of our study and giving thorough knowledge. We owe our
deepest gratitude to following people:
Mr. Ahl Aquino, Dr. A.Kaptiningsih, Dr. Akihiro Ohkado, Mr. Akira Matsumoto ,
Mr. Alan Baird, Mr. Andrew D.Ong, Mr. Angelito L. Umali, Ms. Arianne Dumayas, Ms.
Arlene Calaguian Alano, Mr. Apol T. Jimenez Ms. Ashlee Pattinson, Ms. Belle Nabor,
Mr. Brayant B. Gonzales, Professor Cristine DLR. Villagonzalo, Ms. Czarina Martinez,
Mr. Dan Lapid, Ms. Dinna Sane, Ms. Ecille Go, Ms. Eiko Ohori, Sr. Eline Pascaldo, Mr.
Gerard Servais, Mr. Gessen Rocas. Ms. Harumi Kodama, Ms. Helen Q. Lim, Mr. Hideaki
Noma, Mr. Hisashi Tajima , Ms. Irene Mercado, Ms. Jackeline Acosta, Mr.
James“Bong”Gordon, jr, Mr. James Bryan B. de Guzman, Dr. Jun Nakagawa, Dr.
Kayako Sakisaka, Mr. Kazuki Tsumagari, Dr. Kenji Amamoto, Dr. Kenneth Ronquilo,
Mr. Kiyoshi Nakamitsu, Ms. Lilia GC Casanova, Ms. Lyn N. Capistrano, Ms. Mami Kon,
Ms. Mari Nishino, Ms. Maria Lourdes A. manuel, Ms. Maria Lourdes A.Vega, Mr.
Mario Balibago, Dr. Mario V. Capanzana, Mr. Marlou T. Palomar, Ms. Mary Kristine
Segovia-Sionson, Mr. Melf Kuehl, Ms. Mien Ling Chong, Mr. Naoteru Honda, Ms.
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Natsuko Terauchi, Ms. Nheyshiel Grace Salalila, Dr. Nobuyuki Nishikiori, Mr. Percival
M. Abad, Mr. Rhenz Faustino, Mr. Rolando, Ms. Roxas Anzaira, Ms. Ryoko Nishida, Mr.
Sadakazu Ikawa, Ms. Sakiko Tanaka, Mr. Tadashi Tamura, Mr. Takashi Saito, Mr.
Timothy Grieve, Ms. Ugochi Daniels, Ms. Yolanda S. Quijano, Ms. Yoshie Tonohara,
Mr. Yousuke Tanaka, Ms. Yukiyo Nomura, Ms. Yuriko Oda.
Also, this thesis would not have been possible without support of Suzuki Toshifumi
scholarship.
Finally, we would especially like to thank our Professor, Mr. Mitsuhiro Hayashi for
his continuous support and direction which guided us to a completion of the elaborate
thesis.
v
Table of Contents
Preface i
Acknowledgements iii
Table of Contents v
List of Table xi
List of Figure xii
Summary of the Study xiv
Introduction to the Study as a Whole: Background, Fields and Focal points 1
Background of the study 3
Previous study of the studies 5
Setting 4 fields in order to proceed our study 5
Focal point 1: Relationship between stakeholders 7
Focal point 2 Education 8
References 10
Chapter 1 Improving Adolescent’s Knowledge on Reproductive Health:
Effectiveness and Challenge of Peer Education 11
Introduction 13
Background of our study 13
1.1 Importance of RH 15
1.1.1 Maternal mortality ratio 15
1.1.2 Universal access to RH 17
1.1.3 Adolescent RH 19
1.2 Peer education 22
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1.2.1 What peer education is 22
1.2.2 The possibility of peer education 23
1.2.3 The challenges and limits of peer education 27
1.3 Adolescent RH in the Philippines 28
1.3.1 Politics and religion of the Philippines 28
1.3.2 The policy of the Philippines government 31
1.3.3 Adolescent RH in the Philippines 33
1.4 Peer education in the Philippines 35
1.4.1 Research outline 35
1.4.2 Case example 36
1.5 Analyzing case example 38
1.5.1 Analytical method 38
1.5.2 Conclusion of the interviews and questionnaires 39
1.6 Conclusion 63
1.6.1 Summary and conclusion 63
1.6.2 Issues and foresight 68
Appendix 70
Reference 73
Chapter 2 Direction of Expanding Sanitation Coverage and Its Customary
Usage: Considering the Effect of Awareness Program 76
Introduction 77
2.1 State of the world 79
2.1.1 Rate of achievement of the MDGs 79
2.1.2 Relation between defect of sanitation facilities and water-borne
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disease 81
2.1.3 Economical loss which defect of sanitation brings about 82
2.1.4 A spread of the concept of WASH 85
2.1.5 Previous study 86
2.1.6 Overseas previous research 88
2.2 Condition in the Philippines 92
2.2.1 The sanitation condition 92
2.2.2 The sanitation condition at the school 93
2.2.3 The facing problem of sanitation 93
2.3 Outline of the Case Study in the Philippines 95
2.3.1 Research Outline 95
2.3.2 The definition of awareness program and accustoming themselves
to use facilities 96
2.4 Research cases in the Philippines 100
2.4.1 Case study WASH 100
2.4.2 Case study Fit for school 102
2.5 Consideration from cases focusing on the awareness programs 103
(1) Community participation 105
(2) The collaboration of the stakeholders 107
(3) Low cost 108
2.6 Conclusion 113
References 117
Chapter 3 The Possibility and Limitation of Public-Private Partnership in
Nutritional Improvement 121
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Introduction 123
3.1 Nutrition problems and the state of nutritional improvement activities 125
3.1.1 The relationship between nutrition problems and poverty 125
3.1.2 The nutritional condition in the world 126
3.1.3 The symptoms resulting from malnutrition 128
3.1.4 The approaches for nutrition improvement in the world 130
3.2 Public-Private Partnerships 131
3.2.1 The background of Public-Private Partnerships 132
3.2.2 The classification of the forms of PPP approaches 134
3.2.3 The previous studies 135
3.3 Nutrition problems in the Philippines 140
3.3.1 The problems of the poor and the rich 140
3.3.2 Nutritional problems in the Philippines 142
3.4 Approaches for improving nutrition situation in the Philippines 144
3.4.1 Investigation 145
3.4.2 National Nutrition Council 145
3.4.3 Philippine Plan of Action for Nutrition (PPAN) 147
3.4.4 PPP for nutritional improvement 149
3.4.5 Analysis 154
3.5 Conclusion 158
References 160
Chapter 4 Potential of Relationships among Stakeholders of the TB Control
Programs : A Case Study Focused on the Difference of Network 163
4.1 Introduction 165
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4.1.1 Background of our study 165
4.1.2 Limit of our Study 167
4.1.3 The organization of the paper 167
4.2 About TB 167
4.2.1 Basic knowledge of TB 168
4.2.2 TB and poverty 169
4.3 The Philippine with TB 174
4.3.1 The present situation of the Philippines 174
4.3.2 TB control in the Philippines 175
4.4 Need for relationships between stakeholders in the TB control
programs 180
4.4.1 The current of global TB control programs 180
4.4.2 Previous study 184
4.5 Case study of TB control in the Philippines 187
4.5.1 Study outline 187
4.5.2 Case study 192
4.5.3 Consideration 202
4.6 Conclusion 207
References 211
Analysis and Conclusion 213
Analysis 215
Stakeholder cooperation 215
Education 217
Conclusions 220
x
References 225
Appendixes 227
Schedule for Field Survey in the Philippines in 2011 HAYASHI Seminar, Chuo
University, Tokyo, Japan 229
Visiting List 233
Maternal and child Team 233
Water and Sanitation Team 236
Food and Nutrition Team 239
Infection disease Team 242
Postscript 245
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List of Table
Table 1-1 History of the Philippines 31
Table 1-2 Summary of Interview Research 40
Table 1-3 Attribution 43
Table 1-4 Questions and answers about sex knowledge 45
Table 1-5 improvement in knowledge 60
Table 2-1 Estimated economic gains from improved sanitation (million US$) 95
Table 3-1 Percentage of women taking weekly Iron-Folic acid Supplementation by
pregnancy status and survey period 140
Table 3-2 Targets of PPAN for 2008-2010 148
Table 4-1 The Millennium Development Goals 6: HIV/AIDS, Malaria, and other
disease 170
Table 4-2 Major 22 high-burden country in the world 175
Table 4-3 Transition of TB control in the Philippine 179
Table 4-4 Goals of Stop TB Partnership 184
Table 4-5 Questionnaire to the organizations 189
Table 4-6 Questionnaire to the inhabitants 190
Table 4-7 Answer from WHO, DOH, RJPI and CANOSSA 195
Table 4-8 Answer from ICAN 200
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List of Figure
Figure 1-1 Maternal mortality ratio 16
Figure 1-2 Fertility differences between the rich and the poor Average number of
children by region and quintiles of household wealth 21
Figure 1-3 Adolescent fertility rates 35
Figure 1-4 Gender 44
Figure 1-5 Frequency 44
Figure 1-6 Job 44
Figure 1-7 Partner 44
Figure 1-8 Sex experience 44
Figure 1-9 Questions and answers about sex knowledge 45
Figure 1-10 Having sex on safe day would perfectly prevent girls from getting
pregnant 56
Figure 1-11 You will get pregnant by having sex even once 56
Figure 1-12 You will not get infected with STD by having sex with a particular
partner 56
Figure 1-13 Use of condoms is effective to prevent girls from being infected with
sexually transmitted disease 56
Figure 1-14 You will become susceptible to HIV/AIDS once you get infected with
STD 57
Figure 1-15 Use of condoms would perfectly prevent girls from getting pregnant 57
Figure 1-16 You may get infected with sexually transmitted diseases by having oral
sex 57
Figure 1-17 You will be difficult to get pregnant once you get infected with STD 57
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Figure 1-18 Enjoy peer education 58
Figure 1-19 Peer educator was friendly 59
Figure 1-20 Want to spread peer education to friends 59
Figure 2-1 The economic loss per year by the defect of sanitation facilities and The
economic effect by introduction of health facilities in 2005 (dollars in
millions) Economic losses and gains (dollars in millions) 84
Figure 2-2 Social environmental issue relating to water supply and sanitation 88
Figure 2-3 Economic losses due to poor sanitation, by impact type (million US$) 95
Figure 2-4 These posters painted by pupils as school curriculum for sanitation
education 99
Figure 2-5 Rainwater harvesting tank 100
Figure 2-6 Sanitation facilities of Bagong Ilog elementary school where the project
of Fit for School is ongoing. 102
Figure 2-7 The toilet in the urban poor area 104
Figure 3-1 Rate of extreme hunger in the world by region 127
Figure 3-2 Rate of stunted, underweight, thinness, overweight of 0-5 children in the
Philippines (1990-2008) 143
Figure 3-3 Structure of NNC 147
Figure 4-1 TB and poverty linked in vicious cycle 173
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Summary of the Study
In chapter 1, we have researched about the effectiveness of peer education as an approach
to improve access to the reproductive health in the Philippines. In the Philippines,
adolescent fertility ratio remains high and has not made a considerable improvement
since 1970s. On the back ground, there is an insufficient access to the information
concerned with reproductive health, poor access to contraceptives, fact that the sexual
issues are remarkably sensitive in the Philippines. 83% of the Filipinos believe in
Catholic, and division of the politics and religion has not been achieved in the Philippines.
Hence, there is no national framework of the reproductive health. In addition, there are
fundamental issues of poverty and it is true that pregnancies and birth deliveries in
adolescent are common in the poor adolescents who could not receive education. To
improve access to the information, this research has focused on peer education. Peer
education is an approach or strategy that involves the use of people in similar age group or
upbringings, and it is recently receiving plenty of attention in the field of reproductive
health. This research has set up the hypothesis “peer education improves the adolescent’s
knowledge of reproductive health” To verify this hypothesis, we have set up the
following four research questions. “How is the present situation of the access to RH in the
Philippines?” “How does the religion affect RH?” “What are the needs of RH among
people in the Philippines?” “What kind of effect was provided by peer education?”
Moreover, we have conducted questionnaires to students who receive peer education in
order to measure accurate improvement in their knowledge. Peer education improved
youth’s knowledge of STD, correct contraception, and reproductive function etc. This
research reveals that peer education leads to not only improvement of the knowledge, but
also actually doing these. In addition, these effects are found in not only peer students but
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also peer educator, so peer education is of mutual benefit to students and educator. On the
pretext of conducting research and studies, our hypotheses was proved. However, it is
apparent that the main target of peer education is not only adolescent whom this research
focused on, but also people of all ages, mainly 20s youth. Furthermore, this research
focused on only improving on knowledge, but actually, peer students and educator
become take action based on knowledge gained in peer education.The separation of
politics and religion is not done in the Philippines, and national framework of sexual
education is not defined, too. Moreover, there are many out-of school-youth because of
poverty and some of them get unwanted pregnancy because of lack of knowledge. To
improve this present situation, peer education is one of the effective approaches to
provide youth with knowledge about RH.
Chapter 2 is a research about the effect of awareness program as the approach of
expanding sanitation coverage and its customary usage. In developing countries, it is
considered that defect of sanitation facilities is a big problem. Although access of safe
drinking water tackles preferentially, supply of sanitation facilities is far late. Defect of
sanitation facilities will also be connected with water pollution because polluted water
flows into a river and also causes soil pollution by being forced to excrete in the field.
Such an insanitary situation becomes a cause which causes water borne disease and leads
also to an economical loss of a country. In the Philippines, the sanitation facilities such as
drainage and toilets were improved only to a limited extent because of the delay in
construction causing some serious problems. However, the residents in poverty area have
still no access to safe water. The number of toilets in school is also lacking. It is difficult
to use these facilities even if there are sanitation facilities in school because they have
become old. To assist in this situation, the government of Philippines has been conducting
xvi
activities. However, the government has not adopted definite policies and the lack of
adequate funds has been the biggest barrier against improving the sanitation facilities.
This research believes that the importance of sanitation facilities has to be spread through
the sanitation education or media. As a result, we expect the students and the inhabitants
to get accustomed to sanitation facilities and use them properly and spread the knowledge
about sanitation to a wider sphere of people. Our study was setup under the theme
'Importance of awareness program to spread awareness about sanitation facilities and get
the people accustomed to use properly". We investigate and examine 2 case studies
conducted in Philippines. In this thesis, we focus on spreading knowledge about
sanitation facilities to schools/communities through awareness program. We will express
on what we can do in order to spread the awareness about sanitation effectively and to use
improved sanitation facilities for the community's sustainability.This thesis deal with
WASH project which conduct the spread of water and sanitation facilities and awareness
program for school and habitants living in poverty area, and Fit for School which is aim at
accustom hygienic habit with supported goods for students in the school. Researching the
project, we found 3 common points. They are (1) Low cost, (2) Community participation
and (3) The collaboration of the stakeholders. These 3 points must be the effect of
awareness program and they advance prevailing the facilities and making people adjust
using them properly. Thus the importance of awareness program is proved. Moreover, it
seldom be seen that the participation of the company through CSR activities and BOP
business. Therefore it may be possible to speed up to solve the problem about sanitation
in the Philippines through the cooperation of the companies by CSR and BOP.
The third chapter researched into “The possibility and limitation of public-private
partnership in nutritional improvement”. Solving nutrition problems is important because
xvii
they are related to the whole field of health and sanitation. Nutritional improvement
contributes to cure and prevent every disease. It is also important to maintain and recover
the energy of each person for the development of a country. Based on this opinion, this
chapter focuses on the various methods of nutritional improvement, especially
public-private partnership (PPP). Nutritional problems are divided broadly into two
categories: hunger and hidden hunger. “Hidden hunger” is an undernourished condition
caused by lack of micronutrient such as vitamins and mineral, which are indispensable for
maintaining health. It causes incomplete development, anemia, loss of eyesight, and other
problems. In many of the developing countries, these nutrition problems influence the
next generation, so various approaches have been developed all over the world. Mainly,
developing fortification technologies, spreading supplementation, feeding and education
can be picked up as examples. This research pays attention to PPP along with those types
of nutritional improvement. The origin of PPP is the movement of privatization in 1980’s.
After that, this movement gradually spreads to different fields and the steps and contents
of cooperation changed. This research focuses on PPP, because PPP should be effective
for improving nutrition through complementing the weakness and utilizing the strength of
each actor. At first, PPP is clearly defined and the forms of approaches are classified.
There are various forms of PPP such as funding support, technology transfer and
education. The preceding studies insist that PPP projects are important. Furthermore, in
order to have better results, PPP should include education and improvement of
recognition. In the Philippines, the economic disparity between rich and poor is serious.
The wide disparity makes the wealthy class to have lifestyle-related diseases and the poor
to suffer from hunger and malnutrition. This research focuses on the problems of the poor
people in the Philippines because the nutritional improvement of the poor is important for
xviii
the development the country. According to the national nutrition survey carried out in
2008, while the situation has improved, the nutrition problems of infants somewhat
increased. Therefore, better approaches for nutritional improvement should be
investigated.
Tuberculosis(TB) is one of the world’s three major infection diseases. The epidemic
of that is serious problem in the world. Especially, the epidemic is profound in developing
countries. WHO put 22 countries on the list of high burden TB countries of the world,
but most of these are concentrated in the developing countries, which is Asia and Africa
TB is called “social disease”. Social issues, which are poverty and social structure, are
concerned deeply with the epidemic. In developing countries, poor living conditions,
revenue instability, lack of knowledge, bias are involved in that deeply. The Philippines,
which is candidate for research, is one of the high burden TB countries. As for the
estimated number of TB patient per year, the Philippines is the 9th country in the world.
In the Philippines, tuberculosis is the sixth cause of death. There are regional differences
of the condition of the epidemic. TB spreads prominently in urban poor areas. Urban poor
areas had higher prevalence rate of TB than the other areas. The epidemic in urban poor
areas is serious.The history of the TB control programs is following. In 1993, WHO
declared a state of emergency of TB in the world. The next year, the DOTS strategy,
which is the base of today’s TB control programs, was recommended by WHO. But, the
effect of that program was insufficient especially in the 22 high burden countries. It is
because the problem which cannot be solved by the DOTS strategy, for example lack of
knowledge, bias, access to medical services and so on. Therefore, in 2005, Stop TB
Strategy based on DOTS strategy comes out, which is added 6 components that DOTS
strategy lacked. National TB control program in the Philippines introduced DOTS
xix
strategy and Stop TB Strategy, too.This study, we got interviews to the organizations that
implement TB control and analyze the data of projects, and we clarify the impact of the
difference of the network on the TB control programs. Our study takes up “ ‘The
Tuberculosis Control Project in Socio-Economically Underprivileged Urban Area in
Metro Manila, The Philippines. “Stop TB para sa lahat” PhaseⅢ’ ”conducted by Japan
anti tuberculosis association and “Community-based Rehabilitation Project on Health
and Livelihood” conducted by ICAN as study objects. Filed survey conducted interview
and questionnaire to the 5 related organizations, WHO, RJPI, DOH, CANOSSA, ICAN
and some inhabitants. This study is explored with three research questions as follows:
Who are involved in the programs and how are they involved? What relationships
between stakeholders exist in the programs? What effect do such relationships between
stakeholders have in the outcome of the programs? According to the answer to these
research questions, cooperation between stakeholders has a positive impact for the TB
control programs. But, in the Philippines, private organizations don’t really involve in the
TB control programs, although many patients use private organizations. And, in this field
survey, we got answer that the future challenges of the TB control programs are the
progress of the case detection rate. Many patients go to the private organizations initially,
so it would appear that the entry of private organizations to the TB control programs
contribute to the progress of the case detection rate. As explained above, the network
between stakeholders is important to the TB control programs, and in the Philippines, the
challenge would be to involve private organizations.
Introduction to the Study as a Whole:
Background, Fields and Focal points
Seoungho Kim, Shokei Yunoshita
3
Background of the study
On the planet earth, more than 1.8 billion people are mired in extreme poverty and
making precarious living on less than one dollar a day. Income of 2.5 billion people
living on less than two dollars a day accounts for 5% of the world income. The top 10%
of the richest in global society are mostly living in developed countries and their income
account for 54% of the world income (Ogawa, 2010). In order to redress the gap in the
global society, multilateral and comprehensive approach is indispensable. This is
reflected in the wide vision the eight Millennium Development Goals (MDGs) – which
range from halving extreme poverty to promoting gender equality and providing
universal primary education and health care, all by the target date of 2015 – has implied.
This study has focused on health and sanitation issues to which three out of the eight
MDGs are related. Health and sanitation issues make significant influence on
developing countries economically and socially. Hence development in the field of
health and sanitation is indispensable to reduce poverty.
This study has conducted an investigation under the theme of “Health and Sanitation
Development ”in the Philippines, an island nation located in South East Asia. Filipino
society has been influenced by two-layer structure consisted of the elite and the masses
(Ohno, 2011). Traditional ruling class based on large landholding was formed during the
latter period of Spanish rule (1529-1898). Thereafter, they have grown to family-run
conglomerate under economic system during the period of American rule (1898-1946).
After the independence, they have taken real power even in politics and reinforced their
economic bases. Their existence exaggerated the Philippines’ economic development
and produced an impression of “The top runner of South East Asia” both politically and
4
economically from 50s to 60s. However, immense poverty of the masses emerges at the
rear of this overstated prosperity. Even today, obvious gap remains in the country and it
induces inequality of access to health services and education. This situation is causing
adverse effect on health of the poor and generating additional poverty. Therefore,
development in the field of health and sanitation is deemed as an urgent challenge to
suppress the rapid increase of poverty. We will write up the specific problems in latter
chapters.
This study has taken up four topics (“maternal and child health”, “water and
sanitation”, “food and nutrition”, and “infectious disease”) within the health and
sanitation issues which are considered as major problems in the Philippines. In each
topic, teams in charge focused on “peer education”, “enlightenment activities”,
“nutritious improvement and public-private partnership”, and “countermeasures for
tuberculosis”, and set hypothesis or research questions. Based on that acknowledgement,
we observe efforts of international institutions, governmental institutions, NGOs, and
companies concerned with the four topics to clarify their attempts and cooperativeness.
5
Previous study of the studies
Setting 4 fields in order to proceed our study
Nilufar Ahmad, who investigated the health policy of South Asia, discuss about
improvement in health problem through voices of stakeholders which engage in
Bangladesh’s health sector. He divides the needs into following groups which are
necessary to improve the health problems and all stakeholders consent them. These are
mentioned in his “Priority Services within the Essential Services Package”.
・ Child health: EPI1, diarrhea control; and treatment fotacute respiratory
infections, malnutrition, vitamin A deficiency, and iodine deficiency
・ Reproductive health; Maternal health (nutrition awareness and
counseling); prenatal care (tetanus vaccinations and regular checks of
blood pressure); safe delivery (trained midwife or traditional birth
attendant); menstrual regulation and postabortion and miscarriage-related
complications (referral and treatment); family planning (raising awareness
among men and in-laws, distributing methods, and managing side effects);
adolescent health (especially education on reproductive health and
complications related to menstruation); and the management, prevention,
and control of reproductive tract infection (RTI), sexually transmitted
diseases (STDs), and HIV/AIDS
・ Communicable disease control: Tuberculosis control, elimination of leprosy,
malaria control, and intestinal parasite disease control
From above, you can see that chid health, reproductive health and communicable
disease control are big problems. Sanitation problems related to diarrheal diseases and
intestinal parasites, nutrition problems related to malnutrition and vitamin/iodine
deficiency, reproductive health problems related to maternal health, prenatal care, safe
1 The program of WHO to create vaccine that every children could use
6
delivery, menstrual and family planning, and communicable disease problem related to
tuberculosis and malaria are thought to be the four problems which causes the three
important problems above. Therefore, by focusing on these four fields, we will discuss
what is necessary to improve health problems in this study, especially through case
studies of the Philippines.
7
Focal point 1: Relationship between stakeholders
Public and private sector roles
Ferranti (2004) mention about public and private sector roles and relationship in health
fields by giving examples of health problems and discussing the solution of it.
He mentions; people who are infected by infection diseases (especially tuberculosis)
can’t understand the effectiveness of the medicine even they recognize the attack.
Moreover, due to the price of medicines, they couldn’t take them continually and reach
complete therapy. Io provide medicines and treatment, the involvement of public sector is
important because it is difficult to do them only by private markets.
Furthermore, because sanitation systems are public goods, there are limitations to
diffuse techniques like refining water by private sector alone. Therefore, it is necessary to
emphasize the adequate systems, for example, cost-effectiveness and cost-benefit.
The relationship between government and NGO
“Voices of Stakeholders in the Health Sector Reform in Bangladesh” emphasis that the
relationship between government and NGO. NGO have close relationship with
communities and produce great performance in health and nutrition recognition
through effective communication with inhabitants. Although, the people that NGO could
provide services are limited. This is because the ranges of NGO’s activities are focused on
urban areas, not enough in rural areas. The cost of facilities and programs are high than
local government is the reason, the head of NGO says.
From such reasons, author protest that relationship between government and NGO is
necessary in improving the situation of people by setting up the effective communication
channel.
8
In our study, we will analyze the relationship between stakeholders in health problems
through maternal and child health, infection disease, sanitation and nutrition which are
the four fields mentioned in previous studies.
Focal point 2 Education
The World Bank (2005) analyze the role of government, action of various sectors,
effective systems to breakdown the role of itself in improving health, nutrition,
population problems. According to the forth paragraph of it , ”Education and school
health are important inputs to better health and nutrition and reduced fertility” in
“Multisector Action to Improve Health, Nutrition, and Population outcomes”, education
is important in improving health problems. In this part, in-school children are typically
the most health age group among demography. At the same time, they are the age group
who are easy to become habitual in bad customs. It is mentioned that by doing health
education, we can prevent diseases, reduce child mortality rate and nutritional
modification. To improve these situations, the following four components have been
identified as operationally feasible in both, hard-to-reach rural areas and in accessible
urban areas;
・ Adopting health-related school policies, such as those that provide incenti
ves for girls to avoid pregnancy or to discourage smoking
・ Providing safe water and sanitation and a healthy learning environment
that reinforces hygienic behaviors and provides privacy
・ Promoting a skills-based approach to health, hygiene, and nutrition educa
tion that establishes lifelong healthy practices and reduces the vulnerabili
ty of adolescents and teachers to HIV/AIDS
・ Having teachers deliver school-based health and nutrition services that ar
9
e simple, safe, and familiar, and that address those health problems reco
gnized as important in the community, including counseling to cope with
HIV/AIDS
From these previous studies, we can recognize that education could be one of the
method to improve the situation in maternal and child health, sanitation, nutrition and
infection diseases problems. In our study, we will verificate the importance of the
education in health through above four sections
10
References
Ahmad, N. (2003). Voices of Stakeholders in the Health Sector Reform in
Bangladesh : Building Capacity for Reform. In A. S. Yazbeck, & D. H. Peters
(Eds.), Health Policy Research in South Asia (pp. 369-400). Washington,
D.C.: World Bank.
Atsunobu, T. (2010). The Health and Sanitation Field. In M. Ogawa, Theory of
International Cooperation. Kokin Shoin.
Ferranti, D. (2004). Public and Private Roles in Health: Theory and financing
patterns. In P. Musgrove (Ed.), Health Economics in Development (pp.
35-76). Washington, D.C.: World Bank.
Ohno, T. (2011). The 61 Chapters to Learn about the Modern Philippine (2 ed.). Akashi
Shoten.
The World Bank. (2005). Improving health, nutrition, and population outcomes in
Sub-Saharan Africa : the role of The World Bank. Washington, D.C.: World
Bank.
Chapter 1
Improving Adolescent’s Knowledge
on Reproductive Health:
Effectiveness and Challenge of Peer Education
Moe Sasaki
Kimihiro Kato, Moe Suzuki
Shokei Yunosita, Ayako Shukuya
13
Introduction
Background of our study
This thesis is a summary of the result of our research. This study set up the theme that
“Improvement in the Knowledge on RH through peer education for adolescents” on the
basis of the main theme “Health and sanitation development in the Philippines -
Potential for education and stakeholder cooperation-”
The Millennium Development Goals (MDGs)which started as a global development
framework in 2000, While the target about community systems development is
achieving fixed success towards the goal achievement term in 2015, the MDGs target 5
"An improve maternal health" is most behind in the progress, and it is doubtful of the
achievement in many developing countries. This study paid attention to the access
improvement to RH, in the target 5, and to find the solution in the long term, also
biologically, we focused on the adolescents in which reproductive behavior is possible.
As the educational method, we focused on Peer education which attracts attention as the
main approach method of the access improvement to RH in recent years.
In the Philippines, it is hard to say that access to RH is enough, and There is a big
problem that the unwanted pregnancy in the younger age group. The Philippines
government signed the U.N. population declaration in 1967, the Ramos administration
14
and Aquino administration has promoted the policy of population control based on long
economic growth. However, with local autonomy transfer of 1991, there is the present
condition that the difference of the action in each local government occurs, and the rate
of the birth at the institution of health was 44%. Moreover, contraceptive prevalence
rate was 51% [UNICEF, 2009], and those are the low rate in comparison with other
developing countries. About field of health, Philippine is the Asian greatest Catholic
possession country, and the construction of the cooperation system with the religion
becomes the important problem in the Philippines where separation of church and state
is not legislated. However, The RH bill are going to be approved, and a big change is
going to be accomplished in the field of maternal and child health in the Philippine.
This study set up three research questions that (1)How is the present situation of the
access to RH in the Philippines? (2)How does the religion affect RH? (3)What are the
needs of RH among people in the Philippines? (4)What kind of effect was provided by
peer education? , on the basis of the hypothesis “Peer education for adolescents
improves the knowledge on RH.” This study analyzed the result of the questionnaire
and an interview.
15
1.1 Importance of RH
1.1.1 Maternal mortality ratio
Since 1990, the estimate of the global annual number of maternal deaths has exceeded
500,000. 99% of the maternal deaths have occurred in developing countries. Although
the number of under-five deaths worldwide has fallen consistently – from around 13
million in 1990 to 9.2 million in 2007 – maternal deaths have remained stubbornly
intractable. Limited gains have been made worldwide towards the first target of
Millennium Development Goal (MDG) 5, which aims to reduce the 1990 maternal
mortality ratio by three quarters by 2015; and progress on diminishing maternal
mortality ratios has been virtually non-existent in sub-Saharan Africa.1
1 Sub-Saharan Africa includes Eastern, Southern, Western, and Middle Africa.
16
Figure 1-1Maternal mortality ratio
Source: This was made by author from THE STATE OF THE WORLD'S
CHILDREN,2009,UNICEF
Maternal mortality ratio presents the number of deaths to women per 100,000 live
births which result from conditions related to pregnancy, delivery and related
complications [Universal Journal company, 2004]. Direct causes of the maternal deaths
include atonic bleeding after delivery, uterine rupture, infections due to unclean delivery,
unsafe abortion. However, on the background of these incidents, there are insufficient
knowledge of human sexuality, inappropriate or low-quality information and service on
RH, the spread of high-risk sexual behavior, discriminative social customs, negative
attitudes toward women and girls, and the limited empowerment of women and girls in
relation to sex and reproduction, etc.
17
Moreover, the maternal mortality ratio strongly reflects the efficiency of the whole
health system in a country. In most of the least developing countries, there are lack of
skilled health care professionals due to vulnerable government or insufficient financial
investment to health services and facilities. Facing these circumstances, effective
assistance measures could be for example, implementing HIV examination prior to
delivery, increasing the number of births attended by skilled health attendants2, making
urgent obstetric care accessible when necessary, offering post-delivery care, etc.
Expanding the scale of these measures would sharply reduce the number of maternal
and under-five death in the world. In addition, if women are able to acquire knowledge
of family planning and access to basic health care at the reasonable cost, the maternal
mortality ratio would decrease even more. These measures are definitely not impossible
and unrealistic.
1.1.2 Universal access to RH
Firstly, the concept of RH was globally agreed at the Cairo International Conference in
1994. At the Cairo International Conference, realizing RH is recognized as a
prerequisite to sustainable development centering on human and stability of population
(Taguchi, 2004). According to Population and Development Program of Action (ICPD
2 The term ‘skilled attendant’ refers exclusively to people with midwifery skills (for example, doctors, midwives, and
nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage, or refer obstetric complications.
18
Program of Action) adopted at the Cairo International Conference in 1994, RH is a state
of complete physical, mental and social well-being and not merely the absence of
disease or infirmity, in all matters relating to the reproductive system and to its
functions and processes.
Ever since the Cairo Conference in 1994, many UN organizations and countries
started to reflect the concept of RH in their existing family planning programs and to
modify their policies. In addition, the approach to the population problem has shifted its
emphasis to gender equality, women’s empowerment (improvement of their status and
capacity), and the promotion of RH. However, due to the insufficient fund and gap
between the services provided to people in the least developing countries, there are
numerous problems being unsolved including the spreading HIV/AIDS and unmet
needs of family planning especially of youth, high fertility ratio and maternal mortality
ratio in the least developing countries.
Having many unplanned children would be a big burden for the poor. As an example,
for mothers, giving birth to many children would lead to the maternal death and high
risk of acquiring disease. The whole family would be pushed into poverty if the mother
dies or gets infected to disease. It affects adversely to economic opportunity and
education for girls. In big families, it is likely to make their daughters leave school to
19
take care of their younger siblings. If a girl could not take the sufficient education, she
cannot learn how to do family planning. Due to this kind of vicious circle, the poverty
of family would continue from generation to generation. Hence, improving the access to
RH would contribute to reduction of poverty.
1.1.3 Adolescent RH
According to UNFPA, the number of youth in the world surviving on less than a dollar a
day in 2000 was an estimated 238 million, almost a quarter (22.5 per cent) of the
world’s total youth population [UNFPA, 2003]. Education is a key for breaking the
transmission of poverty from one generation to the next. Yet studies show that the poor
are more likely to not complete schooling. [Deon Filmer, 1999]Consequently, they are
deprived of the education on RH and sexuality that is provided at higher grade levels
and do not know how to find health information.
Therefore, diffusion of modern contraceptive methods would contribute to
improving the access to RH. According to the United Nations Population Division,
contraceptive methods can be divided into two big groups, modern and traditional.
Traditional methods of contraception include rhythm (periodic abstinence), withdrawal,
breastfeeding, douching, etc. These methods are so called natural birth control which
does not accompany contraceptive device or medicine. So they are not grounded on
20
scientific evidence. On the other hand, modern methods of contraception include female
and male sterilization, oral hormonal pills, the intra-uterine device (IUD), the male
condom, injectables, the implant (including Norplant), vaginal barrier methods. Modern
contraceptive use among adolescents is generally low, but increases with economic
status. Fewer than 5 per cent of the poorest young use modern contraception. Inequities
in access to family planning increase the likelihood of unwanted or ill-timed births.
In the world, there are enormous amount of young women dropping out from school
because of pregnancies. Due to limited knowledge and guidance, adolescents are less
likely to practice safer sex or to use contraception. Contraceptive use is still infrequent
in most early sexual experiences. Young women consistently report lower usage rates
than men, evidence of their unequal power in negotiating use of family planning with
their partner or restrictions on their access to services (due to lack of information, shame,
laws, health provider attitudes and practices or social mores) [UNFPA, 2003]. Fertility
differences between the poorest and richest strata in many countries are among the
largest of any health indicator. Early childbearing in poor families perpetuates an
intergenerational cycle of poverty.
21
Figure 1-2 Fertility differences between the rich and the poor Average number of children by region and quintiles of household wealth
0 1 2 3 4 5 6 7
Latin America and the Caribbean (9 countries)
Asia/North Africa(18 countries)
Sub-Sahara Africa (29countries)
Lowest quintile
Highest quintile
Source: This was made by author from The World Bank
Based on such situation and needs of adolescents, it is important that their health
and rights for decision-making be assured and that the risks of unwanted pregnancy and
sexually transmitted infections including HIV/AIDS be reduced by providing
appropriate education, information, service and care in relation to RH. Providing the
same level of information/services to young people as those for married couples
indicates public acknowledgement that unmarried young people are already sexually
active, and there may be social resistance to this, although the degree of resistance may
vary. This is a major difficulty in providing RH/services to young people.
Poorer young women are less likely to have their births attended by a skilled health
22
worker. Skilled attendance is important for the health of the mother and the child,
particularly when there are delivery complications. The younger the mother is, the
greater the chance that she will face complications during pregnancy and childbirth.
Also, those who are poor have the least access to health care services to deal with
increased pregnancy and delivery risks.
As mentioned above, there is a situation that the poorer the adolescent is,
the more insufficient the access to RH.
1.2 Peer education
1.2.1 What peer education is
Recently, peer education has become one of the most common approaches in
addressing adolescent RH. Peer education is an approach or strategy that the members
of a given group affect other members of the same group in behavior and knowledge
[UNFPA, 2003].It is commonly-used in informal situations, such as out-of-school
activities, and often used as a part of programs which aim for the improvement of
adolescent RH. The names used to describe teachers differ in each programs: “peer
educator”, “peer counselor”, “peer helper”, “peer promoter” and “peer distributor”.
Moreover, peer programs provide not only education, but also counseling and distribute
contraceptives to improve RH (Senderowitz, 2000). The best point of peer education
23
is that it is a kind of education which is place taken by the peers. People who give
adolescent peer educations tend to be in similar situations to their students, for example,
in-school, out-of-school and having job.
According to the peer program in Zambia, which we will introduce it in section 2,
the effect of peer education that it change peer’s behavior and mind bases on “social
cognitive theory”. Social cognitive theory is one of the social psychology which
advocated by social psychologist, Bandura at 1963. It says that one can learn from
other’s behavior and emulation.
Through these circumstances, we decided to focus on diffusing knowledge of RH to
adolescent through peer education. The “grape bine activity” which spread among the
youth at England in 1972 is said to be the begging of the sexual peer education in the
world. After that, it diffused to the United States of America, and Milwaukee family
planning church havs practiced it on 1976. Thereafter, sexual peer education had spread
throughout the whole world beginning with the USA, Canada and Latin America [Saito
tadathu, 2002]. Even now, peer education is practiced in wherever feasible, for example,
schools, clinics and community health centers.
1.2.2 The possibility of peer education
Adolescent is an age group who develop from children to adults. Which is to say,
24
adolescent is the stage that achieve a rapid growth in both physically and mentally most
in one’s life. At the same time, it is an age group which increases attention to sex and
become sexually active. Furthermore, they are the age that is sensitive to sexual topics.
If adolescent boys and girls don’t have enough access to RH information and services,
it causes many troubles, for example, early pregnancies/childbearing and spread sexual
transmitted diseases which we mentioned in chapter 1.
Peer education has been one of the most famous approaches to improve adolescent
RH during recent years, which we have mentioned in the previous section, and peer
education programs are practiced in all over the world. We will introduce three of them
in this section.
First is the sexual health peer education project in Cameroon which is called “Entre
Nous Jeunes”. This project aims not only to increase contraceptive use but also to
reduce unintended pregnancies and sexual transmitted diseases, including HIV among
adolescents. The boys and girls who are chosen to be volunteer peer educators are the
youth recruited by program planners and passed the motivation and commitment test.
Every three months, peer educators received additional training to reinforce their skills
and knowledge. Peer educators arranged discussion groups and meet with their peers
one-on-one. They also distributed materials including calendars, comic strips with
25
information about contraception and sexual health, and posters. Increase use of
contraception/condoms and improvement of knowledge on sexual transmitted diseases
were seen as the positive outcome of the project, and the adolescent RH access has
improved. [Advocates for Youth, 2005]
Second is the sexual education program for adolescents in Scotland. While the
annual teenage pregnancy rate fell between 1987 and 1996, in the13-15 age range, the
rate has increased. The teaching style and of information about availability of services
were thought to be inadequate. Therefore, peer education was chosen as a method to
improve the situation. Medical university students provided sex education through 30-
40 minutes discussions as peer educators to 13-14 year old pupils. According to the
questionnaire and interviews, most pupils mentioned that they felt medical students
would be easier than teachers to communicate with. Moreover, many pupils recognized
that their knowledge was incomplete. [James Jobanputra, 1999]
And finally, third is the peer program in Zambia. Zambian adolescents don’t have
correct information about HIV, because the information they receive is often misleading.
At the same time, many of them oppose condom use. This is because, they associate
condoms with immorality. Therefore, safe sex isn’t practiced. 80% of the citizens in
Zambia are Christians, and the rest are Muslims, Hindus and traditional religion beliefs.
26
The wrong view “condoms are ineffective at preventing HIV” supported by many
church groups is also thought as one of the reason which diffused mistaken information
among adolescents and have prevented their access to RH. By considering these
circumstances seriously, in 1999, after receiving permission from the Ministry of
Education to conduct sexual health interventions in schools, Society for Family Health
(SFH) started a peer sexual health intervention aimed at school-based adolescents. The
peer sexual health intervention is an important component of SFH’s social marketing
AIDS prevention activities. Peer educators, consisting of male and females aged
between 18 and 22 years, discussed sexual health issues, for example, abstinence,
condom use, and the risk of acquiring sexually transmitted infections with secondary
school students. In addition, they used drama skits to present scenarios that reflected
actual experiences of many adolescents. The result was that peer education diffused not
only the information about HIV/AIDS itself and how it does infects, but also the
information that proper use of condoms can avoid sexual transmitted diseases have
diffused among students. Therefore, access to adolescent RH improved. [Agha, 2002]
As seen above, improvement of adolescent RH through peer education is attracting
attention in recent years. Moreover, you can understand that peer education could
spread information about RH among adolescents more effectively and more comfortably.
27
1.2.3 The challenges and limits of peer education
So far, we have mentioned that peer education is effective in improving adolescent RH
all over the world. Although, peer education have some challenges left which we can’t
take our eyes off. To begin with, time pressure and shortage is one of the challenges
which peer education faces. The relation-building between clients, providing continual
and high quality education for peer educators are also necessary points. Especially, the
RH education/counseling is a challenging area because it tends to be complicated.
(World Health Organization, 2001)
In the peer project in Zambia, which we have introduced in previous section, it is
said that because the study measured the impact of the peer sexual health intervention
soon after the intervention was implemented, it cannot assess whether those changes in
beliefs are likely to persist. Moreover, because it is not possible to tell whether the
specific peer project is effective in all schools, the method should be chosen if it
matches each school and target.
In Cambodia, Reproductive health Association of Cambodia (RHAC) done peer
program in 1999. It was implemented in three areas including capital city, Phnom Penh,
and high school students were trained to provide RH information to their peers, both in
and out of school. The project was concluded to be effective. However, some problems
28
were also noted in this evaluation too. For example, it was mentioned that because the
peers were still at the stage of learning in certain topics, they couldn’t provide enough
information. [United Nations Educational Scientific and Cultural Organization, 2003]
Thus, because peer education is an approach done by youth, it carries some
challenges too. Moreover, because peer education tend to be used as one of the
approaches in whole adolescent reproductive project, although the project ended
successfully, there is a limit that it is difficult to say whether peer education itself was
effective or not.
1.3 Adolescent RH in the Philippines
1.3.1 Politics and religion of the Philippines
Philippine is a country which is Asian’s largest Catholic country; 83% of population are
Catholic. Considering RH in the Philippines, it must be considered about religious
influence. Protestant church allows all methods of contraceptives and abortion. In
contrast, Catholic Church discourages modern method’s contraceptives and abortion,
whether people are before-marriage or not.
The most salient characteristic of Philippine’s politics, is “religitics”. In effect,
Philippine don’t separate religion from politics. How do they become the situation like
this?
29
Philippine was a Spanish colony between 1565 and 1901. Spain in those days is
puritanical Catholic country [Hagino, 2002]. Before being Spanish colony, general
religion in Philippine is Islam. Christianity arrived in the Philippines with the landing of
Ferdinand Magellan in 1521. In the late 16 th century, soldiers and missionaries firmly
planted the seeds of conversion when they officially claimed the archipelago for Spain
and named it after their king. Spain transformed the Philippines into the first and then
one of the two predominantly Christian nations in East Asia. After American colonial
period and Japanese colonial period ended, Philippine have attained independence in
1946.
Philippine has no religious interference from colonial master than Spain.
Two points had made religion specially in the Philippines compared with other
Catholic countries. First, Philippine is the first country that Catholic became common in
Asia. Second, Philippine’s Catholic has been arranged uniquely by community people.
In addition, other two points made politics of Philippines religitics. First, Philippine was
in religious control by developed country. Second, Philippine had been colony for long
time, so Philippine had not experienced governing their own country. It is so hard that
Government which don’t have know-how of governing preside as many as 700 islands.
Over its long history, Philippine has become Catholic country and it don’t separate
30
church from politics.
These situation influences to RH problems. First, abortion is illegal in the
Philippines. Catholic Church doesn’t allow using modern contraceptive methods and
abortion because they think unborn baby as a person from the moment conception and it
is special gift from the god, so abortion is guilt for any reason. However, each year in
the Philippines, hundreds of thousands of women become pregnant without intending to,
and many women with unintended pregnancies decide to end them abortion. Unsafe
abortions can endanffer women’s RH and read seriously, often life-threatening
complications [DarrochJe, 2009] Also, it change depending on mayor that the rule as
to whether allows using modern contraceptive methods including condoms. For
example, mayor of Manila Atienza enjoin people from using modern contraceptive
methods, but Mayor Alfredo Lim allow it. In this way, policy about RH vary highly
among region. For instance, Mayor of Olongapo city James Gordon Jr. work on RH
problems all over the city and this activity has succeed. The detail will be described in
chapter 4.
31
Table 1-1History of the Philippines
the late 14th century
early 15th century
in mid-15th century
15211565
1898
1899
1942
1946
1978
19862010
Ferdinand Magellan landed southern islands and introduced Christian religion
Before Spanish Control (Before 1521)Introduced Islam into the southern islands and extended
Muslim immigrated to shouthern islands from SumatraBuilt sultanistic regime by in the middle of 15th century
Expanded Islam to Maranao in Mindanao(~early 16th century)Spanish Control Period (1521-1897)
Miguel de Legapsi landed in Cebu.Firsit Philippine republic period (1898-1900)
The Spanish-American War began
Constitution of the Philippine Republic was promulgatedFirst Philippine republic established
U.S. Control Period (1901-34)
Forth Philippine republic period (1981-85)Fifth Philippine republic period (After 1986)Corazon Aguino was elected president and Aquino forms new government
Benigno S. Aquino III was elected president
Japanese occupied period (1942-45)Manila was occupied by Japanese
Third Philippine republic period (1946-71)Philippines becomes independent nation
Martial ru le period (1972-80)Metro Manila become capital city officialy
Source: Yoshio Hagino, 2003, [Philippines no syakai rekishi seiziseido] ”The society,
history, and political institution” Akashishoten
1.3.2 The policy of the Philippines government
Now, the bill of RH is widely discussed in Philippine. This is formally called the RH
and Population Development Bill (House Bill No. 5043/Senate Bill no.3122) and
generally known as RH Bill [Snate Economic Planning Office, 2009]. This bill is
considered important for this country to make an RH policy because this is for aiming at
distributing contraceptives to poor families and giving sex education to students in
elementary schools and students in junior high schools. However, the Catholic Church
is now strongly against this bill.
32
In 1990, it is the first time that the comprehensive package of the RH Bill was
submitted to the Congress, but the Catholic Church strongly resisted it. The president at
the time took care of it, and finally withdrew it. The Church continued to take tough
stance with the RH Bill, and in response, the presidents showed a conservative attitude
to it. In June 2010, when Benigno Aquino III became the president and tried to pass the
RH Bill, it came to attract much attention again, and the Church responded strongly
against that.
Now, what do people in Philippines think of this problem? In June 2011, Social
Weather Station (SWS), which is the social research institution in Philippines,
researched the public awareness on this problem. The research showed that 73% of the
people said “Yes” if they were asked, “If a couple wants to plan its family, it should be
able to get information from government on all legal method”. They are 6 times as
many as the people who said “No.” And 68% of the people answered “Yes” to the
question: “Should the government pay money for all such measurements, when they
have a baby naturally or artificially?” which is 4 times as many as the people who
answered “No.” This result indicates that people in Philippines consider RH a part of
human rights and different from their religion although most of them are Catholic.
If the RH Bill passed through the Diet, it will be considered important because
33
people can have free access to RH, which has been banned legally. It will be a great
progress if the national RH policy framework is established and there is no regional
difference on RH because of that.
1.3.3 Adolescent RH in the Philippines
According to World Bank, Philippine’s population is 93,260,798 and 35% of this is
under 14 years old. It is characterized by high population rate of young. Adolescent
fertility rate is 55/1000 lives. This rate is still high in compared to Cambodia’s 52 and
Vietnam’s 35. No significant change in the fertility of young women during recent years
[World Health Organization, 2010]. This is one of the problems in compared to other
neighbor countries. The numbers of HIV carriers are increasing in the Philippines, it is
rare compared with other Southeast Asia country. In 2010, 30.73% of new cases are
youth aged 15-24 [Department Of Health, 2011].
In the Philippines, it is so hard to speak about sexual topic from religious
background and it have huge effect on RH as previously mentioned. The lack of access
to information and services about RH causes many problems.
First, it is frequent cause of pregnancy in adolescence. Adolescent pregnancy is high
risk because adolescent’s body is developing. In addition, there are many adolescent
can’t help but drops out school because of pregnancy. Therefore, preventing adolescent
34
pregnancy connect to protect adolescent education chance.
Second, STD. If adolescent don’t have enough access to RH, they couldn’t know
how infect STD and how prevent from it and how cope with it. In the worst case, they
will die from HIV/AIDS. In addition, they can prevent from these STD by using
condoms but most of them don’t know how to use its. Also, there is a situation that it is
hard to buy condoms in the Philippines.
It leads to protect not only adolescent but also their partner that they gain knowledge
about RH and do family planning.
In the Philippines, condom use rate is less than 4%. It leads to not only adolescent
pregnancy but also rampancy HIV/AIDS [Population Concil, 2009] . It is one of the
important points that improving access to modern contraceptive methods.
Having sex education in schools is important chance to gain knowledge about RH
for adolescents. However, Philippine can’t make an RH policy framework. Therefore,
sex education has not done in the school, or even if it is practiced, it is lack coherence.
This is why push adolescent from access to correct information about RH. Boys are 2x
likely to repeat or drop out of school. Main reasons for high dropout rates among boys
are these three: They had to work, they don’t have enough money for school
requirement, and they had to take care of siblings. Even though the national framework
35
of sex education has made, if there is no follow-up for the poor, the full access to
information on RH doesn’t be achieved.
Figure 1-3Adolescent fertility rates
Source: This was made by author from World Development Indicators
1.4 Peer education in the Philippines
1.4.1 Research outline
In previous chapter we discussed relationship between government and religion in the
Philippines and present situation of RH revolving around Adolescents. In the
Philippines, there is a climate that sexual topic is taboo because of effect of religion. So,
it is difficult to talk about sexual topics to their parents or teachers. Therefore, education
from their peer could be effective to prove these problems because it could be easier for
them to talk to their peer and peer education also suits their other needs.
36
In our study, we set up our hypothesis that “Peer Education for Adolescents can
improve the knowledge on RH (RH)”. To verify this hypothesis, we held field survey in
the Philippines.
In this chapter we introduce two case examples of peer education in the
Philippines held by UNFPA Philippines (UNFPA) and Family Planning
Organization of the Philippine (FPOP).
We set three research questions to verify our hypothesis, “How does the religion
affects RH?”, “What are the needs of RH among people in the Philippines?” and “What
kind of effect was provided by peer education?”.
We conducted interview to project performer, peer educators and peer students
based on these research questions. Furthermore, we carried out a questionnaire survey to
peer students as quantitative survey to measure the effect of peer education.
1.4.2 Case example
(1) UNFPA Philippines
UNFPA, the United Nations Population Fund, is an international development agency
that promotes the right of every woman, man and child to enjoy a life of health and
equal opportunity in the Philippines. Their main activities are improving maternal health
and access to RH. Peer education program on RH held by UNFPA was surveyed in our
37
study. This is core program of UNFPA Philippines.
Since 2009, UNFPA has started the program to achieve standardization of peer
education in the Philippines and they have been conducting with Y-PEER (Youth Peer
education Network).We inspected peer education program held by UNFPA Philippines
in Olongapo city.
As we discussed in chapter 4, Olongapo city supports RH activity as local
government. This case could be rare because there is serious problem between religion
and government in the Philippines. In Olongapo city there are about 200,000 people. It
could be large population comparing other cities. Increasing population is serious
problem in whole Philippines. Similarly, it is major problem in Olongapo city.
Olongapo city have started supporting RH because population became saturated and
personal income decreased. UNFPA conducts peer education at kalalake high school
and out-of-school in this city. At this school, students conduct peer education
themselves. They offer counseling to students who have problems about sex in “Teen
Wellness Center”. The good point of Teen Wellness Center is that it is located in an
obscure place. Therefore, students can visit there with less resistance to sex.
Furthermore, as you understand from that name “Teen Wellness Center”, there is no
sensitive word like “RH” or “Family Planning”. Therefore, it could be easy for students
38
to use this service.
(2)Family Planning Organization of the Philippines
FPOP in a NGO organization which provides clinic services including obstetric care
services and has many activities to improve access to RH in the Philippines. FPOP is a
member of International Planned Parenthood Federation (IPPF). IPPF is the world’s
biggest NGO in RH. FPOP is a Philippines section of IPPF. FPOP has 26 clinics in the
Philippines.
Since 2009, FPOP has started “YES4YES project (Youth Friendly Service for
Young People’s Sexuality in ASRH in the Philippines Project)”.In this project, FPOP
provides RH services including Peer education and health care service mainly for young
people. The feature of this project is that young people work as youth staff and they
decide contents of the project by themselves. Peer educators as youth staff also give a
lecture to other NGO on peer education and join the meeting with local government.
Then they become a leader of young people. Another feature is that FPOP provides not
only information through peer education but also they enriched health care services.
1.5 Analyzing case example
1.5.1 Analytical method
We set up the hypothesis, “Improvement in knowledge on RH through Peer Education
39
for Adolescents”. In order to prove our hypothesis, we have set three research questions
below, “How much does the religion effects RH?”, “What are the needs of RH among
people in the Philippines?” and “What kind of effect was provided by peer
education?”. Then, we have conducted on on-the-spot investigation in the Philippines
between 28 August 2011 to 9 September 2011.
By using the information we got through interviews/questionnaires for staff and who
participate in peer education in the project sites, which we introduced in Chapter 4, we
are going to prove our hypothesis from now. We will use the analysis software SPSS in
case to analyze the questionnaires.
The below are the limit of our study.
Firstly, the number of questionnaires which we were able to collect was only 20.
Secondly, either the interviews or questionnaires were done thorough staff who could
speak Tagalog. Thirdly, the investigation was done in such a limited time span.
Therefore, we would like you to pay attention that this study was done in such a limited
situation.
1.5.2 Conclusion of the interviews and questionnaires
The conclusions of the interviews and questionnaires are below. We did them by the
method which we mentioned in section 1.
40
Table 1-2 Summary of Interview Research
Location: UNFPA Philippine
Date: 31rd August, 2011 (Wed)
Targets: 6 members of the project which aim to improve the adolescent’s
access to RH in the Philippines
RQ1:How does the religion affect RH?
Q1. How do people in the Philippines think about the relationship between
the government and religion?
A1:Because Catholic is there with us since we were born, I mean, most of
Filipinos were born as Catholic, it is difficult to think religion apart from
our thoughts. Although, there are many Catholics who can think rights
apart from religion too. However, we think that not only the religion
affects people but also the backgrounds they grew up and the schools
they graduated do a lot.
Q2:How is the relationship between religion and RH like?
A2:The Catholic church has big influence. In case of legalizing abortion, it is
thought to be difficult to achieve it. Present president is supportive to
RH. He said that he was amazed to see a 16 years old mother with 2
children, and felt it is important for youth to have needed information.
Although he is supportive, the past presidents were not. The law and
system depends on the leader of the government. Moreover, proceed of
decentralization is making local governments and mayors authorized. By
using their power, they can make rules of their own in their community,
and this make unifying whole nation difficult. For example, condoms
41
must be prescribed by doctors in some areas while in other areas they
oppose it.
Q3:What are the specific characteristic of the RH/Peer education in the
Philippines compared to other countries?
A3:In the Philippines, there is a kind of Catholic churchism and sexual
topics are considered to be taboo. There is no difference seen further than
that. In terms of Muslims, it is also difficult to talk about sex, condoms
and contraception.
RQ2:What are the needs of RH among people in the Philippines?
Q1.:Do people have the needs of RH knowledge?
A1.:They do have the needs, although the point is that whether they
empowered enough to talk about it or not. People who have access to RH
could talk, but who don’t may not even recognize it as problem. In
addition, there are people who do not practice it though they have the
knowledge. Therefore, it is important to change their behavior through
peer education and advocacy. Peer educators are not only diffusing the
knowledge and skills, but also behavior change educations too. Peer
education is also important in the case of the difficulty in talking about
sex with family.
Q2:Are condoms sold in convenience stores?
42
A2:It is sold in convenience stores and super markets. Though, it is difficult
to buy them because of a sense of shame and fear to be stigmatized.
Sometimes, it is displayed at the back of the counter which people can’t
reach it. Furthermore, also there are people who cannot afford for it.
Location:kalalake high school, FPOP’s clinic
Date:September 3rd,4th,5th,2011
Targets:peer educator(15 people)、sex worker(peer student)5people、
Client(student)15people
RQ3:What kind of effect was provided by peer education?
Q1:what kind of effect did you get from peer education?
A1:【peer educators】
・we could become get confident by watching peer students grow up.
・we recognized strongly how important RH issue is in the Philippines.
・we could get many valuable skills and it leaded to educate ourselves.
【peer students】
・we could get confident in our choices.
・we could get correct information about contraceptive method and how to get
infected with STD.
・Taking peer education made us conducting Family planning.
・Taking peer education made it easy to talk about sex.
・we could get many friends who have similar consciousness.
・we could solve personal problems about sex.
・we could abolish prejudice to condom.
43
Q2:Did you have any wrong information about sex before you take peer
education?
A2:we thought that we don’t get infected with STD expect having sex, and
pill is for abortion before we took peer education.
Table 1-3 Attribution
( ):%
Age 17 18 19 20 21 23 24 27 32 34
Number 3(15) 3(15) 4(20) 2(10) 1(5) 2(10) 2(10) 1(5) 1(5) 1(5)
Family
structure father mother
old
sister
young
sister
old
brother
young
brother childlen
I have 8(40) 8(40) 8(40) 5(25) 5(25) 9(45) 6(30)
I don't
have 12(60) 12(60) 12(60) 15(75) 15(75) 11(55) 14(70)
44
Figure 1-4 Gender Figure 1-5 Frequency
Figure 1-6 Job Figure 1-7 Partner
Figure 1-8 Sex experience
Source: Figure1-4 to 1-9: These were made by author from questionnaire.
45
N=20
TRUE Yes No
You will get pregnant by havin sex even once Yes 11 (55%) 9 (45%)
Having sex on safe day would perfectly preventfrom getting pregnant
No 17 (85%) 3 (15%)
Use of condoms would perfectly prevent girlsfrom getting pregnant
Yes 15 (75%) 5 (25%)
Use of condoms is effective to prevent girlsfrom being infected with Sexually Transmitted
DiseasesYes 16 (80%) 4 (20%)
You may get infected with Sexually TransmittedDiseases by having oral sex
Yes 17 (85%) 3 (15%)
You will not get infected with STD by havint sexwith a particular partner
No 9 (45%) 11 (55%)
You will become susceptible to HIV/AIDS once youget infected with STD
Yes 13 (65%) 7 (35%)
You will difficult to get pregnant once you getinfected with STD
Yes 10 (50%) 10 (50%)
Table 1-4 Questions and answers about sex knowledge
Figure 1-9 Questions and answers about sex knowledge
46
(1) How is the present situation of the access to RH in the Philippines?
First of all, we will summarize our first Research Question, “How is the present
situation of the access to RH in the Philippines?” by comparing the information from
the literature and on-the-spot investigation.
In 1.3.3., we mentioned about the dangerousness of early pregnancy/birthing.
During the visit and interview at Cervical Cancer Caravan of FPOP, we had a chance to
talk with few women who experienced early pregnancy. What we heard from a woman,
who experienced pregnancy and birthing when 16, was that not only her but also there
are some people experienced early childbearing around her. From this, we were able to
determine that early pregnancy/birthing remains to be a problem.
The low rate of contraceptive use is also one of the problems in the Philippines.
According to the interview at FPOP’s clinic, the present situation of the Philippines
revealed. It was that pills and injections are more commonly used than condoms. The
correct use of condoms could prevent pregnancy. Moreover, it is also effective to
prevent sexually transmitted diseases. Although, the convenience is the adverse effect in
the Philippines, because controlling the birthing easily is causing the feeling of guilt.
Furthermore, due to the appearance of using condom is very like contraception than pill
or injection that some Catholics in the Philippines refuse to use condoms. Surely, pills
47
and injections are effective in contraceptive but they don’t prevent people from being
affected with sexually transmitted diseases. The situation above seems to be the
influential factor in increase of infected people with HIV/AIDS.
Finally, we will introduce the current situation of sex education. As we mentioned in
1.3.3., the content of sex education differ in each communities and schools. However, in
Olongapo city, which aim to improve their resident’s access to RH, schools and
barangays3 were doing education program for youth who cannot go to school because
of their economic conditions or early pregnancies. If this kind of project is done at a
universal level in the Philippines, the knowledge of RH will definitely improve.
We were also able to hear about the misconception about sex in the Philippines
when we done questionnaires and interviews in teen wellness center. For example, a
woman said that before getting an education, she believed the rumor which said that
pills are effective in abortion. We cannot say it for sure that this rumor is diffused all
over the country, but we can certainly say that sex education is necessary to correct this
kind of misunderstanding.
(2) How does the religion affect RH?
Firstly, we refer to responses we have obtained to the research question “How does
3 Administrative class structure of the Philippine is these three: (1) province and highly Urbanized city (2) city
and town (3) Barangay; the smallest administrative division in the Philippines
48
religion affect RH”. Through on-the-spot investigation, we have recognized that the
custom based on religion is strongly-rooted in the Philippines. In the Philippines, a
country which decentralized government and influence of catholic churches
interdependently lack coherence of sexual education within its nation, there is a custom
which consider sexual issues as taboo. Moreover, even in regions where many Muslims
inhabit, similar custom could be seen and the access to RH is limited. From the
interviews at UNFPA, we obtained the following response, “Religion is innate and it is
difficult to distinct religious belief and our thought. Most of the Filipinos were born as
Catholic.” This custom was appeared in environment which makes people difficult to
discuss sexual issues in homes and schools and also in regulation of the access to
contraceptives. We have recognized the fact that many people are not able to discuss
sexual issues with their family through interviews at FPOP clinics. Since there are many
adults who feel repulsive of adolescent’s early sexual debut, adolescent hesitates to
consult adults. In addition, as for the access to contraceptives, although it differs in
regions, there are regions where contraceptives are completely unavailable or require
prescription of doctors due to restrictive policy of its regional government. As it was
mentioned in chapter 3, Catholic belief prohibits artificial birth control, and this custom
was remained in the Philippines. For example, in Manila, when Lito Atienza took up a
49
post of mayor in 1998, citizen became unable to access to artificial contraceptives
including condoms, pills, intrauterine devices, etc. Atienza was a Catholic, and from his
strong religious belief, he put emphasis on parental responsibility and adhered to natural
family planning. Currently, condoms are available at convenience stores in urban city.
However, since they were disposed behind the cashier and make customers feel sense of
shame or threat of scornful look from salesperson, it’s hard for people to purchase them.
Especially for adolescents, repulse from the society is strongly-rooted and virtually no
one buys condoms at convenience stores. As it was mentioned in Chapter 1, even
though contraceptives are available, custom in society becomes one factor of hindering
its prevalence.
As mentioned above, the Philippines have an environment which limits the access to
knowledge about sexual issues and health care services. As a false rumor about
HIV/AIDS is spread in Zambia, which we have taken up as a case study in chapter 2,
prejudice and false recognition are spread in the Philippines. This is one factor strongly
affecting the existence of unwanted pregnancies and sexually transmitted diseases. In
this regard however, there are some exceptions we would like to mention. First, religion
is not the only factor which discourages people from the access to reproductive health.
There are many people who cannot access to knowledge about sexual issues and health
50
care services due to their economic context. Secondly, although custom which makes
people consider sexual issues as taboo is still remaining in the Philippines, there are
people who deem the access to RH as human rights. Through on-the-spot investigation,
we have met people who pray at church every week but pay attention to sexual issues at
the same time. They were staffs of organizations which aim to improve the access to RH
in the Philippines or peer educators. Moreover, recently, there is a heated debate about
RH bill in the Philippines, and 73% of the citizens agree that "if a couple wants to plan
its family, it should be able to get information from government on all legal methods."
From these factors, we have found a glimmer of hope that the access to RH would be
improved in the future Philippines.
(3) What are the needs of RH among people in the Philippines?
Next, we will analyze the second research question, “How are the needs of reproductive
health among people in the Philippines?”
(i) Analyzing from Questionnaires
In our study, we have done questionnaires to 20 peer students in the project sites of
UNFPA and FPOP. We measured the needs of peer students about reproductive health
by the two questions below, “Do you want to have a conversation with peer educator
about sex?” and “Do you want to take peer education continuously?”. As a result, for
51
the first question, 13 students (65%) answered that they completely agree/agree and 7
students (35%) answered agree a little/don’t agree at all. And for the second question,
while 14 students (70%) answered that they completely agree/agree, 6 students (30%)
answered they agree a little/don’t agree at all. From here onwards, we have found out
that peer students actually have the needs for reproductive health.
(ii) Analyzing from interviews
We have done interviews at UNFPA.
First, on 31st August, when we visited the office in the Philippines, we asked “Do
peer students really have the needs to know about reproductive health, or does the
religion prevents adolescents from telling the needs of reproductive health?” to the 5
staff who engage in the project. We received some replies that “They do have needs.
The problem is whether they are empowered enough to talk about it or not.” “Moreover,
while the people who have the access to reproductive health could tell the needs, the
people who don’t have the access don’t even think it to be a problem.” Thus, we
discovered that while there are people who want to know about reproductive health, also
there are people who don’t even know that they are unaware about reproductive health.
Therefore, UNFPA are teaching about the reproductive rights to both, the people who
cannot tell the needs and the people who don’t even know that they are unaware of it.
Next, on 5th September, we visited the UNFPA’s project site, “teen wellness center”.
52
This is a center which is located in Olongapo city and doing community-based peer
education. Here, we asked “What kind of knowledge do you want to know?” to more
than 10 peer students. “We are joining this peer education to learn about prevention of
sexual transmitted diseases, the effects of early pregnancy and family planning”,
answered the peer students. From above, it became clear that there are peer students
who want to know about reproductive health through peer education, in short, they
surely have the needs. Moreover, according to some peer students, peer education has
corrected their misunderstandings, for example, knowledge about pills and infection
route of sexual transmitted diseases.
(iii) Analyzing from literatures
According to the previous study of peer education program in Scotland, which we have
introduced in chapter 2, peer students felt that they would like to know more about
emergency contraception, correct condom use, teenage pregnancy, communication skills,
homosexuality and local services, although the teachers were feeling that they had
covered many of these subjects in detail already. Moreover, 43% of pupils were feeling
that the amount of sex information given was insufficient. Therefore, you can see that
adolescents do have the needs to know about reproductive health worldwide too.
In addition, according to the reports of YES4YES peer education project and other
materials, which mention about the details of the activities and the problems that
53
Philippine adolescents face, we can say that they certainly carry the needs to know
about reproductive health information from 3 points below. (The reports and materials
we used is the one which FPOP have handed down for us when we visited the Manila
office in 3rd September.)
First, most of women who used the FPOP services were pregnant or married in the
past, but now, many types of youth uses the services. For example, junior high school
student who wanted to know about adolescent reproductive health (ARH) information
came to the clinic. Moreover, prostitute women, who are under the risk of sexual
transmitted diseases, came to get condoms. From above, there are many youths who
potentially have the needs to know about reproductive health.
Second, FPOP extended the opening hours in response to requests from youths. By
extending the opening hours, FPOP made students who are on their way from schools,
youths before heading off to work could use the clinics. In addition, they made the
clinics open on Saturdays too so that more people could use them. From this, you could
see that there are youths who didn’t have enough access while they had the needs to
reproductive health.
Finally for the third, in the Philippines, 73% of the population is thinking that the
government must provide the reproductive health services to the youth. Therefore,
54
including the RH bill discussion, which we introduced in chapter 2, there are
compelling needs for reproductive health information in the Philippines.
(4) What kind of effect was provided by peer education?
(i) Analyzing from Questionnaires
This analysis focuses on two points. First, we focus on a correlation between predicable
and improving knowledge. Second, we try to show a correlation between other
questions.
As we mentioned before, number of questionnaire is few that we could not do
grouping like we have planned, so we manage to demonstrate a correlation between
frequency of taken the peer education and question about improving knowledge. We ask
these 8 questions to measure knowledge of peer students and students answered ○ or ×.
(1)You will get pregnant by having sex even once (2)Having sex on safe day would
perfectly prevent girls from getting pregnant (3)Use of condoms would perfectly
prevent girls from getting pregnant (4)Use of condoms is effective to prevent girls
from being infected with STD (5)You may get infected with STD by having oral
sex (6)You will not get infected with STD by having sex with a particular partner.
(7)You will become susceptible to HIV/AIDS once you get infected with STD
(8)You will be difficult to get pregnant once you get infected with STD.
55
Considering simply percentage of questions answered correctly, it is very widely.
From figure 1-10 to figure 1-17 shows correlation with student’s predicable and class
period. It shows the percentage of questions answered correctly of the “over fifth” group
develop rapidly. However, even though “over fifth”, there are some question which is
low percentage of questions answered correctly, or “first time” is more high percentage
of questions answered correctly than “more than 2 and less than 5”.This showed 1 or 2
times class was not effective and it is important to get an education no single moment
but sustainably. We would like to know why differences occur in percentage of
questions answered correctly during same group but we couldn’t know about it because
of time pressure.
Next, we try to observe correlation between other questions. We focus on these three
questions. “I want to take peer education continuously” ”I want to have a conversation
with peer educator about sex” “I enjoyed participating in peer education”. Please look at
chart from figure 1-18 to 1-20.
Students who agreed “I enjoyed participating in peer education” are more likely to
continue peer education. We would like to define approachability of peer education but
unfortunately, we could not show conclusive correlation. Students who enjoyed peer
education are more likely to want to spread the information of peer education to friends.
56
Figure 1-10 (1)
Figure 1-11 (2)
Figure 1-12 (3) Figure 1-13 (4)
57
Figure 1-17 (9) Figure 1-16 (8)
Figure 1-14 (6) Figure 1-15 (7)
58
Not agree: consolidate “not agree” and “agree a little”
Agree: consolidate “agree” and “completely agree”
Figure 1-18 enjoy peer education
59
Figure 1-19 peer educator was friendly
er
Figure 1-20 want to spread peer education to friends
Source: Fgure1-10 to 1-20: These were made by author from questionnaire.
60
Table 1-5 improvement in knowledge
Peer educators Peer students
Improvement in
knowledge
・Sexually transmitted
diseases
・Correct contraceptive
method
・Biological mechanism
・Right to access to RH
・Sexually transmitted
diseases
・Correct contraceptive
method
・Biological mechanism
Changes in awareness
and action
・Seriousness of RH issues ・Practice of correct
contraceptive method
・Practice of family
planning
・Correct recognition
Expansion of network ・Interaction at the PE
seminar
・Interaction at PE classes
・Interaction at PE classes
Others ・Self-development ・Elimination of one’s
worries
Source: This was made by author from questionnaire.
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(ii) Analyzing from interviews and literatures
We have got interview to find answer for research question “What kind of effect was
provided by peer education?”.
We frame all responses of peer educator and students, and we could categorize the
type of responses. There seem to be three prominent types of these responses. First, it is
improving knowledge. On the peer students’ side, they could take knowledge about
contraceptive and how infect HIV/AIDS. The response for “Did you have wrong
knowledge before taken peer education?” is, for example, according to peer educator in
Kalalake high school, there is student who think pill as medicine to abortion. Even
students like this could improve their knowledge.
Second, it is behavior and mind change. On the peer educator side, they were able to
recognize significances of current RH problems. On the peer students side, actually they
were able to execute contraceptive methods which is knowledge from peer education. In
addition, they said that they were able to have an open discussion about sexual topic,
and some of them said that they could eliminate bias to condoms.
These responses of peer students and educator have 1 feature in common. It is that
they could become get confident through peer education. Peer educator built confidence
by seeing growth of students. On the student’s side, also they built confidence about
their choices.
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Finally, it is growth of network. For both students and educator, there are many
people who have same distress about RH in the peer education class, and they are
understood by contact with them.
Additionally, there are many positive responses for peer students and educator; they
could do personal development, they could eliminate their worries, and so on. Personal
development means that they learned their skill which is essential for living. For
example, they were able to choose correctly less emotionally.
As the results showed, peer education is effective as many ways for both students
and educator. Peer education is especially effective in improving knowledge, changing
behavior, and growing network. The results showed approachability of peer education
supported by social cognition. The situation where it is hard to talk about sexual topic
like Philippines, peer education is effective. Rather, for situation like this, we can expect
possibility of peer education.
1.6 Conclusion
1.6.1 Summary and conclusion
In this chapter, we summarize past chapters and describe the conclusion.
Since 1990, world’s annual maternal mortality is more than 500,000. The most part
of that have occurred in developing country. Though Millennium Development Goal
63
was declare and “Improve maternal health” was set in goal5, it is difficult to say that
there is a great improvement of maternal mortality on present showing. Maternal
mortality is caused by social and economic problem and other complicated problems.
Moreover, it reflects efficiency of health system strongly. In 1994, concept of RH was
agreed worldwide, and some policies reflected this concept. However, unmet need of
STD or Family Planning remains serious issue. Low access to RH causes the vicious
cycle of poverty. Therefore, “Education “makes a great contribution to break out this
vicious cycle of poverty. Education to the adolescent who is an age group which they
start reproductive activity is necessary to challenge these problems in the long term.
Also, RH Bill has a big effect on access of people in the Philippines. Therefore, in our
study, we focus on Peer Education which is common approaches in addressing
Adolescent RH worldwide.
Peer education is an approach or strategy to promote changing one’s consciousness
and behavior.
We focused on the Philippines where the maternal mortality ratio remains high in
Asia and the number of Adolescent fertility and unwanted pregnant is still large. In the
Philippines, it is difficult to access to sexual information because of strong effect by
religion. And sexual education isn’t enough. The usage of condom is very low and
64
people need to improve access to modern method of contraception. It is difficult for
Adolescent in the Philippines to talk sexual topics with elders or parents at public place
or home. So they don’t have enough opportunity to get knowledge on RH. Furthermore,
RH bill has a huge effect on access to RH strongly.
Therefore, Peer education is efficient approach to work on this problem. The
reason why we focus on peer education is that Peer education could provide
comfortable and friendly circumstance to adolescent. Moreover, as we mentioned in
1.3.2 and 1.3.3, peer education has great effects and possibilities.
In this chapter, we also summarize responses of our research questions and our
consideration.
(1) How is the present situation of the access to RH in the Philippines?
First of all, we learned through field survey that early pregnancy/birthing is still serious
problem as reflect our literature survey. And about contraceptive method, taking pill or
using injection is common method. It could be said that there isn’t great improve of
usage rate of condom. And we thought that sexual education is important to improve the
present situation. Especially, about the misrecognition is spreading out. About sexual
education, not only people don’t get an enough education but also there are many
different situations and qualities of education. But still the active action like Olongapo
65
city is necessary.
(2) How does the religion affect RH?
In the Philippines, there is a custom which consider sexual issues as taboo. This custom
was appeared strongly in which makes people difficult to discuss sexual issues in homes
and schools, and also in regulation of the access to contraceptive. Moreover, this custom
affect to policy sometime. So it could be said that this custom has a great effect to social
in the Philippines.
However, there are many Catholics who deem the access to RH as human rights and
pay attention to sexual issues. Moreover, recently, there is a heated debate about RH bill
in the Philippines, and 73% of the citizens agree that "if a couple wants to plan its
family, it should be able to get information from government on all legal methods." It
shows that there are some possibilities of improving access to RH in the future.
(3) What are the needs of RH among people in the Philippines?
As can be seen from result of interview, there are needs on RH in the Philippines.
Expanding the age group of the clients in FPOP shows that there are needs of adolescent
especially. But it could be another problem if there are people who become empowered
to talk about their needs on RH. There are people who don’t even know that they are
66
unaware about reproductive health. Therefore, UNFPA are teaching about the
reproductive rights to both, the people who cannot tell the needs and the people who
don’t even know that they are unaware of it.
(4) What kind of effect was provided by peer education?
As we mentioned before, number of questionnaire is so few that we could not do
grouping what have planned. But we could see that there are some relationships
between frequency and fixing of knowledge, also conscious/interest to peer education
and continuousness.
Moreover, from interview, we found that both peer educator and peer student have
effects through peer education. Peer education has wide range of effects, for example,
they can improve their knowledge on RH, change their consciousness and behavior,
enlighten themselves, and expand their network. In addition, we also found that not only
adolescent but also whole young people including adolescent have effect of improving
their knowledge through peer education.
In this field survey, place or organizations we had visited are very limited, and there
are more than 7,000 islands in the Philippines. Furthermore, there is a quite difference
of living environment between urban and rural. Thus, it’s hard to say that survey
findings in this study reflect whole situations completely. But, from our consideration,
67
we could verify our hypothesis “Peer Education for Adolescents can improve the
knowledge on Reproductive Health (RH)” almost.
1.6.2 Issues and foresight
This study attempted to analyze peer education for improving knowledge on RH.
However, we found that education, of course, is very important,but it is urgent to
enhance access to health care service. We have to accept that as a given when we are
addressing RH issue in the Philippines. Because of lack of medical facility, people can’t
satisfy their needs. And, when people conduct peer education, they might face a lot of
challenges. For example, peer education isn’t really popular in the Philippines, lack of
facility or infrastructures like space or textbook to their needs, and it require long time
to train peer educator. Especially, people who have experienced pregnant in adolescent
or out-of-school don’t have enough time to get peer education because they have to bear
children or they already have job. But it is true that they are target of peer education. So,
we found that it is difficult for them to get peer education continuously. In addition, peer
education doesn’t have standardized curriculum and teaching methods. So, the quality
of education is not same in each project. It is because dimension and definition of
“peer” have not defined yet.
However, as we mentioned in 1.2.2, peer education have a great effect in many case
68
examples worldwide. And we found that it has many effects by analyzing our findings
of field survey in the Philippines. In the future, we hope strongly that UNFPA
(international organization) and FPOP (NGO) keep on addressing to diffuse and
promote peer education in the Philippines, and we hope that visibility of peer education
will be increased and government will address RH more active Moreover, also in Japan
(HIV/AIDS patient are increasing rapidly and there are a lot of misunderstands about
sex), we desire that peer education will be more popular and be a great part of health
education.
Appendix
Questionnaire for peer students
Date Location
I.
・Age ( )years old
・Gender □Male □Female
・Family structure Fill in the parenthesis with the number if you have any.
□Mother □Father □Older sister( ) □Younger sister( )
□Older brother( ) □Younger brother( ) □Children( )
・Frequency (How many times have you taken the peer education?)
□0(Today is for the first time) □1 □2 □3 □4 □More than 5
・Job (What do you do? Where do you work at?)
( )
・Partner (Do you currently have a partner to have sex with?)
□Yes □No
・Sex experience (Have you ever had sex experience?)
□Yes □No
II. True or False
1. You will get pregnant by having sex even once
□T □F
2. Having sex on safe day would perfectly prevent girls from getting pregnant
□T □F
3. Use of condoms would perfectly prevent girls from getting pregnant
□T □F
4. Use of condoms is effective to prevent girls from being infected with
Sexually Transmitted Diseases.
□T □F
III. True or False
1. You may get infected with Sexually Transmitted Diseases by having oral sex.
□T □F
2. You will not get infected with STD by having sex with a particular partner.
□T □F
3. You will become susceptible to HIV/AIDS once you get infected with STD.□T
□F
4. You will be difficult to get pregnant once you get infected with STD.
□T □F
IV. Check in a box
1. I enjoyed participating in peer education
□Completely agree □Agree □Agree a little □Don’t agree at all
2. The lesson was easy to understand
□Completely agree □Agree □Agree a little □Don’t agree at all
3. The peer educator was friendly and easy to talk with
□Completely agree □Agree □Agree a little □Don’t agree at all
4. I want to have a conversation with peer educator about sex
□Completely agree □Agree □Agree a little □Don’t agree at all
5. I want to take peer education continuously
□Completely agree □Agree □Agree a little □Don’t agree at all
6. I want to spread the information of this project to my friends
□Completely agree □Agree □Agree a little □Don’t agree at all
V. Check in a box
1. I can have a talk with my partner about prevention of pregnancy
□Completely agree □Agree □Agree a little □Don’t agree at all
2. I can directly ask my partner whether he has condom or not
□Completely agree □Agree □Agree a little □Don’t agree at all
3. If my partner doesn’t have condom, I can refuse to have sex.
□Completely agree □Agree □Agree a little □Don’t agree at all
72
Reference
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that Work to Prevent Teen Pregnancy, HIV& Sexually Transmitted Infections.
Adovocates for Youth.
AghaSohail. (2002). AN EVALUATION OF THE EFFECTIVENESS OF A PEER SEXUAL
HEALTH INTERVENTION AMONG SECONDARY- SCHOOL STUDENTS IN
ZAMVIA. AIDS Education and Prevention, 14(4), 261-281.
DarrochJe. (2009). Meeting women's contraceptive needs in the Philippines,in Brief.
Guttmacher INstitute(No.1).
Deon FilmerH. PritchttLant. (1999). Estimating Wealth effects without Expendiure Data-Or
Tears: An application to Educational Enrollments in States of India.
Department Of Health. (2011). National Epidemiology Center HIV Registry. Department Of
Health.
Family Plannning Organization of the Philippines. (n.d.). FPOP HP. Retrieved 11 24, 2011,
from htttp://www.fpop1969.org/
HaginoYoshio. (2002). Philippinenosyakai, rekishi, seiziseido(Society, history, and political
institution). AkashiShoten.
James JobanputraR. Clark, Giles J. Cheeseman, Annna Glasier, Simon C. RieyAlice. (1999).
A feasibility study of adolescent sex education:medical students as peer educators in
Edinburgh schools. British Journal of Obstetrics and Gynaecology.
Population Concil. (2009). The Adolescent Experience In-Depth:Using Data to Identify and
Reach the Most Vulnerable Young People:Philippines 2003. New York: Population
Concil.
73
Saito tadathuHIroe, Rie Ikeda, Aiko TakenagaThushima. (2002). Peer counseling wo motiita
sisyunkiseikyouiku to sono zissen(Adolescent sexual education through peer
counseling and practice). The Journal of the Kawasaki medical welfare, Vol.12(No.2),
259-279.
Senderowitz, J. (2000). A Review of Program Approaches to Adolescent Reproductive Health.
Poptech Assignment Number 2000.176.
Snate Economic Planning Office. (2009). Promoting reproductive health: A unified strategy
to achieve the MDGs. POlicy Brief, 1-14.
Social Weather Stations. (n.d.). Social Weather Stations HP. Retrieved 11 24, 2011, from
http://www.sws.org.ph/
Taguchi, T. (2004). Kaihathukadainitaisurukoukatekiapproach~Reproductive health~(The
effective approach to development subject~Reproductive health~). Retrieved 11 23,
2011, from JICA research station: http://www.jica.go.jp/jica-
ri/publication/archives/jica/field/pdf/200408_02_01.pdf
UNFPA. (2003). state of world population "Investing in adolescents' health and rights".
UNFPA.
UNFPA Philippines. (n.d.). UNFPA Philippines HP. Retrieved 11 24, 2011, from
http://philippines.unfpa.org/
UNICEF. (2009). THE STATE OF THE WORLD'S CHILDREN "Maternal and Newborn
Health". UNICEF.
United Nations Educational Scientific and Cultural Organization. (2003). Peer Approach in
Adolescent Reproductive Health Education:Some Lessons Learned. UNESCO.
Universal Journal company. (2004). Kokusai Kyoryoku Yougo syu (International cooperation
glossary version 3). Universal Journal company.
74
World Health Organization. (2001). INFORMATION, EDUCATION AND
COMMUNICATION-LESSONS FROM THE PAST: PERSPECTIVES FOR THE
FUTURE-. WHO.
World Health Organization. (2010). World Health Statistics 2010. WHO.
World Health Organization. (2011). National Epidemiology Center HIV Registry. Department
Of Health.
Chapter 2
Direction of Expanding Sanitation
Coverage and Its Customary Usage:
Considering the Effect of Awareness Program
Momoe Kinebuchi
Naoki Ikeda, Azusa Ochi
Fumie Nakajima, Yuya Hayashi
77
Introduction
The biggest problem developing countries are facing is the lack of sanitation facilities and
access to safe water. Access to safe water has been addressed by many developing countries
and has been given the preference. According to Human Development Report 2006, about 2.6
billion people around the world lack proper sanitation facility. People who are lacking the
sanitation facility are almost 2.5 times more than the people lacking access to safe water.
Wastes from household are directly released into river without prior treatment because of
poor sanitation facility. This intern pollutes the river water causing water pollution. Moreover,
soil is contaminated because the lead waste is discharged directly into land people living in
unsanitary conditions use the water from contaminated source for drinking and washing
purpose. The soil is polluted because of excretion of waste outdoors due to lack of sanitation
facilities. Conditions like these will induce and spread diarrhea, and other water borne
diseases1. To be infected with diarrhea has brought a big impact for less than 5 child mortality
rate and health hazards, economic losses to people living in developing countries
According to “Economic Impact of Sanitation in Southeast Asia Summery”, The
Philippines, where our study was primarily focused on, has had considerable economic losses
due to lack of sanitation facilities, about 1.4 billion dollars per year. The economic losses can
be cut down by 45 %, the mortality rate can be brought down by 32 % and the health impacts
can be reduced by 32% by improving the sanitation facilities and the condition. In the
Philippines, the Manila water supply and sewerage supply corporation (MWSS 2 ) was
privatized. The water supply was improved significantly over the years but the sanitation
facilities were improved only to a limited extent because of the delay in construction causing
1 Waterborne diseases are kind of infection disease acquired by water. For example: trachoma and diarrhea
and so on. 2 In 1997, Metropolitan Waterworks Sewage System is become private. So Manila Water took over the East
Zone and Manilad took over the West Zone.
78
some serious problems. It is said that after the improvement in water supply facilities, many
people have got access to safe water, but actually the people living in poverty and inferior
living conditions have never been able to access the safe water. The sanitation and water
facilities although present in elementary school, the children face difficulties in using them as
they have become old and the facility provided is small when compared to the strength of the
students. To assist in this situation, the government of Philippines has been conducting
activities; Waterborne diseases are kind of infection disease acquired by water. For example:
trachoma and diarrhea and so on.
In 1997, Metropolitan Waterworks Sewage System is become private. So Manila Water
took over the East Zone and Manilad took over the West Zone. Several laws have been
passed to control water pollution and improve standards of hygiene, a national hygiene
summit was held to spread awareness. Although several activities being conducted, the
government has not adopted definite policies. To improve the sanitation, the government of
Philippines has to spend 600 billion pesos per year but presently the government has been
investing only 15 billion pesos per year. The lack of adequate funds has been the biggest
barrier against improving the sanitation facilities.
In our studies on sanitation facilities, we included toilet and hand washing stand. We
believe that the importance of sanitation facilities has to be spread through the sanitation
education or media. As a result, we expect the students and the inhabitants to get accustomed
to sanitation facilities and use them properly and spread the knowledge about sanitation to a
wider sphere of people Our study was setup under the theme 'Importance of awareness
program to spread awareness about sanitation facilities and get the people accustomed to use
properly". We investigate and examine 2 case studies conducted in Philippines. In this thesis,
we focus on spreading knowledge about sanitation facilities to schools/communities through
79
awareness program. We will express on what we can do in order to spread the awareness
about sanitation effectively and to use improved sanitation facilities for the community's
sustainability.
In 2.1, we comment about the spread of sanitation facilities in the world. In chapter 2.2,
we analyze the present situation of sanitation in Philippines. In chapter 2.3 and 2.4, we have
summarized our study by including the details of case studies, content verification and
definition of terms. In chapter 2.5, we examine the interview conducted with the inhabitants.
The reference and links related to the contents are included along with the conclusion in
chapter 2.6.
2.1 State of the world
2.1.1 Rate of achievement of the MDGs
As the international community's goal in the 21st century Millennium Development Goals
was adopted in the UN Millennium Summit in the year 2000. The target 7.C in seven of the
goals of MDGs set a target of halving the proportion of people without access by sustainable
to safe drinking water and sanitation facilities by 2015. The desired value of the population
which can access safe water and sanitation facilities by 2015 in a developing country is 89%
in safe water supply and 71% in sanitation facilities. About sanitation facilities, people who
cannot use the improved sanitation facilities amount to 2.6 billion people all over the world
and people who cannot use fundamental sanitation facilities in a developing country reach to
48% as of 2008 (The Millennium Developing Goals Report 2010,2010,P61). The global
effort of MDGs relating to drinking water is progressing and now more than one billion
people worldwide have been accessible to safe drinking water. If current efforts continue, it is
possible to use safe drinking water than before for the people of the world population more
80
than 90% by 2015 (The Millennium Developing Goals Report 2010,2010,P58)
However, even in comparison to the problem of improving access to safe drinking water,
progress of sanitation facilities is too slow in a developing country. Unless sanitation facilities
are immediately improved, they will not be able to achieve even half of the target by 2015;
sanitation facilities coverage goals will remain difficult. According to Human Development
Report 2006 (2006,P136), “About 2.6 billion people cannot still use improved sanitation
facilities and its population is 2.5 times that of people without available safe water” is said.
As the reason sanitation facilities do not spread rather than safe drinking water, it is
considered that the lack of safe water is a threat pressing for the life rather than sanitation
facilities, such as a toilet and the profits by the improved sanitation facilities are not more
widely understood than the profits by use of safe water. Moreover, a political leader in and
outside the country is negative for excrement and its safe processing are set on the subject of
international development cooperation and compared with water supply, the insufficient
national strategy, insufficient fund supply and the lack of ability of local governments are the
factor from which spread is prevented because it is thought that the improvement of
sanitation facilities is a result of economic growth, and is not a factor which determines
economic growth (Human Development Report 2006,2006,P143).
But the defect of sanitation facilities causes many illnesses and is leading the younger age
group, especially a child to die in fact. According to Human Development Report 2006(2006,
P23), “It becomes obvious from investigation among many countries that the disposal method
of excrement is one of the greatest factors that influence infants' survival situation. The
improvement of sanitation is decreasing all the mortality rate of infants by a third, and also
brings a merit to public health, a life, and dignity, and the profits spread from the home to the
whole community” is said. In fact, it can be said that improving sanitation facilities may
81
become a driving force which significantly enhance economic efficiency for a long time. It
can be said that the offer both of continuous accesses to safe drinking water and sanitation
facilities becomes an aid which saves poor people from poverty, and it is one of the most
important development support.
2.1.2 Relation between defect of sanitation facilities and water-borne disease
As Passage1also described, the defect of sanitation facilities causes many illnesses and is
making the younger age group, especially little children to die. According to The Millennium
Developing Goals Report 2010 (2010, P61), “About 1.1 billion people are defecating outside
by the defect of sanitation facilities. Open defecation is not only the insult to man's dignity
but also fundamental cause by which illness is infected from a mouth and brings about fatal
result to little resistless children” is said. About 1.4 million infants die every year owing to
the diarrheal illness which can be prevented. Infants who die owing to the usual diarrhea also
among the illness related water supply, sanitary facilities and health are 43% and it’s the
most common cause of death (The United Nations World Water Development Report
3,2009,P8). Moreover, 300 million tons of excrement are not processed by defect of
sanitation facilities every year and pollute the riverhead. This is the biggest causes of
diffusion of more than 20 kinds of infection disease. About 50% of the number of sickbeds of
the hospital in a developing country is formed by the patient of water-borne disease through
water (Joint G8+ science academies’ statement on Water & Health, 2011).
Unless sanitation facilities are improved, the effect of the expensive vaccine for
controlling water-borne disease or a chemotherapy is spoiled remarkably. Improving
sanitation facilities becomes a role which saves a life for disease such as diarrhea. Suppose
the use of improved sanitation facilities that a child's mortality rate in Cameroon and Uganda
is decreased by not less than 20%. Moreover, the flush lavatory in a home supposes that the
82
risk of the infant death in Egypt and Peru will be decreased by not less than 30 % (Human
Development Report 2006, 2006, P4). If the decline of open defecation rate continues, it
mainly becomes preventive against of diarrhea and the growth inhibition and malnutrition
following it and it can be said that it may be able to have big influence on an infantile
mortality rate reduction.
2.1.3 Economical loss which defect of sanitation brings about
According to the investigation report of World Bank East Asia and the Pacific Ocean office
(2007, P6)“it was investigated that the defect of the sanitation facilities in Cambodia,
Indonesia, the Philippines, and Vietnam affects health, water, environment, the tourist
industry, everyday life, etc. The defect of sanitation facilities suffer the about 9 billion dollar
(2005) loss per year only in four countries. (Refer to Figure 2-1) This deserves about 2% of
GDP in four countries” is said. However, it is considered that the improving of the whole
sanitation facilities and sanitary conditions reduce the losses resulting from it by 45% (except
for the health effect). Moreover it is estimated that the economic effect will bring in 6.3
billion dollars a year to countries (World Bank East Asia and the Pacific Ocean office, 2007,
P6). As health impairment the defect of sanitation facilities makes caused the symptoms of
many illnesses, such as diarrhea. Also, as almost all homes are pouring drainage from the
household and solid waste to a river or the sea, it is the cause of serious water pollution or
environmental pollution. According to those causes, expenditure, productivity, governmental
annual revenue, and the income of the household/company were affected, and it has led to the
economic loss. Also in the tourist industry, tourism is an important industry to accrue income,
employment and foreign currency for these four countries and it is considered that the
economic loss is induced owing to insufficient sanitation facilities because the travelers set
one of the factors whether to be able to use sanitary and suitable toilet with guaranteed
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privacy and perform use of water service and soap in order to determine the destination of a
vacation (World Bank East Asia and the Pacific Ocean office, 2007, P6).
Moreover, the economic loss of everyday life influences the quality of life greatly
because the existence of the toilet of the single room where water service equipment has for a
woman is especially important. The long distance toilet and outside use has a high physical
danger in especially the night. At the home without a toilet, or the home in which only the
below standard toilet is established, as they go to the place of public toilet and open
defecation, or as they have to wait in an insufficient public toilet on a population basis and, it
takes time. For this reason, the economic loss of the spent time reaches also in 1.3 billion
dollars per year as the whole country. In the case of the female who makes account of
especially privacy, the loss of time is larger than a male. Moreover, the state of a toilet and
the existence of a toilet in an institution influence the capability in order to go to work or
school. In many offices, suitable water and sanitation facilities run short and it has especially
had influences of many on a female use, productivity, and employment determination.
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Figure 2-1 The economic loss per year by the defect of sanitation facilities and The economic effect by introduction of health facilities in 2005 (dollars in millions) Economic losses and gains (dollars in millions)
Source: World Bank East Asia and the Pacific Ocean office, 2007, P6
Additionally, there is an economical loss in a school. When a child is suffered from water-
borne disease, there is the present condition of suffering many disadvantages as an
educational beneficiary in many cases. If health condition is bad, intellectual and mental
development will be inhibited directly and long absence and early dropout of school will be
caused indirectly. According to Human Development Report 2006(2006,P49), “days for 443
million days of school attendance are lost with the illness relevant to water every year and the
days of school attendance which are lost by the influence of the parasite which is infectious
through water and feces are nearly half. More than 150 million who reached school age are
severely troubled by the parasite of the intestines through water. In the rate which is absent
from a school, the child infected with the parasite doubles rather than the child who has not
been infected. Even if the infected child attends a lesson, he is worse off academically than
85
the child who has not been infected. It is shown clearly by the test result that infection with
parasites exerts a bad influence on power of memory, the capability to solve a problem, and
duration of concentration” is said. Thus, disease transmission is expanded by the defect of the
sanitation facilities in a school, and as a result absence is increasing. The illness of infancy
and the loss of an educational opportunity are being connected to the poverty of adulthood
and falling into spiral of poverty.
2.1.4 A spread of the concept of WASH
Nowadays, the concept of WASH is quickly spreading all over the world by making a project
called WASH in schools of UNICEF into a subject. WASH is Water and Sanitation Hygiene
and refers to safe water supply and sanitation facilities. In this project, it aims at healthy
promotion of children or those homes, surrounding people, and the next generation by
improving sanitation facilities and supplying safe water for school. While safe water supply
has spread preferentially as Passage1 may show, the view through at both of them must be
circulated is going to spread through the concept of WASH, as neither safe water nor
sanitation facilities can be separated. Although Section 2 described the influence which the
shortage of sanitation facilities brings about, without a supply of safe water even if only
sanitation facilities spread, water and a health problem will not be solved. According to
Human Development Report 2006(2007, P140), “when a certain investigation for two or
more villages in Kyrgyzstan is conducted, it turns out that there are few people who wash
hands and about a half of homes are throwing away their excrement on the yard or street” is
said. The problem was not the ignorance on hygiene but rare opportunity to wash hands at
home because water was not supplied and it was difficult to purchase soap. At the home in
which water service passes and which has a washstand, the frequency of hand washing was
going up by 3 times. As it may understand from here, it becomes an effective measure to
86
solve problem only after there are elements of both safe water supply and suitable sanitation
facilities.
Moreover, call to action is in one of the big measures of WASH in schools. This measure
increases mainly the stakeholder in connection with WASH in schools by the appeal from
media or stakeholders, and spread the measure of WASH in schools. By increasing
stakeholders, various stakeholders, such as not only the national organization and
international organization but the local government, NGO, are concerned and they are
working on a project together. Thus, WASH in schools increases many stakeholder and is
extending the concept of WASH further now by introducing the data of the effect of a project
and activity with using various media.
2.1.5 Previous study
On this section, we will introduce to corroborating previous study. First, we take up “The
Intermediate Technology to Cope with Sanitation Relating Issues in Bangladesh” as relating
awareness campaign. This thesis shows the problems of environmental and sustainability of
toilets. Moreover, it mentions how to solve those problems.
In the Bangladesh pit latrine toilets are spread, but these are not maintaining properly.
This thing connects to water pollution or worsening of toilet’s sanitation situation. There are
2 reasons of impediment. One is not having properly technologies, second is lacking of
citizen’s awareness to activities for implement sanitation situation.
This thesis conducted questionnaires in 2 areas of Manikganj province. In one area, more
than half habitants don’t have toilets. On the other hand, in the other area, relatively rich
people live. They ask 2 questions. One is “Do you keep on now using toilet?” Against the
question, only 30%~40% people answered “No. We would like to improve our toilet”. The
other is “In order to prevent disease from unsanitary, do you want to implement your toilet?”
87
They answered “Yes, we want.” These result shows citizen feel alarmed by effect for health
from unsanitary, but people who have awareness be willing to implement toilets
preferentially are not so many.
This thesis describes that introduction of intermediate technology is a must to two
subjects. Intermediate technology means “Technology corresponding to the local
characteristic which contains various constraints and the local needs using the funds which
can supply and human resource”. We use the word, Appropriate technology , to enphasize the
nuance that it is appropriate to the community because Intermediate technology is relative
concept. This technology realizes that mitigation of an environmental impact or sustainability
of using sanitation facilities. In order to introduce this intermediate technology, “the approach
1) Institution of the problem from local residents, 2) Selection of the solution by local
residents, 3) The integration with training and the service offering from the local government
or NGO, 4)Self-supporting management by local residents” are effective.
It is important for conducting these approaches to build their consciousness in order to
recognize the problem of sanitation situation. By making consciousness formation, residents'
ownership is raised and they improve their sanitation situation by themselves. Hence their
own management system is built by themselves. Residents' positive participation makes it
easy to collaborate with external organization or people such as the government and NGO.
Communication between the external organizations and residents leads to exact technical
propagation. Moreover, they recognize the needs of sanitation facilities. After all, it leads also
to the sustainability of use and the suitable maintenance management. Therefore, it can be
said from the above that intermediate technology is required for improvement of the
sanitation situation in the Bangladesh. Besides, residents' consciousness formation is a
success function to improve sanitation situation. Since awareness program are needed for
88
consciousness formation, awareness program are important for improving a sanitation
situation effectively.
Figure 2-2 Social environmental issue relating to water supply and sanitation
Source: This made by author from Akira Sakai, 2005, “Mizu to eisei ni kakawaru kaihatuenjo no houkousei”
(Directionally of development assistance relating to water and sanitation), Japan Water Forum,
Figure- 10
2.1.6 Overseas previous research
This section introduces the project a company currently undertakes as part of CSR activity
which is the philanthropy of a company or BOP business BOP business aiming at the
business for a low income group from the problem by the delay in progress of global
sanitation facilities spread. Consideration of Chapter 2.5 describes the possibility of the CSR
activity or BOP business in the Philippines.
First, there is NEPIA’s 1000 toilet project which OUJI NEPIA, Inc. has been undertaking
as part of CSR activity since 2008. "The support activity about water and sanitation" in East
Timor of UNICEF is supported with some sales of the NEPIA goods. UNICEF is carrying out
construction of the home toilet of 1000 households and construction or reparation of school
the toilet of 15 schools (The project in 2008) in East Timor and also is supporting activity for
89
the spread of sanitary practice and fixing. NEPIA is supporting those activities. In
implementation of a project including construction of a toilet, construction work and
awareness program are carried out chiefly by residents under the instruction and the
education of UNICEF or local NGO. According to investigation of UNICEF in 2006, in East
Timor, it turns out that 77% of the population of farm village part has an environment that
cannot use a toilet and that 61% of schools need the improvement of a toilet and a water
supply system. One per six persons of less than 5-year-old children has suffered from
diarrhea owing to the defect of polluted water and a toilet and especially the toilet and the
environmental improvement of water in a rural area have been an urgent subject. In building
a toilet first, it starts with achieving the understanding of importance of a toilet to the
residents. It is because residents do not have the custom of excreting in a toilet, so they don’t
feel the necessity for a toilet the project starts from that problem and builds a toilet together
with local NGO and residents, and advises on the way of repairs. Although the form and the
system of a toilet to be built are simple, residents can build by themselves and its
maintenance is also easy. Of course, not only a toilet but simple hand washing place to wash
hands and a cistern to keep with the water to stream after excreting are built. Moreover, as
activity for the spread of sanitation customs, the education can be sociable and get interesting
to children when an external person performs sanitation education to school with using
teaching materials, a picture-card show. The educational campaign of the sanitation education
using media is performed, under the lead of UNICEF, the radio program about water and
health and the comic books about parasitic prevention are produced, and also it is offering
technical support for the radio programs and magazines for children. Thus, this project carries
out not only installation of toilets and water supply system by resident himself but also the
spread of the various required knowledge in order to reduce the illness about sanitation and
90
sanitation consciousness and still awareness program.
Second, Hindustan Unilever Limited (HLL), the subsidiary company in India of
multinational Unilever, is a company which deals in various housewares and foodstuffs such
as soap and detergent. HLL has run BOP business named “Project Shakti” for the residents
living in rural area. It has employed the women living there as salesperson in order to make
them independent and providing them income. The basic work of the salespeople is to
promote of soaps and shampoo in the market. Moreover, it aims to prevent the people from
various water borne diseases by giving them sanitation education and accustoming them to
wash their hands with soaps.
In India, a total of nearly 18 million children are killed by diarrhea owing to lack of
sanitary practices and unsanitary environment conditions annually. Although many
households have soaps, the poor does not regard washing hands with soaps as a precautionary
measure. The HLL came up with the business model which can sell product in low price for
rural areas. The company has also introduced antiseptic elements to its products in order to
make an appeal regarding health and aroma chemicals to them for women and kids. Moreover,
it has incorporated newer technology in order to make soaps more durable. Besides, it also
empowers women living there by employing them as salesperson called “Shakti Ammas”.
In order to be “Shakti Ammas”, they must understand the products they sell and also know
the information of effect for health and sanitation by using products during cohabitation in 6
weeks.
It can be said that “Project Shakti” is managed by many stakeholders because it makes
use of “Global Public-Private Partnership for Hand washing with Soap” for sanitation
education and awareness program. It means that government and HLL works side by side by
getting manpower and money resources from USAID, World Bank and UNICEF.
91
Furthermore, more than 400 NGOs have been involved in the awareness program in schools
with HLL.
According to Japan Water forum (2008), attention should also be paid to “new idea such
as toilet business” as well as “awareness-raising” as the key for widely installing sanitation
facilities. These 2 items are important when thinking about the ways to widely installing
sanitation facilities and accustom people to use them properly in the Philippines; therefore
they are abstracted and quoted here.
<Who should work for realizing “Toilet as business” and what should be done? >
*Through public activities, media, NGO and donor should work together to create
demand for toilet from the local people.
*The stakeholders such as NGO should create a system which relates the ideas on new
type of public toilet or innovation toilet developed to creating an opportunity for business.
*Supporting institution should contribute technological support for efficient excretion
usage.
*NGO should make the measure and construct a system in each community, which
provides toilets incentive such as using excretion as fertilizer and fuel to possess.
*Government should encourage NGO to widely install toilet through subsidy, and
company should do so as CSR (corporate social responsibility) activities.
<Who should work for realizing “awareness-raising” and what should be done?>
*Donor, local government and NGO should help to adopt sanitary education as one of
local education programs.
*Designers should design the toilet which everyone wants to use.
*To involve leaders into the action is important to encourage participation in the political
level.
92
* School builders should add installing toilet and sanitation education into the project.
*Local people, NGO, and local government should find and solve problems through
conversation, coalition and role division.
*Communities should conduct awareness-raising for children.
*Toilet manufacturer should implement awareness-raising which appeals visually, as CSR
activities in cooperate with the communities.
*NGO should provide (portable) tools of awareness-raising about toilet.
Source: Japan Water forum, (2008), Pages 4-1 and 4-2
2.2 Condition in the Philippines
2.2.1 The sanitation condition
The privatization of the waterworks in Manila, capital of the Philippines, has been passed for
14years.As a result , Asia Development Bank reports that the coverage rate of water supply
has been boosted from 60 % in 1997 to 87% in 2011.On the other hand, the coverage rate of
drainage is still low to 7% in Manila. There is a condition that the residents living in urban
poverty area let raw sewage and drainage flow into a river. As for the coverage rate of
improving sanitation, according to World Bank, East Asia and the Pacific Region (2007), it
came to 80% in Manila but to 56% in rural area in 2004. However, UNDP (2006) points there
exists a possibility that these figures do not include the residents in poverty area and useless
infrastructures because of overage. Hence, World Bank, East Asia and the Pacific Region
(2007) mentions that the total number of 13,000,000 people in the Philippines does not have
access to safe water and 27,500,000 people do not have access to improving sanitation.
Moreover, improving sanitation includes also the toilet style of pit-latrine which is simple and
basic. The usage of pit-latrine is that vacuum car takes raw sewage which is collected into the
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tank. However, pit-latrine which is not set up correctly at times causes the water
contamination because the human waste leaking to soil from tank reaches water resources.
As a result, according to UNDP (2006), most of the rivers in the Philippines have been
contaminated. The Pasig-river in Manila which is one of the most polluted rivers in the world
is piled up with drainage and excrement from the residents living around the river coming up
to 35 tons. A total number of 10million inhabitants live around there. Hence the 4.4million
people living along the river are always confronted with acute problems such as water-borne
and infection diseases, especially during the rainy season in the June to October.
As mentioned above, in the poverty ridden areas in the Philippines, water contamination
in the river occurs because they do not have enough water supply, drainage and improved
sanitation .These conditions contribute to increasing the number of people suffering from
water-borne diseases. According to Department of Health, the third highest cause of infant
mortality rate is diarrhea. The number of deaths came up to 1,038 people per year and the
cause of infant mortality rate comes up to nearly 12%. Moreover, the rate of people suffering
from other water-borne diseases such as trachoma and malaria is high.
2.2.2 The sanitation condition at the school
Schools in Philippines have still been short of access to water supply and drainage. Moreover,
most of the schools still lack sanitation facilities. Therefore some pupils are forced to
discharge outside. Even with toilets present, problems still do exist. Such as, Common toilets,
unclean and unsanitary facilities, lack of enough toilets and toilets being too distant from
classrooms. According to the Department of Education of the Philippines, low number of
toilets is the biggest problem currently. Their aim is to provide at least one toilet for 50 pupils.
PCWS announces that sanitation facilities are short in schools with a deficit of 26,736 toilets,
composed of 12,796 urinals for males and some 13,940 for females. A number of 1,000
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pupils cannot possibly help using the same sanitation facilities. In fact, some pupils tend to be
absent from school because of these problems.
2.2.3 The facing problem of sanitation
The Philippine government also recognizes such problems and they are conducting some
projects to make sanitation facilities using low cost and proper technology in schools and
public places with NGOs and international organizations. Besides, there are some laws in the
Philippines such as the Sanitation Code of the Philippines, Clean Water Act and so on.
Moreover, PCWS says that the local governments are responsible for providing sanitation
facilities and services to their residents as mandated by the Local Government Code of 1991
and section 15 of the Philippine Constitution mentions that “The state shall protect and
promote the right to health of the people instill health consciousness among them.”.
Additionally, they have held Philippine National Sanitation Summit with local governments,
journalists, NGOs and so on. They have made a framework of measure of sanitation in the
Philippines by holding discussions, etc. Furthermore, Department of Education of the
Philippines, Department of Health and Department of the interior and local government have
also dealt with sanitation problems.
Poor sanitation causes an amount of economic loss of about PhP77.8 billion per year. 3
Department of Health says that it is same as 1.5% GDP of the Philippines. Although a total of
PhP60 billion per year is needed to provide water supply and sanitation facilities for all
Filipinos, the annual budget amounts to only PhP1.5billion per year. However, they can get
much economic profits by solving the problem of sanitation (Table.2-1). Besides,
enforcement of various rules has also been weak owing to the weakness and limitations of the
3 The details of an account(US$923 billion for health impacts, US$323 billion for water impacts,US$40 billion for
tourism impacts, US38 billion for other welfare impacts)
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many institutions expected to enforce them. Moreover, awareness for sanitation of the poor in
the Philippines has been low as mentioned in the example of "Pasig" river. Hence it is
difficult to solve these problems in the Philippines.
Table 2-1 Estimated economic gains from improved sanitation (million US$)
Source: World Bank, East Asia and the Pacific Region (2007)
Figure 2-3 Economic losses due to poor sanitation, by impact type (million US$)
1,011
323
38 40
1,412
0
500
1,000
1,500
Health Water Other
welfare
Tourism Total
Economic losses due to poor sanitation
(millionUS$)
Economic losses
Source: World Bank, East Asia and the Pacific Region (2007)
Hygiene
Practice
Latrine Physical Access
Improved toilet system
Reuse Treatment or
disposal
Health 455.0 - 323.6 - - Water - - - - 323.4 Other
welfare - 37.5 - - -
Tourism - - - - 40.1 Sanitation Markets
- - - 1,500.2 -
Total 455.0 37.5 323.6 1,500.2 363.5
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2.3 Outline of the Case Study in the Philippines
2.3.1 Research Outline
This research was focused in schools and communities for “Awareness programs for
spreading sanitation facilities effectively and sustainably”. In order to prove three research
questions―“The problem of installing sanitation facilities” “How can the awareness
programs be effective” and “The necessities for installing sanitation facilities and to
accustoming themselves to use them properly in the future”, this research shows two
organizations which realize of spreading sanitation facilities in schools and communities
which do not have effective and sustainable access to them. This research gives an answer by
analyzing three views. Finally, we suggest a solution of which two project problems are
found by examining three points of view by comparing them to overseas cases.
In this research, two organizations for spreading sanitation facilities have been
considered: (1) PCWS (Philippines Center for Water and Sanitation) (2) Fit for School Inc.
The entire research was conducted in Manila. The name of this project was "Fit for school".
We conducted two interviews for the persons concerned in PCWS and for the persons,
students and teachers related to the project "Fit for school". Moreover, we visited Bagong
Ilog elementary school, in order to inspect the sanitation facilities which were made by the
students’ parents. Inspections were conducted in various places. PCWS had conducted them
in communities and in the school. On the other hand, Fit for School had conducted in the
school only. Discussed below are the details about definition and merit of the awareness
program when providing sanitation facilities.
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2.3.2 The definition of awareness program and accustoming themselves to use
facilities
The measures for improving sanitation in the Philippines have not advanced not only because
of limited of budget of the government, but also because of the low awareness of sanitation
facilities and its access. They do not consider sanitation facilities as Basic Human Needs
which is minimum necessity stuffs on living with dignity such as education,
food/clothing/shelter, and health care. In order to boost recognition, and create awareness, it
is necessary to give lectures to the bodies regarding the bad effects of unhygienic sanitation.
Such as, lack of sanitation facilities makes the environment unsanitary, and unhygienic usage
of water may lead to contamination and various water-borne diseases. In order to prevent
such events, they have to accustom themselves to use facilities correctly after setting it up,
which is why awareness programs are necessary. Generally, these awareness programs
promote proper behavior by spreading knowledge or information through lectures in schools
and communities or through publicity works. This research defines the awareness program as
sanitation education, training and publicity work in order to learn and follow appropriate and
hygienic rules of sanitation and to be able to make sanitation facilities by themselves. We
judge whether the people have achieved the appropriate level of behavior by using our
research readings in the Philippines with the transtheoretical model of health behavior change
4and KAP model5.
4 It theorizes about behavior change by dividing it into 5 steps. It can be said that their behavior have changed when to
reach final step. First step is called “Precontemplation”( People have no intention to take action in 6-months future). Second
one is called “Contemplation”(People have an intention to take action in 6-months future ).Third is called
“Preparation”(People have an intention to take action in one month)Fourth is called “Action”(People have taken action for
less than 6-months)Final step is called “Maintenance”(People have taken action for more than 6-months and they can do
without intention.)
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As stated above, the awareness program has a lot of aspects such as publicity work through
mass media, training and sanitation education for the schools and communities. The goal is to
increase the number of stakeholders who are involved with the project, to make their
behavior accurate and to make them join the project for sustainable development. We have
basically focused on three activities―sanitation education for school, sanitation training for
community and publicity work by mass media.
First, in the awareness program for the communities, one of the relief organizations and a
leader from the community conduct conference several times, causing a gradual increase in
the number of attendees. At first, they are given the importance of living in a hygienic place.
After which, information on the ways to construct and manage facilities are told. Finally, they
are to decide whether to construct the facilities by themselves. The sequence of these
activities is most general approach in communities. However the way is depending on various
different factors present in each of the communities.
Secondly, sanitation education in school can be classified into two types. First, it is
practical education which teaches how to use sanitation facilities to the pupils. For instance,
the usage of soaps correctly and the way to use the toilet without making it dirty. Pupils can
get the habit of behaving correctly by learning the exact use of sanitation facilities and the
proper way of hand washing. The other one, it is being theoretical education providing the
reasons why sanitation is as important as the school curriculum itself. For example, the need
for washing hands, the reason why diarrhea occur, how good sanitation contributes to a clean
environment and so on. A student’s awareness of sanitation can also be boosted by providing
the basic knowledge of sanitation. Two sanitation educations cause the multiplier effect for
5 The installation of knowledge is eventually connected to desirable habit through to let them think the problem and to make
their attitude desirable.
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behavior change of children.
Finally, programs through mass media such as TV, radio, newspapers and posters can
induce a lot of awareness on the
importance and the basics of
sanitation within the general public.
Mass media being popular amongst
the general public obviously makes it
a very efficient way to spread
awareness. However, the choice of
the medium depends on the
popularity of the medium. For
example, if most of residents possess a television, then, broadcasting the program on the
television would provide the best results.
'Bandwagon effect' is generated by conducting three awareness programs effectively.
The 'bandwagon effect' is a general rule which basically means that conduct or beliefs spread
among people, as fads and trends clearly do, with "the probability of any individual adopting
it increasing with the proportion who have already done so". It can be said that the speed of
accustoming themselves to use it correctly has been faster because many people recognize the
importance of sanitation.
Source: This taken by author in Bagong Ilog elementary school
Figure 2-4 These posters painted by pupils as school curriculum for sanitation education
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Figure 2-5 Rainwater harvesting tank
2.4 Research cases in the Philippines
2.4.1 Case study WASH
The Wash project aims to spread knowledge of
sanitation and provide safe water supply facilities to
schools and inhabitants living in poverty ridden areas
in the Philippines. This project works with various
stakeholders, mainly WASH Philippines Coalition. The
WASH Philippines Coalition is supported by WCCSS
and PCWS. They have two main activities. One is to
spread of various water supply and sanitation facilities.
Second is awareness program aiming to make a
combination of policy making, to increase the
number of people who are aware and to build their capacities.
The WASH project has utilized various facilities such as sewage, septic tank, rainwater
harvesting tank and water supply facilities and so on. One of the main features of this project
being the use of low-cost technologies for the construction some facilities. Most of the
facilities have been made from Ferro-cement 10 which is comparatively reasonable and
durable. The community, NGO and local government are taught the methods of construction
and management of low-cost technology facilities. Hence it is possible to reduce the costs
needed to build facilities with the help of NGOs and habitants.
Awareness programs in WASH aim to spread such facilities over wider area by spreading
more knowledge of their stakeholders and encouraging their initiative. The awareness
Source: PCWS HP (http://www.itnphil.org.ph/ Access 2011/12/1)
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campaigns are held for various masses such as, for policy makers, for communities and for
students in the school.
Awareness programs for policy makers have been conducted in order to get financial
support from them. Various project proposals have been submitted to international institutions
and NGOs for their support and resources. Actually, project proposals, in this case were
approved by four institutions, including WHO and DAR. As a result, they could construct
water supply facilities for household in communities affected by flood in the Philippines.
In awareness programs for the inhabitants, building low-cost facilities highlight the fact
that sanitation facilities are not expensive and are easy to construct, use, and maintain and the
sanitary conditions of household and the communities also get a drastic improvement.
Another prevalent program is the awareness program using radio. Not only hope of access to
sanitation facilities, but also various WASH messages are broadcast on the radio from
Monday to Friday from 6 to 8 in the morning by collaboration of the WASH coalition and the
local University. These messages are intended to raise attention, intent and awareness.
Awareness programs for children in the schools are called ‘School Toilet Campaign’
whose purpose is to raise awareness about sanitation. As mentioned in chapter 2.2, water-
borne diseases are easy to spread in the schools of the Philippines because of inadequate
sanitation facilities. Hence various rainwater harvesting tanks have been installed and
education about the way to reuse water and its management is being taught. Additionally,
workshops about sanitation are conducted in summer vacations. Where they discuss about
sanitation facilities and draw posters including messages about environmental sanitation
facilities. Moreover, children write about their experiences in order to use them for the
activity next year.
As described above, in the WASH project, inhabitants get to know the importance of
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Figure 2-6 Sanitation facilities of Bagong Ilog elementary school where the project of Fit for School is ongoing.
sanitation and can familiarize themselves with sanitation facilities by the spread of facilities
using low-cost technology and awareness program. These methods make the effective spread
of facilities possible.
2.4.2 Case study Fit for school
As a part of education activities, Fit for
School advanced focusing on Fit for
School Inc. of the NGO in the
Philippines carries out the project to
educate and routinize daily hand washing
at school, brushing-teeth and parasitic
extermination (take the medicine which
exterminates the parasite included in an
abdomen twice per year),and still to make
children perform these acts spontaneously
in order to solve infection or the problem
of many cavities especially in the
Philippines, in the view of construction of
children's sanitation custom. Three measures, such a hand washing, brushing-teeth, and
parasitic extermination, are called EHCP (Essential Health Care Program), those right
methods are taught to children by teachers and health workers with the manual which Fit for
School Inc. created and are made to practice with using actual facilities and goods. Therefore,
the local government and others is to provide all goods, such as soap, brushing- teeth powder,
and medicine not so that it may become a burden of children or a community. The manual for
teachers and health workers describes clearly the contents of sanitation education by each
Source: This taken by the author at Bagong Ilog elementary school
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field, such as how to wash hands rightly with using soap, the reason to take the medicine for
parasitic extermination, and how to brush teeth, and also it shows how to make sanitation
facilities and their designs, such as simple hand washing stand. They educate the children in
this way, monitoring about whether it was actually routinized by children is also performed
by the check point with the manual and sanitation education is thoroughly performed. In Fit
for school, sanitation education is performed to children in this way, and it aims at making
change of behavior so that finally hand-wash can be spontaneously performed. Teaching
children sanitation education repeatedly such as hand-wash, brushing-teeth, and parasitic
extermination as a part of school education from the elementary school stage where a
fundamental lifestyle is formed leads to effect of routine behavior and a healthy life.
Moreover, it has participated in various meetings, a workshop, an event and others as
enlightenment activity. In order to strengthen the partnership of rural areas and a center, it
will hold the 2nd National School Health Summit and participated in Global Handwashing
Day in the sponsor's position and has told importance of a hand-wash at least in fiscal 2010.
In addition, in eight workshops including SEAMEO INNOTECH, Closing Ceremony of the
Governing Board Meeting, or University of Handwashing share experience of them to other
persons, and it is also performing positively activity for spreading EHCP (Essential Health
Care Programme) in order to increase a partner also internationally
2.5 Consideration from cases focusing on the awareness programs
Our research in the Philippines revealed that the sanitation situation which is showed at
chapter 2.2 was much more serious than we expected. According to the report of WSP-EAP
(2007), the sanitation coverage in urban areas is 80%. However, most of the poor citizen in
the urban area cannot have access to the sanitation facilities such as toilet. In poor urban areas
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Figure 2-7 The toilet in the urban poor area
near the Smokey Mountain, open-defecation is still popular. There, people cover their feces
with newspapers and throw them away, or they excrete them into the river nearby their living
area. Such actions make people live under insanitary environment and cause serious water
pollution in the rivers. Also, the coverage of the water supply system is low, so people depend
on expensive selling water in order to gain drinkable water. Except for drinking water and
cooking water, they use rain water without any treatment. When there is no rain, they use
water from polluted rivers. Nevertheless, the poor living in the slum often has recreation
facilities such as TV and DVD player.
Even though, it should not be thought
that their awareness of the sanitation is
low. It is said that people living in the
poor area also prefer to use the toilet if
possible. The problem is that they feel
they must pay immeasurable costs to get
sanitation facilities, and the system of the
facilities is too complicated to
understand. The agent of DepED (Department of the Education) says “Although there is no
water, no facilities to utilize, no soap for washing or cleaning, soon they get used to it,
unaware that it may cause them to be unhealthy, sick or even worse, lead them to death”.
Hence it is necessary for people to re-realize the relation between water-borne diseases and
insanitary life, and accustom themselves to sanitary behavior like hand washing as well as
installing sanitation facilities. At the same time, they should be informed that sanitation
facilities are not something given by someone but something they get by themselves, by
awareness program and introduction of low-cost technology. That is why awareness program
Source: This taken by the author in the urban poor area
105
is the considerable process for solving the sanitation problem.
Looking on the statements reported by the Japan Water Forum (2008), most of them have
already been worked on in the Philippines. The fact may be obvious from PCWS’s project
and Fit for School. Moreover, the NGO named CAPS (the Center for Advanced Philippine
Studies) has implemented the project introduced above. Besides offering technological
support and awareness program, they are deeply engaged in widely installing Ecosan toilet in
the poor areas and communities in rural districts. Ecosan toilet which they promote is urine-
diverting dehydration toilets that use ash to cover and dehydrate the feces. Using this
technology, urine and feces can be converted into soil conditioner or fertilizer and useful for
agriculture. In fact, Ecosan toilet is eco-friendly. By having and using Ecosan toilet, people
can get soil conditioner or fertilizer easily. Thus it is very effective to generate incentive of
inhabitants. Additionally, some of the institutions which are challenging to solve water and
sanitation problem are holding a meeting once every few months at the DepED. When we
participated in the meeting in September, they were discussing about the child-friendly
designed toilet ―a toilet that can be used by any child easily― at that time.
Thus the fact that words like ‘awareness program’ and ‘public activities’ are used often in
the list indicates the importance of awareness program. In chapter 2.4, we picked up the
projects focusing on awareness program for widely installing sanitation facilities and forming
the habit of using them properly, and we found 3 things in common. These are (1)
Community participation, (2) The collaboration of the stakeholders and (3).Low cost. In this
part, we would like to go through these 3 points.
(1) Community participation
The important point of this project is that the resident themselves are related to this project
directly. Mr. Masatsugu Simokawa (n.d.) says “Mr. Amartya Sen claims that the poor should
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be seen as the agent of the development, not as objects. In fact, the poor acts with their will
only in the individual project brought from outside. I do not think that the poor acts with their
will in terms of the process of development.” As he claims, the poor is often an outsider of
the project in the actual work for development.
PCWS, however, actively carry out the projects which grows the self-direction of the
residents. In one of the projects called LOCAL WATCH, all facilities set up with low cost
technology are made not only by engineers but also by the residents. The engineers of PCWS
actively go to the poor regions to advertise low cost technology and create the demands. Then,
they teach how to make the facilities using low cost technology to the members of the
communities. Also, all the washstands in the elementary schools under Fit for School project
are made by parents of the students. The design is created by Fit For School Inc, but they will
take good care of washstands or fix them when they are broken because they know how to
make washstands. These two projects start with training the residents and teaching that they
have to make everything by themselves, therefore, the facilities will be used with good care
and be used by whole community.
When the residents try to solve the problems by themselves, we may get better results
than we expected. In Orangi Pilot Project carried out in Pakistan, the residents set up the
drain pipes underground with the help of NGO called OPP to solve drainage problem. Once
the projects went well, the residents changed their way of thought eventually, though they
would only make a request and wait until the government would start to work before the
project started. Finally, the residents started to work on the business territory which the
government should be responsible for; therefore, the government which had done nothing
before had to start working. As a result, the system of drainage spread rapidly. We can learn
many things from this example. The most importantly, if we keep working on enlightening
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movement based on the facilities spreading and encouraging the habit of using the facilities,
the resident will realize that they have to work on the projects themselves and try to solve
their problems such as drainage problem which are not worked on in the Philippines where
the coverage of the urban sewage connection treated is still 7%.
(2) The collaboration of the stakeholders
Various stakeholders take part in the project carried out by PCWS. They lead not a formal,
legal and flexible entity called WASH Philippines Coalition and work with people who
decide the policy of the country or the regions for improving the saturation level of water and
hygienic facility in the poor region. And WASH Task Force, organized by PCWS and WASH
Philippines Coalition, conducts the advocacy action. WASH Task Force is composed by
teacher, parents of students, government employees, members of the community and NGO.
Moreover, WSSCC which endeavors to solve international water and hygienic problem gives
financial aid. Because of cost effectiveness of EHCP, Fit for school project is carried by
Philippines NGO called Fit for school Inc. Various stake holders are involved in it too, such
as, Philippines office of education which hastens to achieve, the local government which
offer supplies. In addition to it, the program gets the international cooperation from German
NGO called GTZ (the Deutsche Gesellschaft für Technische Zusammenarbeit), CIM (Centre
for International Migration and Development) and Inwert.
Through an observation of the elementary school in the project, we found that a part of
supplies like soaps are donated by the companies. At the school, they are cooperating with
health workers and teachers who coach students. Like this example, thanks to help or
cooperation from many stakeholders or the community, this project is carried out in 23
regions in Philippine and more than 900,000 children have got the benefit of EHCP. We
expect that if many stake holders are involved, they can take advantage of a strong point of
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every sector. Also, if many groups cooperate together and residents do what they can do, they
will be able to overcome the biggest problem that they have a limited budget of water and
hygiene section. In addition, through teaching people who decide policy the importance of
water and hygiene facility, the speed of spreading them will get much faster.
(3) Low cost
On the project implemented by PCWS, people in the community have built rainwater
harvesting tanks which collect rain water effectively to use it for daily life, and biogas
digester septic tanks which converts biogas ― it is generated during treating excretion - to
methane gas used for cooking, with the help of technologists. These facilities can be made of
relatively cheap and durable material called ferro-cement which is thin cement. Installing the
biogas digester costs only 8000 peso (about 184 dollars) except the wage of the engineers.
Compared to the price of smallest shared septic tank system - it costs from 7,000,000 to
8,000,000 yen -, that of PCW’s septic tank is much cheaper, though the way of treatment is
different and it is difficult to compare. The facilities using low cost technology with
sustainability is appropriate than the one using high cost and high quality technology, because
government in the Philippines is worried about the lack of the budget for sanitation.
On Fit for school, people adopt the low cost technology to build facilities for daily hand
washing and tooth brushing. For example, they adopt a simple design for washstands with
water pipe connected to stands made from wood or iron, not expensive steel. The price for
one washstand which 21 students can use at the same time is less than 500 peso6 (about 11
dollars) so it is relatively cheap. Simpler facilities such as PET bottles with some holes
6 Average monthly wage of a family in the Philippines is 6000 pesos (about 138 dollars). Legal minimum wage is 280
pesos (about 6 dollars) per day in Metro Manila. (The Fukuoka Asia Urban Research Center,(2007), Research on the water
supply for the urban poor in the reign of Asia)
109
suspended from a long stick are built. This is much cheaper than the one which we introduced
above. The ingredients of soaps and tooth pastes supplied for the project are eco-friendly.
Hence the water is collected in a bucket after using and it can be given to plants near the
washstand. Like this, they use resources effectively and cut waste. More surprisingly, it costs
only 25 peso (about 0.58 dollars) for a student per year to conduct provision like hand
washing, tooth brushing and deworming using EHCP (The Essential health Care Package)
designed by the NGO called Fit for School Inc. Even so, forming hygienic habits using EHCP
has contributed greatly to improving child health. Though this project launched in 2008, it
was announced that there was 40% reduction in dental caries, 42-47% reduction of diarrheal
incidence and 30% reduction of respiratory infections.
While the government in developing countries still tends to prefer high quality and high
cost technology, usage of Appropriate technology is becoming important in the field of
development assistance. Though there are many definitions for Appropriate technology, we
use the definition of APEX focusing on the Appropriate technology in this thesis. The
definition is that: “the technology appropriate to the social, economic and cultural conditions.
It can be used by many people, meets the needs adequately and eco-friendly.” The
appropriate technology has an advantage that it is not harmful to both human bodies and
environment. Also, since it matches the needs of the residents, it has better chance to be used
preferably.
Moreover, Appropriate technology is sustainable socially, economically and
environmentally because of using sustainable resources and capitals. Therefore, residents can
use the technology by themselves even after the project is finished. If the sanitation facilities
are widely installed but people don’t use them every day at their own initiative, they may not
get their benefit enough. Hence it is important to teach Appropriate technology suiting the
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residents’ needs to solve the sanitation problems.
It can be said that these three factors were gained as a result of an awareness program.
Inhabitants recognize their sanitation problems by conducting awareness program. It means
that they take part in the project independently. Moreover, they keep holding ownership for
such facilities. In other words, they continue to maintain the facilities correctly. In two
Philippines’ cases, it is true that awareness programs which involve residents have been
conducting and inhabitants last to use the facilities. Besides, various stakeholders take part in
the project by awareness program. Moreover, it is also considered that communication
between inhabitants who have already recognized their sanitation problem and external
organization becomes better. It is really important for them to complain what is needed for
them and to work side by side together thinking how they should do because external is able
to know their needs easily. It is connected to spread appropriate technologies which are really
needed for them because they can use and maintain easily. In the case of Philippines, since
the lack of budget is subject, low-cost technology spread out as appropriate technology. It can
be said that negative chain which this research shows in overseas previous research can be
resolved by conducting awareness program.
We consider whether awareness programs contribute to promotion of widely installing
sanitation facilities and accustoming themselves to use these facilities properly by analyzing
the result of the projects. We could go to the Bagong Ilog elementary school where Fit for
School project had been implemented to research our study in the Philippines. In front of the
class rooms, a lot of washstands which the parents had built were installed and they worked
well. Of course, the number of the washstands was enough for the students. Also, awareness
program including sanitation education in the school caused behavior change of the students.
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The students washed their hands before eating and brushed their teeth with their own tooth
brush put their name on it after eating using the facilities. According to the interview to the
students and teachers, the students had not washed their hands and brushed their tooth.
However, we found they always washed their hands and brushed tooth using the facilities
properly after students had been had the awareness program and the washstands had been
installed by the project. The report of Fit For school Inc. said the hand washing caused about
40% reduction of diarrheal incidence. Considered from these facts, it is appropriate that
project focusing on the awareness program contributes to accustom the students use the
facilities properly. Thus awareness contributed not only to widely install the facilities but
only to accustom them use the facilities properly.
However, the Filipino awareness programs still have some challenges. It can be said the
citizens may not carry on doing awareness programs because NGO has become the key sector
who conducts them now. It is important to train the residents who is illuminated to conduct
the awareness programs for the other people. The approach like this makes the effect of
programs spill over. Especially, the awareness programs conducted mainly by children are
important to spread their effect. In the project of Malawi, Safe Water Clubs was established at
the school of Neno area in 2007. 5500 people learned the importance of clean water, adequate
sanitary practice and improved sanitation and they produce songs, dramas and simple games
by themselves to tell the other people. It was reported that 90% reduction of school absence
by diarrheal incidence was achieved through this activity. Children also appealed to their
parents and members in the community. As a result of it, the diarrhea patients decreased by
35% in the hospital of the community. Thus, it is effective that the residents including
children are proactive in conducting the awareness program.
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While in study of two projects, we found that there is few companies’ entry into hygiene
area through CSR movement or Bop business in Philippine. On Fit for School, we found that
the companies contributed some goods to the school as charity. One-sided assistance like this
is not sustainable. If this assistance is stopped suddenly, the well-established sanitary practice
might fade out. For this reason, the participation through CSR activities and BOP business is
preferable.
As we mentioned before, in the report of the Japan Water Forum (2008), “New idea
related to toilet business” is introduced as a key to spread hygiene as well as “consciousness
revolution”. Also, companies encourage NGO to set up toilet through CRS”, “Toilet makers
make visual enlightenment movement in CSR in cooperate with the community” are
proposed. In Philippine, few companies work on it. In other countries, some companies are
starting to work for solving hygiene problems of field in CRS or BOP business. As we
claimed in an earlier research, Ojinepia co. is trying to spread toilet and enlightenment
movement in east Timor as a part of CSR activities in ‘1000 toilets project’ carried. In ‘Shakti
project’, a multinational corporation, Unilever, conduct BOP business. It is for residents in
farming areas in India. Like this, they contribute to widely install the sanitation facilities and
accustom them use the facilities properly. After referring to these examples, we think that if
they take part in the projects carried out in Philippine with different point of views from these
companies; they can enlarge the project and fasten the spread of facilities and forming the
habit.
Some companies entry into this field for business. In fact, an example of public sanitation
business in Nairobi7 was tried at individual level. As mentioned before, hygiene facilities,
7 In 2008, the company called Ecotact Limited has been implemented the project of Ikotoilet in the Nairobi, the capital
city of Kenya. The most of the poor in Kenya do not have the basic sanitation facilities. They excrete into the plastic bag and
throw it away outside. (This action is called ‘flying toilet’.) To improve this situation, they provide the high quality sanitation
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such as toilet, are not spread enough in slam in urban areas of Philippine. If many of residents
in slam open-defecation, hygiene level in the community would not change dramatically even
if somebody paid a lot to set up sanitation in one’s house. Then, one woman in slam set up
public sanitation and started business that charged 10 peso (about 0.23 dollars) for one person
to use sanitation for one time. This is all for the community. She used to be an owner of a
groceries store so she had some income. This is why she could start this business. According
to her, she has just started this business; people in slam take positive attitude toward using the
public sanitation. Philippine in slam have some knowledge of hygiene therefore they have a
will to pay money for the sanitation.
If the companies support the approach and make it effective, the project like this would be
more sustainable than the one conducted by the individual. Therefore, the status of sanitation
in the poor area would be dramatically improved. Moreover, the famous companies’
participating in the project would inform the residents the sanitary problem, collect the funds
easier and expand the scale of the project. What is most important for letting businesses to be
involved in the solution of sanitation problems is that they get incentives to make profits from
projects in the field of sanitation. To construct the win-win relationship between company
and other stakeholders through CSR activity or BOP business such as case studies of overseas
is more sustainable than one-sided support. In any case, it is true that companies should
struggle for solving social issues such as water and sanitation because CSR activity is
watched all over the world. In any case, nowadays CSR activities and BOP business are paid
attention to, so the companies should take responsibility for solving the social problem like
water and sanitation.
facilities and shower for everyone. If they want to use them, they have to pay 5 schilling a time.
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2.6 Conclusion
Before this chapter, we considered an awareness program and accustom them to use properly
by comparing two cases in Philippines. On a basis of these examinations, this chapter is to
provide the way to popularize sanitation facilities effectively and to let people keep using
them from three points of view: the problem of the spread of sanitation facilities, the effect of
awareness program, and what kind of institutions collaborates and how they do.
Three common things have been found by comparing two cases in Philippines on chapter
2.5. The first point is the low cost providing, the second one is citizens’ participation and the
last is various stakeholders’ collaborations. A low cost providing of facilities which is using
relatively cheap materials enables people to realize a sustainable spread of them. Additionally
citizens’ ownership is enhanced by an activity with their participations and it can help
accustoming them to use these facilities. 2 case studies compared each are concerned with
NGOs, government of the Philippines, a local government, communities of habitants and so
on. Cutting cost, the sustainable spread of sanitation facilities, and more wide speedy spread
can be expected by involving various stakeholders. We think these 3 methods are results of
awareness programs from various public relations with using education, workshop and media
for citizens. When citizens and policy makers understand the importance of sanitation
facilities and the merit of low cost technology, they will try actively to spread of sanitation
facilities. Moreover they can work on that effectively even at lower cost if they can involve
various stakeholders.
As stated above, we will show answers for research questions. First, the answer to the
problem point with spread of sanitation facilities is serious lack of fund. Moreover there is the
problem on recognition of Philippines. They have an image that sanitation facilities are
expensive and complicated, so they can’t spread of sanitation facilities willingly. Second,
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awareness campaign helps people who have to do with spread of sanitation facilities like
inhabitants and policy-makers to understand importance of sanitation facilities. Furthermore,
understanding of that importance connects to get accustomed to use sanitation facilities
properly and to involve various stakeholders. Involving stakeholders enables them to spread
of sanitation facilities and take awareness program in a wide sphere. This thing makes spread
of sanitation facilities sustainable and cut funding. Therefore it can be said that the awareness
campaign is very effective. Last on collaborates with stakeholders, we found that each case is
concerned with government of the Philippines, local government, NGOs and inhabitants.
These stakeholders like NGO or government support them in funding, materials and
technique, so citizens join up actively to build facilities or awareness campaign. It makes a
lot of fruits. Many stakeholders’ support connects with cost cut and the spread of sanitation
facilities in wider sphere, so such support is important for the spread of sanitation facilities.
However, we couldn’t find the cooperation with companies on BOP business or CSR in
this study. In other country, some companies conduct BOP business or CSR, for example
“Project of thousand toilets” by Oji Nepia Corporation or “Project Shakti” by Unilever. They
achieved good results. In addition, there is business that toilets are lent people by 10 pesos
per once in Philippines. If companies participate in developing support with different
perspective like this, new advantage will be born and the people will be able to spread of
facilities more effectively.
On this paper, we come to a conclusion as follow about the way to be able to spread of
sanitation facilities effectively and the way to make people use them habitually, from above 3
research questions. Awareness campaign is effective in spread sanitation, and it is important
for making people use them habitually to encourage people to get accustomed to use them
properly through awareness programs. With conducting awareness programs and spreading of
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facilities at the same time, to get accustomed to use properly can be took root in citizens.
Moreover, understanding of sanitation facilities from using them habitually raises demand of
sanitation facilities. Therefore making accustom of using sanitation facilities properly and
awareness program are essential elements for the spread of sanitation facilities in Philippines.
As future prospects, we think the cooperation between firms with aim of BOP business or
CSR and various stakeholders expands possibilities for the spread of sanitation facilities in
Philippines. Although there are some differences on purposes or opinions between
development side and business side, we can expect more speedy spread in the future.
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Chapter 3
The Possibility and Limitation of
Public-Private Partnership in
Nutritional Improvement
Seoungho Kim,
Keisuke Tagawa, Kana Togo,
Manabu Ito, Miyuki Ito, Mizuki Hayashida
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Introduction
These days, the alleviation of global hunger has been attracting attention and GOAL 1
of the Millennium Development Goals (MDGs) sets the target of halving “between
1990 and 2015, the proportion of people who suffer from hunger”. However, the
number of people suffering from hunger, which was as high as 925 million in 2010, had
only decreased by 16%. Moreover, nutrition problems lead to other serious problems as
well as poverty. Addressing nutrition issues is a necessary part of solving health and
sanitation problems such as high infant mortality rate and maternity rate, and diffusion
of infectious diseases. In GOAL 8 of the MDGs (“develop a global partnership for
development”) cooperation between private and public sectors is stressed. The
Philippines, which is the target country of this research, is one of the countries which
focuses on the cooperation between different sectors. Therefore, this research pays
attention to public private partnership (PPP) between various approaches to solve and
improve nutrition problems and we take the Philippines as the focus of our analysis.
As it is explained in the preceding studies of the whole research, since the roles of
public and private sectors are different, the cooperation between them is necessary for
eliminating world poverty. Although NGOs have networks in local communities, they
don’t have enough funds or a wide range of activities, so the need for the cooperation
between governments and NGOs is emphasized. In this way, PPP is essential because
each actor has its own role. Furthermore, the preceding study shows the importance of
nutrition education in combating nutrition problems and how each actor is expected to
include nutrition education in their future activities. Considering these studies, this
research develops the theme, “The possibility and limitation of public-private
partnership in nutritional improvement”, and is organised around an on-the-spot
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investigation based on the following research questions:
1. What approaches are used to improve nutritional problems?
2. Which stakeholders are involved? How do they cooperate?
3. What are the objectives of such cooperation?
4. What are the difficulties of such cooperation?
Based on these research questions, this thesis discusses and examines the state of
nutritional improvement projects in the Philippines and tries to uncover the problems in
order to build better partnerships in the future.
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3.1 Nutrition problems and the state of nutritional improvement
activities
3.1.1 The relationship between nutrition problems and poverty
As mentioned above, nutrition problems and poverty are closely related. Nutrition
problems are caused by inadequate access to food for some reasons, which leads to a
lack of nutrition for keeping a person healthy, and life-threatening conditions such as
chronic hunger or malnutrition. Nutrition problems bring about further poverty. For
example, health impairment in pregnant women affects not only women’s bodies but
also fetuses. Undernourished mothers tend to give birth to underweight babies. More
than 20 million low birth-weight infants are born in developing countries every year.
Low birth weight infants have the risk of dying in growth and are likely to face physical
and mental difficulties. Also, mental retardation causes lack of sufficient education and
decreases the rate of school attendance. Insufficient education deprives opportunities of
stable accession and lowers one’s income, and results in further poverty. If the low birth
weight infant is a girl, she also has the high risk of giving birth to an underweight child.
As stated above, nutrient deficiencies continuously have effects on the next generation.
Nutrient deficiencies also lead to the decrease in immune strength against infectious
diseases. Over 75% of the causes of death are disorders of newborn and possibly
curative infectious diseases like diarrhea, malaria, pneumonia and measles. These
deaths are due to nutrient deficiencies. As mentioned above, the decrease in immune
strength resulting from nutrient deficiencies damages the health of people and deprives
people of opportunities to work. As a consequence, labor productivity decreases. In this
way, nutrition problems have negative effects on countries and promote further poverty.
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Therefore, nutrition problems are related to MDGs – GOAL 1: Eradicate extreme
poverty and hunger, GOAL 4: Reduce child mortality, GOAL 5: Improve maternal
health, and GOAL 6: Combat HIV/AIDS, malaria and other diseases. In other words,
solving nutrition problems not only improves the nutritional status of people, but it is a
key to achieving these goals.
3.1.2 The nutritional condition in the world
Basically, there are two types of malnutrition. Limited access to food leads to
malnutrition, which is caused by lack of basic energy such as fat, protein and
carbohydrates. On the other hand, another type of malnutrition is caused by lack of
micronutrients such as vitamins and minerals due to lack of economic strength in
households or nutritional knowledge although they have access to sufficient amounts of
food.
First, it will look at the nutritional problem caused by lack of energy. According to
the World Food Programme (WFP), there are approximately 925 million people who
suffer from hunger in the world. Seen by region, there are about 578 million people in
Asia-Pacific, 239 million in sub-Saharan Africa, 53 million in Central and South
America and 37 million in the Middle East and North Africa. It turns out that more than
half are in the Asia-Pacific region. In addition, the number of people who die from
hunger a day is about 25,000. The background of the increasing number of people who
suffer from hunger is related to the unfair system of food distribution, rising food prices,
increasing world population, war, global warming and so on. Nutrition problems caused
by these matters raise the child mortality rate, spread infectious diseases such as
HIV/AIDS or malaria, and damage maternal health.
While there are a lot of people who suffer from hunger, a lot of people suffer from
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Figure 3-1 Rate of extreme hunger in the world by region
Source: United Nations Food and Agriculture Organization statistics retrieved 30th Nov, 2011
“hidden hunger”, which we can define as micronutrient deficiency. “Hidden hunger” is
an undernourished condition caused by lack of micronutrients such as vitamins or
mineral. Malnutrition caused by lack of main energy can be easily recognized visually,
but malnutrition caused by lack of micronutrients is difficult to identify. That is why it is
called “hidden hunger”. Today, it is said there are about 200 million people who suffer
from hidden hunger. A sufficient intake of micronutrients is essential for maintaining
good health. Lack of micronutrients causes incomplete development, intelligence
impairment and decay of immune strength against infectious diseases. In these ways,
lack of micronutrients becomes the cause of death for many people all over the world.
According to the World Health Organization (WHO), lack of iron, vitamin A and zinc
are to be included in the 10 major causes of death by diseases. In fact, the deaths due to
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pneumonia, diarrhea, malaria and other infectious diseases are caused by decay of
immune strength from lack of micronutrients.
As stated above, nutrition problems in developing countries ruin health, reduce labor
productivity and encourage further poverty. For these reasons, the issue of nutritional
improvement for poor people should be prioritized.
3.1.3 The symptoms resulting from malnutrition
This section describes the symptoms of diseases caused by lack of essential nutrients
and the outline of nutrients because nutritional knowledge is central to a discussion of
this topic.
3.1.3.1 Essential nutrients
Essential nutrients can be classified into carbohydrates, protein, fat, vitamin and mineral.
These are called the five major nutrients. Among them, carbohydrates, protein and fat
are called macronutrients. These are the most necessary for a human body in quantity.
Macronutrients are the source of essential energy (calorie) for vital activity. This energy
is necessary for not only daily activities like walking and working, but also physiology
activity like maintaining organ functions, breathing and so on. Macronutrients are
essential for composing the body and maintaining health.
Vitamins and minerals are called micronutrients because the small amounts of these
nutrients play very important roles for health. Micronutrients must be taken from food
or supplements because they are not made in the body. Many kinds of vitamin are
essential for keeping body functions. Minerals compose the body, and maintain function
of the body as well as vitamin. Though micronutrients can’t be made in the body like
macronutrients, they support the function of macronutrients. Micronutrients play an
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important role in maintaining or controlling the body, so they are essential for human
health.
3.1.3.2 Malnutrition
In this section, diseases caused by nutrition deficiency, especially Protein Energy
Malnutrition (PEM), Vitamin A Deficiency (VAD), Iron Deficiency Anemia (IDA),
Iodine Deficiency Disorders (IDD), are explained. These four diseases are often
common in developing countries. These diseases are harmful for human health and can
be potentially deadly at worst.
PEM is the condition where the amount of protein doesn’t reach the required
amount. PEM is often seen in the poor, especially infants under 5 years of age. In
general, people suffering from PEM also lack micronutrients, accompanied by a decay
in immune strength and an increase in infectious diseases.
The livers of infants store some vitamin A, and the deficiency of vitamin A can
occur because of the diarrhea in early infancy. If the lack of vitamin A becomes serious,
it is likely that illnesses connected to the eyes such as night blindness will increase. In
addition, if such illnesses are untreated, loss of eyesight may follow, and this is a serious
problem in developing countries. Vitamin A plays important roles for the immunity
function, and the lack of vitamin A increases the risk of infectious diseases such as
malaria, measles and so on.
The lack of iron is also a serious problem in developing countries. The lack of iron
may lead to malaria, hookworm infection, and so on. Anemia by the lack of iron may
result in dizziness or palpitations. If pregnant women lack iron, they may die from a loss
of blood when they give birth. The lack of iron ranks higher on the causes of mortality
of pregnant women. In addition, iron deficiency is linked to a decrease in immunity,
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anorexia, weight loss and loss of learning ability.
Iodine has to be taken in constantly because a constant amount of iodine is
discharged from the body every day. A lack of iodine causes underproduction of thyroid
hormone. Since fish or seaweed includes iodine, deficiency symptoms are often seen in
areas where the soil doesn’t include iodine or inland areas where the custom of eating
seaweed does not exist.
Children born to mothers who lack the nutrition are malnourished or underweight
from when they are born, and it is difficult to improve the malnutrition of them. If they
can continue to live, they have difficulties in their health, mental and learning ability in
their lives.
3.1.4 The approaches for nutrition improvement in the world
As seen above, nutrition problems in the world are serious conditions, so it is need to
improve the present situation immediately. In this section, we describe different
approaches taken in the world to address serious nutrition problems. There are four
main methods: fortification, supplementation, feeding and education.
3.1.4.1 Fortification
This is the method of making up for lack of nutrition by fortifying nutrients in daily
food. The merit is that it is easy for poor people to get fortified foods because they are
cheap. Though it comparatively takes a long time to see effect, people can sustainably
take in some nutrients every day, for example, flour-fortified vitamin A, salt-fortified
iodine and rice-fortified iron.
3.1.4.2 Supplementation
This is the method of making up for lack of nutrition directly by taking in nutrient
supplements. It is possible to specify and take in necessary nutrients. Since supplements
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condense nutrient components, it is possible to take in necessary nutrients in a short
time. But it is difficult for the poor to get supplements because they are more expensive
than fortified foods and people have to take in supplements until the effect appears.
3.1.4.3 Feeding
This is an approach that provides food to the poor mainly by NGO/NPO or international
organizations. This is effective for the people who have difficulty in getting access to
enough food. It is part of the projects conducted by NGOs or international organizations,
but is not suitable for solving the lack of specified nutrients because it only focuses on
the balance of nutrients. There is also danger of lack of sustainable nutritional
improvement because feeding is usually conducted as one big project.
3.1.4.4 Education
Nutritional education aims to help to improve awareness of health care with the
knowledge of nutrients’ influence on the body. It is said that the lack of knowledge is
also one of the cause of malnutrition, so educational approach is important for
nutritional improvement. Educational activities are conducted in not only formal places
such as schools, but also in non-formal places such as communities for targeting broad
age groups.
These four approaches to nutritional improvement help us confirm what advantages
or disadvantages they have. It is important to choose the best approach which meets the
needs of local people.
3.2 Public-Private Partnerships
In establishing the theme, this research focuses on ‘Public-Private Partnership’ (PPP) as
the key to solving the nutritional problem. First it looks at why PPP became the main
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current of approaches in the world and why PPP was chosen for this research. It then
considers in particular the definition and the grouping of PPP in this research. Finally,
the preceding study will be explained.
3.2.1 The background of Public-Private Partnerships
Public-Private Partnership (PPP) is a cooperation between public and private sector on
public services, which has been encouraged since early times. However, it was
implemented as a method in 1980’s, when the so-called ‘Limited government’ policy
spread and services provided by government were cut. In that trend, government made
use of the private power positively, that is, privatization was made popular. The trend to
deal with projects together grew strong all over the world.
First of all, Private Finance Initiative (PFI) became popular. It is an approach that
was promoted in Western countries such as England and the U.S.A. It was introduced
for the purpose of trying to make operations more efficient through sharing risks and
using private capital. In the Japanese case, after the law referring to PFI was established,
many local governments looked for the good effect and carried out PFI projects.
Through the join activities such as PFI, the central government as a big player got to
reduce its own role because local governments and companies were appearing on the
scene as new players that could shoulder public services and social capital. At the same
time, NGOs also got to be more and more important. PPP has a wider definition and
includes not only funding support but also the cooperation from planning the projects.
Thus, PPP includes PFI. However, Japan still has the strong idea of PFI while western
countries adopt various forms of PPP with different stakeholders. The conditions of PPP
are very different from each country.
After so-called “Market failure” and “Government failure”, PPP was formed as a
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concept in the flow of decentralization and privatization from the above. What is more,
this concept was regarded as important in terms of development and collaboration
between different countries. Donor countries try to conduct PPP activities because of
they can take advantage of private capital, management know-how, specialization and
dispersal of risks. In many Japanese reports, the word ‘PPP’ has often been taken up.
Besides the above stream, this research regards PPP as a very important approach
for dealing with nutritional problems in the context of international cooperation. In
particular, it focuses on the roles of each stakeholder.
The following are the characteristics of each actor:
・ Governments can design the policy and conduct projects or research on a large
scale. Moreover, they often are trusted by the citizens, so they can carry out
sustainable projects. However, it is demerit that the government spends time and
money uselessly because of complicated procedure. So its demerit is inefficiency.
・ Companies may have specialist knowledge and skills or great amount of capital
and also have management ability. But in most cases, they don’t build local
networks so they cannot respond to specific needs and it is hard for companies to
get a feeling of trust from the people. It is also likely that companies cannot
continue PPP because they are conducted as single projects as part of the
company’s strategy.
・ NGOs act in local areas, so they can conduct activities that reflect the local
minorities or specific needs. The weak point of NGOS is greater insufficiency of
funds than others, so they lack the ability to act according to the best plan
possible and to maintain continuous activity.
Thus there is a limit to how each actor can cope with problems by themselves. It is
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so important to tackle problems by making the most of PPP as an effective approach. Of
course, this could apply to nutritional improvement projects and plans.
3.2.2 The classification of the forms of PPP approaches
The classification of public and private sectors and the forms of cooperation will be
explained next. The public sector refers to government agencies and international
organizations. Government agencies are configured of government ministries and local
governments. International organizations cover the organizational framework of the
United Nations: World Bank, Asian Development Bank (ADB), World Health
Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations
World Food Programme (WFP), Food and Agriculture Organization of the United
Nations (FAO) (Apart from these, there are many other international organizations. The
above-mentioned international organizations are concerned in this research.) The private
sector covers companies, laboratories of companies, Non-Government Organizations
(NGOs) and Non-Profit Organizations (NPOs). Companies and NGOs are not just
domestic but also transnational. Therefore, PPP is the cooperation between different
actors from public sector and private sectors through various projects.
Next we describe PPP in more detail. At present, there is a wide range of types of
PPPs; this section describes the specific types of PPP that we focus on in this research.
The first aspect is funding. PPP has started to fund other sectors as described in the
origin of PPP approaches. Both sectors fund projects. Especially, the companies as a
part of a Corporate Social Responsibility (CSR) program fund government agencies of
developing countries, NGOs and NPOs. Ajinomoto is a Japanese food company, and it
strives to promote a healthy and vibrant society by pursuing global corporate citizenship
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activities focusing on nutrition and health. Ajinomoto is advertised programs from
NGOs and NPOs fund to them as a part of a CSR program whenever Ajinomoto assents
to the project content. The contents are various from supporting projects in local
communities to providing training of human resources, and facilitating the creation of
social networks and information sharing. These include, for example, nutrition
education, promotion of kitchen garden and providing school lunches. Ajinomoto makes
a point of the project’s sustainability as a criterion for supporting a project. This is
considered as the developmental potential of the project after the end of Ajinomoto’s
support. Ajinomoto International Corporation Network (AIN) program is evaluated the
result through about 176 million yen financial support from 1999 to June 2011. AIN
program is spreading not only financial support but offering experts’ advice and
personal support such as local staff training. This activity acquires great reputation as a
CSR activity.
The second aspect is supporting technology, information and knowledge. For
example, international organizations and government agencies research what kind of
nutrients are lacking in the world and in particular countries. The company produces
fortified products build on information from international organizations and government
agencies. Furthermore, the company supports their technology, know-how and the
information it gets from marketing. These supports will stimulate to improve nutrition
problems.
The third aspect is abolishing trade barriers and taxes. If the government abolishes
or sets low level trade barriers and taxes to fortified foods, the company can go into the
market and sell their fortified products more low price. So people at the base of the
pyramid can buy fortified products more easily.
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3.2.3 The previous studies
Here we focus on the preceding studies on PPP in nutritional improvement, finding the
point of view about the viewpoint of PPP for nutrition improvement and the role of the
public and private sectors in PPP projects.
3.2.3.1 Previous study 1 – viewpoint of PPP for nutrition improvement
In the Manila Forum 2000: Strategies to fortify essential foods in Asia and the
Pacific, Glen F. Maberly and Jack Bagriansky reviewed PPP in food fortification for the
eradication of micronutrient malnutrition from 2000 from three points of view:
1. While the rhetoric calling for collaboration with the private sector has been
consistent, but real partnerships have been rare.
2. Stakeholders related nutritional problems looked at the consumption of basic
staple foods such as wheat, maize, vegetable oils, and sugar in countries around
the world.
3. The barriers to food fortification and public-private sector collaboration were
known from some survey of some food companies and included lack of public
awareness of micronutrient malnutrition, ambiguity of health claims, lack of a
“level playing field” and no research consensus on the need for fortified products.
Glen and Jack said that the advancement of food fortification as a viable solution to
micronutrient malnutrition will require investment by both public and private sectors
and the complementary role each sector can take in supporting such projects. They
claimed that public sectors need to advocate, increase awareness of nutritional problems
for the people through public educations, and promote food fortification foods through
tax/tariff incentive to the companies related in food industry. And they also claimed that
private sectors need to recognize their own position as nutritional experts, develop and
assure the products, and promote nutritional foods through marketing and researching
about consumer. Thus, public and private sectors have different roles so each sectors
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need to make up for the weak points.
3.2.3.2 Previous study 2 – Viewpoint of PPP in nutrition improvement and the role
of public and private sectors
In a paper called “Role of public-private partnership in micronutrient food
fortification 1 ”, Venkatesh and Ameringen insist that effective and sustainable
fortification will be possible when only the public sector, private sector, and social
sector collaborate to develop, produce, and promote micronutrient-fortified foods. And,
they also claim that there is a critical need to initiate national dialogues to form links at
the national level among government, industry, scientists, non-government
organizations, and international agencies such as: opening channels of communication,
creating public awareness, developing consumer demand, defining coverage and market
segments, identifying food vehicles, marketing campaigns, keeping products affordable,
and assuring quality (S152-153). And, Venkatesh and Ameringen claim there has been
progress in eliminating micronutrient malnutrition and they classify the role of public
and private sectors in the process of PPP project as the following:
Process
» Public sector performs initial educational efforts
» Private sector takes the lead in market research
» Public and private sectors collaborate in developing themes and messages
» Public and private sectors partner in dissemination campaign
» Private sector tracks and fine-tunes the campaign
» Public and private sectors collaborate to revise messages
» Public sector evaluates national impact
1 “Unlocking the Potential of the World’s Children through Sustainable Fortification and Public-Private Partnership” Cincinnati, Ohio, USA, 10-11 October 2002
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Public sector
Governments need to develop political contact at the highest level and set policy and a
program framework within which food fortification can be promoted. Government’s
primary role when they work the program is in education and awareness campaigns and
the necessary integration. In certain cases, fiscal incentives (tax/tariff exemptions) and
physical incentives (preferred access to public infrastructure) may be necessary to
catalyze the process. Government could also ensure quality by providing a seal of
approval to fortified foods that meet specified standards.
Private sector
The food and pharmaceutical industry could work with governments to assess mutual
needs. By being part of the process from the start, industry can ensure its needs and
concerns are considered. Industry has the primary responsibility of creating products
and technology and developing marketing and distribution mechanisms. Industry could
create “best practices” codes for production and marketing of fortified products, so that
all companies can compete with regard to quality and excellence.
As is pointed out by these two studies, public and private sectors have appropriate
roles in the PPP to improve the nutrition situation. Actors in the public sector have to
make efforts to make awareness of nutrition through education, make the system
through policy and law such as tax/tariff exemption. Actors in the private sector try to
make awareness of nutrition through marketing, keep products quality from quality
assurance and develop products/mechanism as demands’ needs. Collaboration between
the public and private sectors is needed to develop products and invest infrastructure.
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Certainly, there are several problems in PPP projects. Lack of awareness about the
importance of nutrition in government, problems of access from product price increases
for wanting too much profit in private sectors, and adjusting these differences of
purpose between public and private sectors are the main problems. Likewise, it is
important to adjust differences of purpose, increase awareness from education and
marketing, and supply products from clarifying effects of products.
3.2.3.3 Previous study 3 – The approach to improve the recognition of the
nutritional improvement project
The weekly iron-folic acid supplementation project studied by Paulino et al (2003) is a
good example of awareness of nutrients and the project through marketing. This project
was based on guidelines from Weekly Iron and Folic Acid Supplementation (WIFS) for
Preventing Anemia in Women of Reproductive Age from WHO. It had been
implemented from 1998 to 1999 in Pangasina in the Philippines. In this project,
International Nutritional Anemia Consultative Group (INACG)/World Health
Organization (WHO)/UNICEF worked as programme planner, and the Department of
Health(DOH) and United Laboratories of the Philippines (UNILAB), a local company,
worked together to improve the nutrition of the women in reproductive age through
social marketing. The social marketing strategy for this project was structured as “4Ps”
of social marketing:
Product: the target audiences were made aware about the importance of iron and
its benefits to the body.
Price: the target audience was informed of the cost of the iron tablets and their
willingness to buy the product was encouraged.
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Place: the target audience was informed of the availability of the iron tablets at
all times in places such as drugstores, barangay health stations, rural health units,
and secondary schools.
Promotion: efforts were made to tell the target audience about the product, price,
and place, including advertising, packaging, point-of sale displays, and special
events.
Table 3-1 Percentage of women taking weekly Iron-Folic acid Supplementation by
pregnancy status and survey period
Pregnancy
Status
Survey Period
1 2 3 4
Pregnant 5.7% 63.3% 84.3% 95.2%
Not
pregnant 6.1% 64.0% 88.5% 98.6%
Total 5.9% 63.8% 87.8% 98.1%
Source: Paulino et al (2003)
This project surveyed the percentage of women taking weekly iron-folic acid
supplementation by pregnancy status over 4 periods, and the Table 3-1 shows that
percentage of women taking weekly iron-folic acid supplementation had been increased
5.9 percent (first period) to 98.1 percent (fourth period).
3.3 Nutrition problems in the Philippines
The previous chapters were about the background of the nutrition problems in the world.
This chapter explains about the background and condition of nutrition problems and the
nutritional status in the Philippines through the specific data.
3.3.1 The problems of the poor and the rich
The Philippines is considered as a developing country, but has recently accomplished
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swift growth. According to the Ministry of Foreign Affairs, the economic growth in
these five years, except for 2009 when the Lehman Shock influenced the economic, was
4.6% at lowest and 7.6% at highest. On the other hand, because many farmers in the
Philippines are still bounded to large-scale landowners from the colonial age, it is said
the economic gap between poor and rich is large. Even the urban areas face serious
employment issue with the increase in population, and there are street children or
beggars in the town while there are scavengers who earn a living by picking up garbage
on the smoky mountains in the suburbs.
Today in the Philippines, the unemployment rate tends to be lower than that of 2006
when it was 11%, but it is still higher than 7% and unstable. There are three methods for
measuring poverty in the Philippines: the measuring standard of the government based
on incomes, the World Bank standard based on expenditures, and the method by the
National Statistics Office (NSO) based on the access to essential infrastructures. The
poverty line has been slowly raised since 2000. It is because the domestic prices rise.
Poverty Ratio had been improved before 2000, but the incomes didn’t increase for the
price rise, consequently Poverty Ratio and the number of poor people based on the
poverty line increases. According to the investigation of household economy by the
NSO in 2009, the number of poor people increased by a million from 2006, and become
about 23 million. This means 30% of people in the Philippines are poor. Poverty Ratio
in Mindanao, south of the Philippines, is 61.8%in 2006 by region. The Gini Coefficient,
which shows a gap between the rich and poor, was also 0.46 in 2006 (generally if the
index is higher than 0.4, there is a large gap). The gap has become worse since 2003.
With such a gap, rich people live in comfort and have the same health problems as
people in the developed countries. Therefore, the main cause of their health problems is
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lifestyle-related diseases, which are caused by high calorie intake, high lipids and high
blood sugar. According to the Ministry of Foreign Affairs in Japan, the 10 main causes
of death in the Philippines are tuberculosis, pneumonia, cancer, diseases of circulation
organs and diabetes. Compared with fatalities in 2003, about 40,000 people died from
diseases of circulation organs, 33,000 from pneumonia, 32,000 from cancer, 28,000
from tuberculosis and 9,000 died from diabetes. A lot of poor people are farmers, so
they tend to have carbohydrates like rice or corn, and they lack micronutrients like
vitamins or minerals which are essential also for the health. The lack of micronutrients
is a serious problem in the Philippines. Thus, the nutrition problems in the Philippines
tend to be misinterpreted as hunger or diarrhea, but in fact, having both nutrition
problems in developed countries and developing countries is a feature. In this thesis, the
nutrition problems of poor people are focused on.
3.3.2 Nutritional problems in the Philippines
The government of the Philippines has been outsourcing the national nutrition survey to
the Food and Nutrition Research Institute and officially publishing a report on the
nutritional status of the Pilipino every three years. The present situation of nutrition in
the Philippines is going to be explained next based on the 2008 national nutrition survey.
The rates of stunted and wasted children are mainly used as the indicators for
nutritional status. The WHO states that it is difficult to continuously research the
nutritional status of adults compared to that of children, so children often become the
subjects of research and the data is used as the essential indicator. The statuses of
underweight, stunted, and wasted are defined by Standard Deviation, which is evaluated
by the gap from the average.
In 2008, 26.2% of the infants between the ages of 0-5 were underweight, 27.9%
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were stunted and 6.1% were wasted in the Philippines. All of these three nutritional
indicators have the highest rate of increase between the ages of 0-1. These are related to
the infant mortality rate, especially suggesting that improving the nutrition of infants
leads the improvement of the mortality rate and other physical status of children.
The Philippines has been successfully approaching MDGs Goal 1, “Halve, between
Figure 3-2 Rate of stunted, underweight, thinness, overweight of 0-5 children in the
Philippines (1990-2008)
Source: FNRI, 2008
1990 and 2015 the prevalence of underweight children under-five years of age” and
other nutritional goals. However, continued efforts should be made since the three rates
increased by about 1% compared to the 2005 national nutrition survey.
Moreover, different characteristics appear when the nutritional status is evaluated by
region. The rates of underweight children are considered “high” between 20-29% and
“very high” over 30%. 28 states marked very high and 38 states were considered to as
high. The result shows that there are many states with serious problem of underweight
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children. In Metro Manila, the rate is “average ~ low”, but most of the southern parts of
the main land have very high rates, which demonstrate the regional gap.
Almost the same result is shown between the ages of six to ten. Although there has
been some improvement, there is the gap between the urban and rural areas.
Additionally, the central islands have very high rates of underweight children but
Mindanao Island has a very high rate of stunted children.
The research also included pregnant women who are likely to have nutritional
problems. Since 2005, the number of pregnant women who are in “nutritionally high
risk” has decreased. Women who are under 20 are especially in severe nutritional status,
and more than 35% of them are at high risk.
Moreover, there are results on the nutritional status based on the status of iron and
iodine. Firstly, when the research result is classified by age, more than 55% of the
infants under one are suffering from serious anemia and 42.5% of the pregnant women
also have anemia. It means that there are two age groups with more than 40% of serious
rate, which is said to have great influence on Philippine economy. Although they are not
reaching 40%, the rates of lactating women and the elderly suffering from anemia are
also high. While the rate of children under twelve who have anemia is decreasing, the
high rate of anemia among infants is still a problem which should be continuously
coped with.
3.4 Approaches for improving nutrition situation in the Philippines
As mentioned earlier, the Philippine have both nutritional problems can be found on the
rich—lifestyle diseases—and can be found on the poor—hunger, micronutrient
malnutrition—. Philippines’ nutrition problem is not only nutritional problems but also
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problems that have impinged on economics and culture. So, government of the
Philippines composes council to make plans and collaborations to improve nutritional
problems.
This passage explains the National Nutrition Council and PPAN programed by the
National Nutrition Council, examining several approaches on public and private
collaboration in the Philippines.
3.4.1 Investigation
Visiting the organizations related to nutritional improvement in the Philippines, this
research analyzes the types and availability of approaches for improving nutrition. The
target places were the Department of Health and Food and Nutrition Research Institute
as a government organization, Asian Development Bank as an international agency, and
Ajinomoto Philippine Corporation as a private company. To analyze the theme that
“Possibility and Limitations of Public-Private Partnership in Improving Nutrition”, the
research investigated the following four research questions:
1. What are the approaches to improve nutrition problems?
2. Which stakeholders are involved? How do they cooperate?
3. What are the objectives of cooperation?
4. What are the difficulties of cooperation?
Through investigating these four research questions, we look at the present nutrition
situation, approaches to improving nutrition status, and collaborative relationships with
other sectors.
3.4.2 National Nutrition Council
The National Nutrition Council (NNC) is the council for making country’s highest
policy and coordinating body on nutrition since 1974. NNC is made from several
departments in need of collaboration for improving the nutrition situation because this
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cannot be achieved by a single sector. NNC works for improving nutrition situations
under the six following core functions:
1. Formulate national food and nutrition policies and strategies and serve as the
policy, coordinating and advisory body of food, nutrition and health concerns;
2. Coordinate planning, monitoring, and evaluation of the national nutrition
program;
3. Coordinate the hunger mitigation and malnutrition prevention program to
achieve relevant Millennium Development Goals;
4. Strengthen competencies and capabilities of stakeholders through public
education, capacity building and skills development;
5. Coordinate the release of funds, loans, and grants from government
organizations (GOs) and nongovernment organizations (NGOs); and
6. Call on any department, bureau, office, agency and other instrumentalities of
the government for assistance in the form of personnel, facilities and resources
as the need arises.
3.4.2.1 Structure of NNC
NNC is composed of 10 Departments. Under the chairperson, Department of Health,
Department of Agriculture and Department of the Interior and Local Government play a
role as vice-chair. And Department of Budget and Management, Department of
Education, Department of Labor and Employment, Department of Science and
Technology, Department of Social Welfare and Development, Department of Trade and
Industry, and National Economic and Development Authority participate in NNC.
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Figure 3-3 Structure of NNC
Source: http://www.nnc.gov.ph/
3.4.3 Philippine Plan of Action for Nutrition (PPAN)
The Philippine Plan of Action for Nutrition is a set of measures against malnutrition
as an integral component of the Medium-Term Philippine Development Plan 2004-2010.
PPAN provides the framework for improving nutritional situations and contributes to
the achievement of the UN Millennium Development Goals as well as poverty
reduction. Medium-Term Philippine Plan of Action for Nutrition (MTPPAN) in 2008-
2010 worked for improving nutritional situation under 3 main directions in following;
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1. Reduce disparities by prioritizing population groups and geographic areas
2. Increase investments in interventions that could impact more significantly on
under-nutrition
3. Revival, identification, and adoption of good practices and models
4. Going to scale in the implementation of nutrition and related interventions to
have wider coverage
And, table 3-2 is some of targets of PPAN for 2008-2010.
Table 3-2 Targets of PPAN for 2008-2010
Key performance indicator Baseline Target
2005-2010 (Year)
Reduce the proportion of households with intake below 100 percent dietary energy requirement
56.9% (2003) 44.0%
70.0% (1993)
Reduce the prevalence (in percent) of Underweight children, 0-5 years old
24.6% (2005) 21.6%
34.5% (1989-90)
Reduce the prevalence (in percent) of Underweight children, 6-10 years old 22.8% (2005) 22.6%
Stunting among children, 0-5 years old 26.3% (2005) 25.4%
Anemia among Infants 66.2% 41.7%
Anemia among Children, 1-5 years old 25.1% 15.1%
Source: http://www.nnc.gov.ph
3.4.3.1 Roles of stakeholders in the PPAN
NNC
NNC and its networks including local nutrition committee and community nutrition
volunteer provides structure and mechanism for coordinating and adjusting the plan.
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National Government Agencies
National Government Agencies examine various policies about nutrition and announce
that policies and guidelines. Also that advocates to various stakeholders, support to do
capacity building and provision of logistics support to improve nutrition.
Local Government Units
Local Government Units conduct situational analysis to determine appropriate
interventions and implement and fund interventions to be implemented at different
levels.
Other sectors
Various sectors and many stakeholders are involved in the PPAN. NGOs conduct and
continue implementing nutrition and related programs and projects. International
organizations continue to provide technical and financial support to the national
government and local governments. Business organizations consider the possibility of
including nutrition and related services in a package of non-wage benefits for their
employees, especially the poor and marginalized. Food industry continues to develop
and market food products that are nutritious and safe, accessible, and affordable to the
consumer. Rice, flour, sugar, cooking oil, and salt industries continue to exert efforts to
comply with the food fortification law and ensure the availability of fortified foods in
the market. Business corporations with their own social foundations encourage
corporations to shift their programs according to the priorities for nutrition action.
3.4.4 PPP for nutritional improvement
There are various forms of PPP in the improvement of nutrition in the Philippines:
Sangkap Pinoy Seal Program (SPS Program) conducted by DOH, the transfer of food
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fortification technology from Food and Nutrition Research Institute – Department of
Science and Technology (FNRI) to local companies, nutrition education provided by
Ajinomoto Philippines Corporation (APC), and Project Iron Deficiency Elimination
Action (Project IDEA) implemented by International Life Science Institute. This
chapter explains about the characteristics of each approach.
3.4.4.1 The activities of DOH and FNRI
DOH and FNRI, which are both parts of the public sector, understand the importance of
the approaches of PPP. They even believe that the cooperation with the private sector is
indispensable for improving nutrition. When they try to develop PPP, they first discuss
and share the objectives and work together in line with the discussions. If by any chance
the public sector doesn’t share the objectives with the private sector, which seek profit,
the project might be different from its original goal and might not succeed.
DOH conducts various PPP projects such as one-time and several-time cooperations.
Sometimes they ask the private sector to develop fortified food products and buy them.
What they are especially focusing on is called Sangkap Pinoy Seal Program. In this
program, they give certified seals to the local companies and allow them to put the seals
on their fortified food products that meet the standards and sell them in supermarkets
and convenience stores. In order to be certified, the fortified food product should
include more than two thirds of the standard daily intake of the nutrients such as
minerals and vitamins. It is difficult for the companies to get the trust of the people and
make them buy fortified food because fortified food is not well known especially in the
rural areas. Therefore, in order to expand the sales and use of fortified food, government
certification is essential. DOH believes that they should sustain their PPP projects and
other approaches, cover the whole country, and cooperate with other stakeholders in
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order to improve the nutrition of the Filipinos.
FNRI carries out the national nutrition survey and develops the food fortification
technology. They are concentrating on transferring the food fortification technology to
local companies. Since FNRI cannot produce and distribute fortified food products by
themselves, the roles of the companies are important. The companies utilize the
technology and consequently spread fortified food throughout the country. Before FNRI
transfers the technology, strict assessments and meetings are carried out in order to
examine the sustainability of the business and to share the objectives of the companies.
Moreover, the supporting and monitoring systems after the technology transfer are
created so that the companies can use the technology for the right purposes. Although
the system to distribute fortified food has been developed, there still is the problem of
low degree of recognition of fortified food itself. Less than 10% of the Filipinos know
what fortified food is and the percentage is even lower in the rural areas. Distributing
food fortification is necessary as well as improving the degree of recognition.
3.4.4.2 APC
Ajinomoto Group Philosophy is to “create better lives globally by contributing to
significant advances in Food and Health and by working for life”. They provide healthy
and nutritional food as well as deliciousness for the sustainable health and happiness of
the people. APC is providing funds and information and conducting joint projects with
other stakeholders and highly contributing to nutritional improvement of the Philipinos.
There are the three main forms of PPP between APC and FNRI: providing funding
support, providing information, and jointly implementing self-planned programs. Firstly,
APC is providing funding supports to FNRI. Although FNRI is one of the governmental
organizations, they don’t have limited funds to spend for nutritional improvement. Thus,
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the funding supports from APC and other cooperative companies is important. APC
helps FNRI to promote the nutrition development programs and to disseminate the
research results through supporting 1st Brown Rice Culinary Challenge and the poster
presentation exhibit.
Secondly, APC is providing information on nutrition to FNRI in order to educate
FNRI staff on new scientific information and to update with new knowledge. For
example, APC held Allergy Symposium in 2009 attended by FNRI heads and
researchers. Thirdly, APC and FNRI are jointly implementing self-planned programs for
more resources and better results. APC has been supporting FNRI’s activities in
Nutrition Month every July since 2000. In Nutrition Month, FNRI holds symposiums
and meetings so APC donates giveaways and materials in place of putting
advertisements on them. In the near future, APC is planning to carry out nutritional
improvement projects with DOH, NNC and Department of Education.
The challenge of APC for nutritional improvement through PPP is how they can
cooperate with as many stakeholders within the limited funds they have. Many of the
governmental organizations are expecting APC and other strong companies to support
their activities but APC cannot help all of them. The problems are how APC can
distribute the funds effectively to cover all the requests.
3.4.4.3 ILSI
ILSI is a nonprofit worldwide organization founded in 1978 with the global network of
more than 400 companies and 3000 researchers. Their mission is “to provide science
that improves public health and well-being by fostering collaboration among experts
from academia, government, and industry on conducting, gathering, summarizing and
disseminating science.” They especially focus on nutrition and health promotion, food
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safety, risk assessment, and the environment. Providing scientific data, they are closely
connected to the international organizations such as WHO, FAO, and UNICEF, and
gains reliability on policy decisions for international harmony. Furthermore, they build
relationships with NGOs for health and security of the people in the whole world.
In 1997, ILSI has started a campaign to eradicate iron deficiency anemia, which is
called Project IDEA. In Project IDEA, ILSI works together with the governments of the
developing countries and fortifies their principal food and seasonings with iron. As a
result, they make it possible for the people to take in iron through daily diet and prevent
anemia. This program was launched because there was no clear measure to eliminate
iron deficiency anemia while many programs for the reduction of vitamin A deficiency
and iodine deficiency have been successful.
ILSI pays attention to rice and works together with FNRI to develop iron fortified
rice. Through the research, they proved the effectiveness of iron fortified rice for the
reduction of anemia and carried out the market trial in Orion City, Bataan State to
introduce the new technology. As part of the project, education and advertising
campaigns on iron fortified rice were conducted and the effectiveness of the rice and the
behavior of the consumers were analyzed. Using the result from the trial, the market of
the rice will be expanded to the whole country. Project IDEA is carried out not only in
the Philippines but also in Cambodia, Vietnam and other developing countries. China
has its national policies to distribute iron fortified soy sauce and the research on iodine
and iron fortified salt is developed in India.
ILSI has been working on the dissemination of fortified food through Project IDEA.
They recognize the roles of the private and public sectors and actively build the
relationships with other stakeholders. ILSI also believes that the government should
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certify fortified food products to make them reliable, as in SPS Program, and increase
the demand. The seals also improve the quality of fortified food themselves by ensuring
that the products contain the nutrients written on the labels. ILSI suggests that other
Asian countries should use this system to expand fortified food market.
Many of the stakeholders believe that PPP, in which the public and private sectors
have their special roles, is important for nutritional improvement. There are some PPP
projects going on in the Philippines, such as SPS Program and Project IDEA, and they
are expected to be highly effective in the future.
3.4.5 Analysis
In this chapter, the PPP projects for nutritional improvement in the Philippines
described above is summarized along with our answers to these following research
questions:
1. What are the approaches to improve nutritional problems?
2. Which stakeholders are involved? How do they cooperate?
3. What are the objectives of cooperation?
4. What are the difficulties of cooperation?
Firstly, there are various types of nutritional improvement activities in the
Philippines: Sangkap Pinoy Seal Program by DOH, national nutrition surveys and
development of the food fortification technology by FNRI, funding support and
nutritional information distribution to by APC and eradication movement of iron
deficiency anemia called Project IDEA by ILSI. Additionally, as an international
organization, ADB is building the base for the stakeholders to cooperate with each other,
covering whole Asia. In these ways, there are many PPP projects for nutritional
improvement in the Philippines and many of them are actually producing good results.
About the second question, DOH cooperates with companies since they give
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certified seals to their fortified food products, FNRI also has partnerships with
companies for its transfer of food fortification technology to them, APC and FNRI are
working together and supporting each other, and ILSI, together with FNRI, is
developing iron fortified rice. Each of these cooperation involves both public and
private sectors. Therefore, although the projects vary from financial support to
cooperation in the planning stage, all of them are PPP projects.
Next is about the objectives of the cooperation. DOH wants to spread the fortified
food products, which meet the standards, and improve the reliability of the companies
through SPS program. FNRI’s purpose is to distribute fortified food products through
the whole country, while APC expects to advertise their food products. The cooperation
between ILSI and FNRI enabled them to conduct the research on iron-fortified rice and
the large-scale market trial.
For these projects, this research finds three problems in making the nutritional
improvement projects more effective. First, one of the challenges is that nutritional
improvement projects and fortified food themselves are not well known among
Filipinos. For example, SPS Program is highly reputed but only 11% of the Filipinos
know about fortified food and the percentage of those who actually know the definition
of fortified food is even lower and drops to 9.8%. Some people, especially in the rural
areas, misunderstand that fortified food is harmful for their health. The awareness
should be improved and their behavior should be changed to make the projects
successful and lead to nutritional improvement. Secondly, the difference in the
objectives between the public and private sectors sometimes becomes the problem.
While companies seek profits, governments seek improvement of nutrition. It is natural
for them to have different purposes of cooperation, but both of them should share and
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adjust each of their objectives to make PPP projects succeed. Thirdly, it is a challenge
for some of the companies to utilize their limited funds to help many of their
governmental partners. APC wants to help all the governmental organizations and
provide them with plentiful funds, but they have limited funds to use for nutritional
improvement projects. The framework is needed to manage effective projects which
benefit all stakeholders.
3.4.5.1 Problem 1: Awareness
As mentioned above, although the reputation of SPS Program is high in and outside the
Philippines, it is not well known enough to directly contribute to nutritional
improvement of the Filipinos. Moreover, the misunderstanding towards fortified food
prevents it from dissemination. In order to improve the awareness of the people, as
stated in Chapter 2, the public sector should educate the people on nutrition and remove
their misunderstanding. Additionally, the private sector should make the people aware
of the safety of fortified food through marketing.
The factors of success in PPP projects are going to be analyzed and the possibility of
improving the awareness of the people will be considered.
According to Paulino et al (2003), “Weekly Iron and Folic Acid Supplementation”
succeeded to improve the awareness among the people in reproductive age of iron-folic
acid supplementation. In this project, the awareness rate was surveyed four times. The
rate was 5.9% at the start, but it increased to 98.1% and most of the women in the
region came to use the products.
It is assumed that the factors of success are improving the awareness rate and
providing the products at the appropriate price. PPP worked well to provide safe and
affordable products and constant education and advertisement campaigns.
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This research pays attention to the improvement of the awareness rate through
community-based marketing. Improving the awareness of the people through marketing
is one of the effective approaches which can also be used for fortified food and other
projects.
3.4.5.2 Problem 2: Objectives
The difference in objectives between the public and private sectors can sometimes
become a problem. While the public sector is working to improve the nutrition of the
Filipinos, the private sector seeks profits so they should get benefits through nutritional
improvement projects. Therefore, it is essential for them to share and confirm their
primary objectives of the projects. In order to overcome the difference, FNRI sets
meetings and assessments to share the objectives when transferring the food
fortification technology so that the companies can use it for their profits and the
improvement of nutrition of the people. M.G. Venkatesh and Marc Can Amerigen
mentioned in “Role of public-private partnership in micronutrient food fortification” in
“Unlocking the Potential of the World’s children through Sustainable Fortification and
Public-Private Partnership” about the importance of comparing and adjusting the
purposes to carry out projects effectively.
3.4.5.3 Problem 3: Fund Management
The third challenge in the Philippines is to improve the fund management efficiency.
It is important for both the public and private sectors to decide which projects to
focus on and how to utilize their limited funds. The last chapter explains about the
problem of fund management mentioned by APC. DOH, FNRI and other governmental
organizations demand funds from APC to support their projects. APC has limited funds
to help them, even though APC wants to provide funds for as many partners. Thus, the
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management of funds should be efficient. The standards and frameworks to benefit all
the stakeholders are needed to be created. Overcoming these three problems leads to the
effective nutritional improvement project in the Philippines.
3.5 Conclusion
This research focuses on “the possibility and limitation of public-private partnership in
nutritional improvement” and then arranges various aspects such as the backgrounds,
activities, classification, summarizing preceding studies. First of all, this research might
have a risk of not finding precedents in Philippines because there was not enough
Japanese date and documentation. However the more deeply research we did, the more
clear facts we found, that is, we could reach the opinion that it is important positioning
for PPP in the nutritional improvement programs.
We got various answers for research questions based on this research theme. First,
this question “What are the approaches to improve nutritional problems?”, gave the fact
that each group which could agree to an interview carried out their own various actions.
For example, there is one group that builds the network and advocacy to support the
whole activities and another one that analyzes researches about nutritional status, and on
the other hand there are also players that plan the national nutrition policy or try to
expand distribution channels of fortified foods. So they take positive actions for PPP to
bring out the best in their own strengths. As for the question, “what are the approaches
to improve nutritional problems?”, there are various relationships such as technology
transfer from research and development institution to small and medium businesses,
capital cooperation, and announcement of official report.
As for “what purpose do you have through PPP?” it is more effective and essential
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that their group conduct with other group to carry out their mission related nutritional
improvement. The different thing is their background of their mission. One group thinks
improving nutritional problem is their duty as national government, and another group
thinks it is possible to make the most of this national experience to other regions in the
all world. Of course actors such as companies might have an incentive to make a profit.
Finally, each group thinks various things for the question “What are the difficulties of
cooperation?” according to their role and activity content. The group which takes
great interest in advocacy thinks more active relationship with other sectors for it, and
the group which is devoted to researching needs recognition of the product made by
developed technique. They think that it is important to promote the activity by public
announce. If one is good at capital support, they shape the strategy to make the most of
it for the better project management.
Through hearing such groups, the approaches of nutritional improvement and the
relationships between stakeholders became clear. It is natural to solve the problem with
more efficient result that all groups cooperate with others. So they didn’t explain the
signification. But this research shows the three common problems to investigate the
possibility and limitation: “improvement of recognition”, “the difference among
sectors”, and “improvement of fund management”. This research explores the
implication by comparing and analyzing the field studies and the precedence research.
However, since the researches, which overcome on the problem of the difference in
objectives among sectors and the improvement of fund management, were not available,
this research could not go further into those topics. There is a case in which the
recognition succeeded which proved that the strategies of advertisement and education
should be included in the projects. In conclusion, there still is a scope for further study
160
about these two problems and various solutions.
161
References
Ajinomoto Philippines Corporation. (n.d.). Retrieved 9 27, 2011, from Ajinomoto
Philippines Corporation: http://www.ajinomoto.com.ph/default.aspx
Asian Development Bank. (2001). Manila Forum 2000: Strategies to Fortify Essential
Foods in Asia and the Pacific. ADB publishing.
FAO. (2004). The State of Food Insecurity in the World. Rome: Food and Agriculture
Organization of the United Nations.
Ferranti, D. d. (2004). Public and Private Roles in Health: Theory and financing patterns.
In P. Musgrove (Ed.), Health Economics in Development (pp. 35-76).
Washington, D.C.: World Bank.
Food and Nutrition Research Institute. (n.d.). Retrieved 9 25, 2011, from Food and
Nutrition Research Institute: http://www.fnri.dost.gov.ph
ILSI. (n.d.). Retrieved 9 25, 2011, from ILSI: http://www.ilsi.org/Pages/HomePage.aspx
ILSI Japan. (n.d.). Retrieved 9 27, 2011, from ILSI Japan: http://www.ilsijapan.org
Japan Bank for International Cooperation(JBIC). (2008). The poor profile (hincon
profile). JBIC.
Kazuhiro, U. (2008). The newest guide of food hygiene; to be a nutrient expert
(Shokuhineiseisaisingaido Eiyousonotsuninaru). Kagawa Nutrition University
Publishing Division (jyoshieiyoudaigaku shuppanbu).
Paulino, L. S., Agdeppa, I. A., Etorma, M. M., Ramos, A. C., & Sforza, T. C. (2003).
Weekly Iron-Folic Acid Supplementation to Improve Iron Status and Preven
Pregnancy Anemia in Filipino Women of Reproductive Age: The Phlippine
Experience through Government and Private Partnership. International Life
Sciences Institute.
162
PPAN. (n.d.). Retrieved 9 30, 2011, from NNC: http://www.nnc.gov.ph/
Ritsuko AIKAWA, Masamine JIMBA, JICA. (2003). Iron Deficiency Anemia Control
in Developing Countries (Kaihatsutojyoukokuni okeru
tetsuketubouseihinketsushoutaisaku). The study of International Cooperation
(Kokusaikyouryokukenkyu), 39-48.
The World Bank. (2005). Improving health, nutrition, and population outcomes in Sub-
Saharan Africa : the role of The World Bank. Washington, D.C.: World Bank.
The World Bank. (2008). The Poor Profile.
Venkatesh, M. g., & Ameringen, M. v. (2003). Role of public-private partnership in
micronutrient food fortification. Food and Nutrition Bulletin, 24(4), pp. 151-
154.
Chapter 4
Potential of Relationships among
Stakeholders of the TB Control
Programs :
A Case Study Focused on the Difference of
Network
Yuji Tashiro, Sahori Takei,
Yukako Tomii, Megumi Hagiwara,
Miha Matsubayashi
165
4.1 Introduction
4.1.1 Background of our study
According to The World Health Organization (WHO), 8.8 million people come down
with TB each year, and 1.4 million people die from TB1. Among them, 95% of the
people who die from TB are in developing countries including the Asian region.
Infectious diseases including TB account for 50% of the cause of death in the
developing countries. The disease causes not only the patients pain and individual
economic burden but also economic losses. These losses impede the development of a
country. Abmad, N (2003) takes up the infectious diseases control as a high problem of
a priority.
According to WHO, the Philippines is one of the 22 high-burden countries of TB
with reference to prevalence rate. 80% of the world’s total TB patients are found in
these countries. In the Philippines, situations of the spread vary per region. TB spreads
prominently in urban poor areas.2 According to the national TB prevalence survey in
1997, urban poor had four times higher prevalence of TB than the other areas. In order
to solve the TB problem in the Philippines, we have to focus on this urban poor area.3
1 Stop TB partnership TB FACT sheet 2 Poor people live in slum 3 Manila, The Philippines Tropical Disease Foundation. Final Report.1997National Tuberculosis Prevalence
Survey.1997
166
DOTS is the most effective TB control program advocated by WHO. A detailed
explanation is presented in section4.3.1.1. The situation of TB in the world has
improved significantly thanks to DOTS. But TB still continues to spread in the world.
Similarly, in the Philippines, about 100 people per day die from TB. WPRO areas,4
including the Philippines, are the only one who succeeded in the goal. Despite this, the
case detection rate of patients has stopped growing from 2005. Poor patients cannot
afford to receive medical treatment, so they don’t go to hospitals. Therefore, it is
difficult to find the TB patients even if DOTS systems are organized in the present
situation.
Our study focuses on the network between stakeholders in the TB control programs
and presents three research questions. Two cases of effective TB control have various
stakeholders, and this study analysis with the object of how to give the effect for TB
control. With the study method, we gain knowledge about our study-related material
from literature and report about TB control programs of the Philippines or the world,
and we had preliminary survey in Japan Anti Tuberculosis Association. After that we
conducted field survey in the Philippines. In the Philippines, visit the spot of the
projects, and conduct interviews and questionnaire for project staff, inhabitants and so
on.
4 Western Pacific Regional Office members are 37 countries including Japan, China and so on
167
4.1.2 Limit of our Study
There were various limitations such as time and distance between transfers and so on
during the course of our study. At first, we could only find two cases for study objects.
Furthermore, just one part of these two cases could conduct on-the-spot investigation.
Therefore, this research is just one part of the TB control programs in the Philippines. In
addition, we cannot gather enough information because some of the groups could not be
reached for communication after got back to own country.
4.1.3 The organization of the paper
In the section4.2, we give an explanation about TB from medical findings and TB
control programs, refer to the relationship between poverty and the status of TB in the
world the section4.3 explains the current situation of TB in the Philippines, and the
national TB control Programs by the Filipino government. In the section4.4, we
express the importance of relationships between stakeholders in the TB control
programs from previous study and the history of TB control programs. In the section4.5
gives an overview of the survey and outcome of the study, and explain the observations.
And in the section4.6 gives our conclusion.
4.2 About TB
This section explains medical information about TB, which is its symptoms and
168
treatments, while also referring to the relationship between poverty and the situation of
TB in the world.
4.2.1 Basic knowledge of TB
TB bacterium was discovered by Robert Koch in Germany in 1882. TB is infectious
disease which gets infected from person to person through the air. For example, coughing
or sneezing by people with TB causes the bacteria to be scattered in the air, causing others
to breathe air that people infected with TB. The symptoms of TB are about two weeks to
prolonged coughing, sputum, hematemesis, fever and others. There are individual
differences in the onset. In general, a person got infected with TB who has a strong
immunity will suppress the bacteria in the body for decades. The bacteria enter into a
dormant state, and it is prevented from developing further into the disease. On the other
hand, people with a weakened immune system are more likely to develop the disease.
Leptosome people, smokers, the like contained in the socially disadvantaged elderly,
homeless, and children are also likely to develop TB. TB bacteria are bred mainly in the
lungs, but may develop and spread to the spinal cord, the brain and others parts of the
body. Infections that occur outside the lungs are called extra-pulmonary TB. Also, there
are infant TB that infects children, HIV/AIDS complication of TB, and Multi
Drug-Resistance Tuberculosis (MDR-TB) that is caused by drug-resistance incomplete or
169
interrupted therapy cause. In this study, we focus on lung TB accounting for 80% of all
TB cases. There is sputum test to examine TB, which can be divided into smear test and
culture test. Smear test is the way to place sputum on a slide glass and stain it, for
detecting TB bacteria. The way of culture test is raising the bacteria in the sputum to
examine it. Sputum smear-positive patient who has positive reaction for TB bacteria can
be pointed out by sputum smear test.
4.2.2 TB and poverty
4.2.2.1 Status of TB in the world
The 6th goal of the Millennium Development Goals includes preventing the spread of TB,
as shown in Table4-1. It has improved compared to the 1990s, but the target value is still
far from what has been stated. DOTS in 6.10 of Table4-1 are an effective TB control
program recommended by WHO. The details about this are given in section4.4 TB is a
serious issue as it is included in the three major infectious diseases, along with malaria
and HIV/AIDS. According to WHO (2011), currently there are 128 people with TB per
100,000 people, and 15 people per 100,000 die from the TB in the world in 2010. The 22
high-burden countries that have been determined based on the height of TB prevalence
rate by WHO has been focused on developing countries of Asia and Africa. One of the
major causes of the spread is due to HIV / AIDS. HIV / AIDS patients are susceptible to
170
TB. These people have a weak immune system. At this point, we would like to present the
situation of TB in Japan. Japan is unique among developed countries about middle
epidemic country of TB where patients are increasing year by year. According to (WHO,
2011), the numbers of infected people are 27 per 100,000; out of which 1.5 people die per
year in 2010. Some of the factors are increase in the number of the elderly and the
socially vulnerable.
Table 4-1 The Millennium Development Goals 6: HIV/AIDS, Malaria, and other disease
Target 6. A Halt and begin to reverse, by 2015, the spread of HIV/AIDS
6.1 HIV prevalence among population aged 15-24 years
6.2 Condom use at last high-risk sex
6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge
of HIV/AIDS
6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged
10-14 years
Target 6. B Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who
need it
6.5 Proportion of population with advanced HIV infection with access to antiretroviral
drugs
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Target 6. C Halt and begin to reverse, by 2015, the incidence of malaria and other major
disease
6.6 Incidence and death rates associated with malaria
6.7 Proportion of children under 5 sleeping under insecticide-treated bednets
6.8 Proportion of children under 5 with fever who are treated with appropriate
anti-malarial drugs
6.9 Incidence, prevalence and death rates associated with TB
6.10 Proportion of TB cases detected and cured under directly observed treatment short
course
Reference: official development assistance of international cooperation (ODA), Ministry of Foreign Affairs of Japan as a reference
4.2.2.2 The relationship between TB and poverty
Looking at nature of TB, TB is big aspect of social disease. In particular, when
considering the circumstances leading to the disease TB, rather than the onset of a disease,
it is often connected to social problems such as poverty and social structure, and it is more
likely that it is deeply involved with the development of the disease. Figure4-1 shows
their relationships clearly.
As the cause of spread of TB in developing countries, including the urban poor areas
in the Philippines, there are three reasons in general. The first one is related to unsanitary
172
living environment. In fact, when we went to the urban poor areas in the Philippines, we
were able to observe the actual situation. Under these circumstances, access to safe water
is difficult, and people are living in overcrowded housing. Due to poor ventilation,
infection can easily spread to other people in the same household. The delay in the
detection of the disease, therefore it is easily to spread TB. The second reason is unstable
income. It becomes difficult to continue the treatment because the amount of one’s
income is insufficient to pay for treatment costs or transportation costs to hospitals.
Widespread TB in developing countries has a major impact on the economy due to the
concentration of TB cases being high among productive age groups between 15 years to
below 65 years. The poor becomes poorer because they use up all their money and
allocate it for medical/treatment costs. These circumstances lead to low productivity
because the time they spend working also becomes less and this results in reduced income.
Decrease in income leads to nutrient deficiency due to less food intake, and therefore
increases the risk of contracting infectious diseases including TB. The problem of poverty
is a vicious circle. This is described in Figure4-1. The third cause is the lack of knowledge
about TB. This is because poor people have less opportunity to receive education
compared to other people that are likely the reason for their lack of knowledge about TB.
Also, many people have wrong information about TB. In a survey conducted to
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inhabitants, some of the responses were "TB infection leads to death" or "getting infected
with TB is embarrassing".
Thus, TB is most closely related to various social backgrounds, and therefore we
should think of solutions that will solve not only TB but also social problems, including
poverty.
In the next section, we will explain a description of the present situation of TB in the
Philippines when we conducted a field survey and TB control programs.
Figure 4-1 TB and poverty linked in vicious cycle
Reference: Prepared by author based on a document of WHO (2002)
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4.3 The Philippine with TB
In this section explain about the present situation of the Philippines and TB control by
government.
4.3.1 The present situation of the Philippines
According to World Health Organization, The Philippines is the 9th in the top 22
high-burden countries of TB. In the Philippines, TB is still one of the common diseases.
According to the national TB prevalence survey in 1997, there are regional differences,
and the TB prevalence rate in the urban poor area is about 4 times higher than the rate in
the other urban area. It is clear that the TB situation in the urban poor area is alarming.
Table4-2 compared the TB situation in other Southeast Asian countries with in the
Philippines. It shows the highest infection country is China; second is Indonesia in 2010.
However, the highest diseased number per 100,000 populations is 275 people in the
Philippines. It points out as the highest number in the Southeast Asia, compare to 185
people in China and 189 people in Indonesia .So we can find that the Philippines has a
higher rate of people infected with TB than China and Indonesia. It is because these two
countries have larger population than the Philippines.
This is the reason why we focus on Philippines which urgently needs to improve the
TB situation in the urban poor area.
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Table 4-2 Major 22 high-burden country in the world
Country Total (number in thousands) Rate per 100,000 population
Prevalence incidence mortality prevalence incidence mortality
Bangladesh 610 330 64 411 225 43
China 1,500 1,000 54 108 78 4.1
Congo 350 220 36 535 327 54
Ethiopian 330 220 29 394 261 35
India 3,100 2,300 320 256 185 26
Indonesia 690 450 64 289 189 27
Nigeria 320 210 33 199 133 21
Pakistan 630 400 58 364 231 34
Philippine 470 260 31 502 275 33
South Africa 400 490 25 795 981 50
Vietnam 290 180 29 334 199 34
Reference: Prepared by author based on a document of WHO (2011)
4.3.2 TB control in the Philippines
The Philippine Department of Health has established the National TB control Program
(NTP) as TB control policy. It is a fourth revised version of the current state.
176
First, give an account of TB control. Today TB control has vision of a country where
TB is no longer public health problem, mission of ensuring that DOTS services are
available to the communities in collaboration with the local governments and other
partners, goal of 85% treatment success rate of the new sputum smear-positive TB cases
discovered and 70% case detection rate of estimated new sputum smear-positive TB cases.
Problems of TB are considered as one of the highest priority issues in the Department of
Health, moreover cooperation with various agencies such as international agencies, local
governments and NGO are needed for overcoming the problem of the TB control. The
government is currently offering some of free TB drugs or medicines of need in step for
tests and treatments.
Next, what kind of approach has been done for TB control until now in the Philippines.
Table4-3 explains that the main flow of TB control in the Philippines. In the Philippines,
TB control started with the establishment of a TB hospital in Quezon City in 1910.
However, treatment of TB at the time still had not been established, so treatment was
limited to patients only to rest and isolation. In 1930s and 1940s, due to the increased
number of cases, many of organized efforts had been seen. In the 1950s, the treatment of
TB had dramatically evolved all over the world. Also, since BCG treatment or MMR
vaccine containing the streptomycin-TB drugs had been introduced in the Philippines, TB
177
treatment had incredibly developed. In addition, TB centers were established in the
Department of Health, so TB diagnostic tests or x-ray inspection had been increased. In
1964, the first TB prevalence survey was conducted at Cebu. During the late 1960s and
the mid-1970s addition, TB was promoted by local governments, expanded to nationwide
TB.
Since 1968, it has been incorporated into general health services even TB, and health
centers and those branch offices mainly in the municipalities have been discovered and
treated patients. Patients with suspected TB because of symptoms such as cough more
than two weeks, need to go to the health center three times also take smear examination
performed in the laboratory. If the tests were positive, a patient would be registered with
the health department as a smear-positive TB patient.
In 1976, the National Institute of TB (NIT) was established, with supports of
UNICEF and WHO. In addition, the BCG vaccine was mandated the same year. In the
early 1990s, it was transferred to the jurisdiction of local health services from the
Department of Health. Therefore, local governments managed TB control programs and
provided services to the inhabitants through the Barangay5 Health Stations and local
health centers. In addition, because JICA introduced the DOTS TB control recommended
by the WHO in Cebu, testing equipment and data collection were improved. This measure
5Barangay is the smallest unit of government in the Philippine
178
became a showcase of new TB model. Then, for forming the assisted partnership such as
NGOs, government agencies, the private sector, unions and researchers, PhilCAT were
formed in 1994. In 1990, for TB control various sectors cooperated mutually and held
activity. TB control center is a reliable as early diagnosis and treatment of TB, therefore
DOTS (short-course chemotherapy medication directly confirmed) was introduced in
Philippine Department of Health as a national strategy for TB control since the late 1990s
for promoting TB control and striving to improve the treatment success rate and improved
case detection rates of TB. In 2003, for integrating TB control measures between the
private sector and government, Department of Health and PhilCAT promoted
Comprehensive and Unified Policy.
The Philippine Department of Health adopted Public-Private Mix DOTS (PPMD) in
TB control strategy, advocated to carry out TB control by cooperation with the public
sector such as health centers and the private sector such as NGO and private hospitals
since 2003. Philippines is becoming increasingly decentralized, has been delegated to
local authority policy implementation. However, because only local governments lack the
money and resources, it is considered to be effective that implement TB control in
collaboration with an NGO who has personnel and facilities, which is lack in the local
health centers.
179
Table 4-3 Transition of TB control in the Philippine
year History
1910 TB hospital establish in Quezon City
1964 First time about the TB prevalence survey in Cebu Island
1976 ・National Institution of TB(NIT) was established support by WHO and
UNICEF
・make BCG vaccine obligatory
1982-83 The first national TB prevalence survey conducted by NIT
1986 Health public and TB Control Service(TBCS)
In early
1990s
・Transfer of jurisdiction to local governments from the Department of
Health Services.
• Health implementation of DOTS in TB control was introduced by JICA in
Cebu.
1990 Financial assistance and technical cooperation in health development projects
in the Philippines for five years by Italian government and World Bank
1994 Government and NGO agencies, private sector, the establishment of a
cooperative partnership PhilCAT like to help researchers
1995 Government policy Preparation of guidelines for the diagnosis of TB
management and revision of the direction of TBCS
1996 ・Create of the National TB Day and the National World TB Day introduction
of DOTS in TB
・Department of Health implemented CRUSH-TB project through the DOTS
strategy
2002 • National TB Reference Laboratory (NTRL) was established
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2003 ・DOH and PhlilCAT cooperating to forward Comprehensive and Unified
Policy
・Adopted PPMD as a national strategy of TB by DOH
Reference: Made from DOH resource
4.4 Need for relationships between stakeholders in the TB control
programs
This section explains the current of global TB control programs and previous studies,
refer about relationships between the stakeholders in the TB control programs.
4.4.1 The current of global TB control programs
4.4.1.1 DOTS strategy
The chemotherapy of TB was established in the 1940s. Subsequently the numbers of TB
patients were decreased in developed countries. But the numbers have not been
decreased in developing countries, because the developed countries could not
effectively transfer the treatment techniques to the developing countries. In the 1970s,
the TB control programs including the microscopic examination, BCG vaccination, and
Direct Observed Treatment (DOT) were managed. In the 1990s, the pandemic of
HIV/AIDS and the increase of the patients of MDR-TB became serious. According to
M C Raviglione, A Pio (2002), the major socioeconomic crisis that happened with the
181
dissolution of the Union of Soviet Socialist Republics (USSR) made situations for the
USSR countries to have the following things: the deteriorated economic situation, the
existence of poverty, concentration of population, and malnutrition, which are favorable
to the transmission of the TB infection and the progression of infection to disease.
Through this worldwide of TB, TB control programs attracted global attention.
The International Union against TB and Lung Disease (IUATLD) promoted the TB
control programs that mainly focused on improvement of treatment success rate with
the effective short-course chemotherapy regimens, a regular supply of drugs, full
supervision of drug intake, and rigorous cohort analysis. According to Styblo, K (1989),
this approach showed that it was possible to achieve 80% treatment success rate in field
situations in Tanzania, Malawi, Mozambique, and in other poor countries. This
experience proved that effective case management of TB could be achieved in any
situation. In 1991, the two targets of a global TB case detection rate of 70% and a global
TB cure rate of 85% by 2000 were set in the 44th World Health Assembly. In 1993,
WHO declared TB a “Global Emergency”, which cautioned about the expansion of
damages from TB around the world. And in 1994, the DOTS strategy which is the base
of today’s TB control programs was recommended by WHO. The DOTS strategy
composed of five elements. They are sustained political and financial commitment,
182
diagnosis by quality ensured sputum smear test, standardized short-course anti-TB
treatment given under direct and supportive observation, a regular uninterrupted supply
of high quality anti-TB drugs, and standardized recording and reporting. This TB
control program is known as the most cost-effective way. The DOTS strategy was
adopted by at least 127 countries by 1999 and achieved great results. However the two
targets set by WHO had not been achieved. According to WHO (1998), the 22
high-burden countries of TB that were responsible for 80% of the global prevalence rate
became have a particularly severe problem. The coverage reached in many countries
was limited and only 23% of the estimated cases of infection worldwide were treated
under DOTS in 1999. As a consequence, nearly 80% of estimated cases of infection in
1999 still lacked access to rapid diagnosis and proper treatment.
The managerial challenge of TB control, therefore, was not that of adopting DOTS,
but rather of expanding coverage to all countries.
4.4.1.2 STOP TB STRATEGY
In 1998, a WHO ad-hoc committee was convened to discuss the global constraints to
widening TB control and to identify potential solutions. According to the resulting
report, the political will and commitment must be strengthened through increase social
mobilization and the technical consensus could be achieved by a global partnership with
183
non-governmental organizations (NGOs) or the private sector. Correspondingly Stop TB
Partnership was established by public/private sector, domestic/foreign and
organization/individual involved in TB control in 2001 (Mori, 2009). But the two
targets of a global TB case detection rate of 70% and a global TB prevalence rate of
85% by 2005 set by Stop TB Partnership also were not achieved. The TB case detection
rate and the TB cure rate have improved, but remain the two targets keep failing. The
problems that DOTS strategy could not solve emerge from the environment surrounding
TB in developing countries. They are fragile health systems and the lack of the budget
and human resources; inadequate diagnosis and treatment technique; the access to
health and medical service for poor, high immigrant population; lack of knowledge, or
bias to TB; and private medical institutions not implementing DOTS. DOTS strategy
lacks socioeconomic development and poverty programs, which are the most important
in providing health and medical service and the perspective of support to individual
patient (Ishikawa, 2007).
On the basis of these problems, Stop TB Partnership came out with Stop TB Strategy.
This strategy is based on DOTS strategy, but added six components were lacking. The
six components are to pursue high-quality DOTS expansion and enhancement, to
address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations, to
184
contribute to health-system strengthening based on primary health care, to engage all
health workers, to empower people with TB and communities through partnership, and
to enable and promote research. The stop TB Partnership is active with these goals
(Table4-4) to achieve the target 6th of MDGs.
Table 4-4 Goals of Stop TB Partnership
Goals
1 Achieve a case detection rate of 70% for new smear-positive cases and a
treatment success rate of 85%
2 Reduce prevalence and death rates by 50%, compared with their levels in 1990
by 2015
3 Eliminate TB as a public health problem, defined as a global incidence of active
TB of less than one case per 1 million popular per year by 2050
Reference: Made from Stop TB partnership
4.4.2 Previous study
Recently, the importance of network in the TB control programs is recognized. A
countermeasure for infectious diseases, including TB, conducted by one organization is
having a small impact. The partnerships as represented by Global Fight AIDS TB
Malaria Fund are promoted worldwide. Due to the presence of a coordinating
organization, which has the macro view of analysis advantages and disadvantages of
several donors in the network, both the effectiveness of this project and the TB control
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programs in the area are improving (Ishikawa, 2007). In many countries, especially in
Asia, the private sector is the dominant medical provider and the first part of call for
most TB patients. The quality of diagnostic and treatments in private medical
organizations is often substandard. According to Lönnroth etc (2010), the necessary
solution will have to include strengthened government stewardship of the private sector.
Kawahara( 2008) mentions that there is a need for private medical institutions of doctor
to get involved in the national TB control programs. And the TB control programs also
need involvement with NGOs and communities. A Mushtaque R Chowdhury (1999)
mentions that grass-roots NGOs are in the right position to hold over and entrench for
the communities. And NGOs facilitate the involvement with the communities by
cooperating with government. Atun, Weil, Eang and Mwakyus (2010) say that the two
major approaches are the use of community health workers and public-private mix
including use of NGOs or the private sector. They expand the access to treatment for
patients and the delivery of services, also improve treatment outcomes and coverage.
For examples include Cambodia, Bangladesh, Ethiopia and Pakistan. In Cambodia, the
health center with medical supervision by foreign NGOs earned inhabitants’ trust and
the number of the health center users have increased. In Bangladesh, a public-private
approach has enabled NGOs to have a key role in the NTP and has expanded access
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through community health volunteers (CHVs), cured patients who provide advocacy
and peer support, and private providers. In Ethiopia, community health workers have
been used widely to improve case detection and treatment success. In Pakistan,
community health workers have been used widely to expand TB control with the Lady
Health Worker Program. Public-private approaches have frequently been used in
high-burden countries of TB to improve care and outcomes, including Kenya, Indonesia,
Burma, Nigeria, Pakistan, the Philippines, and South Africa.
We introduce the projects that established the network in Zambia. According to
Yamada (2005), the characters of this project are involving the inhabitant’s group in the
TB control program. The network is established by JICA, ministry of public health,
health service bureau, health center, health worker, social worker, and CHV. The
activities among organizations are increasing awareness about TB in the communities,
promoting involvement with specialists, implementing DOTS, picking out the problems,
involvement with patients, empowerment of patients, establishing and promoting the
network, coordinating with NGOs, mobilizing the funds, advocacy, monitoring fund
management, development of human resources, and sharing information. As a result, the
analysis of the information gathering in this project was reflected in politics, and human
resources were ensured.
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According to these previous studies, the TB control programs need to be involved
with the various sectors like international agencies, global funds, central/local
governments, public/private medical organizations, NGOs, CHVs and so on. The
activities among partners are sharing information and development of human resources.
And the network needs the organization coordinating with the partners. The TB control
programs with the network show that improvement of the access to therapy and
knowledge. It also shows the improvement in case detection rate and treatment success
rate.
4.5 Case study of TB control in the Philippines
This section explains about outline of study in the Philippine, consideration from survey
results.
4.5.1 Study outline
4.5.1.1 Survey method
This study focuses on the network between stakeholders of the TB control programs.
This study targets two projects that have different types of the network between
stakeholders of TB control programs as study objects. First is “The TB Control Project
in Socio-Economically Underprivileged Urban Area in Metro Manila, The Philippines.
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‘Stop tuberculosis para sa Lahat’ PhaseⅢ” conducted by RIT/JATA Philippines,
Inc.(RJPI). Second is “Community-based Rehabilitation Project on Health and
Livelihood” conducted by I-CAN Foundation Philippines, Inc (ICAN). This field survey
interviewed to five organizations related to the projects and an inhabitant in the ICAN’s
action area, also this field survey had questionnaires to eleven CANOSSA’s staff and
twenty inhabitants in CANOSSA’s action area. The details of these organizations are
explained in the next section. Table 4-5 is the survey items used by our interview to the
organizations, and Table 4-6 is the survey items used by our interview to the inhabitants.
Our study had questionnaires that are the same in our interview’s content to get a lot of
information because our field survey had only short time.
Our study had done a comparative analysis of our field survey and previous study
with the three research questions; 1) who are involved in the programs and how are they
involved, 2) what relationships between stakeholders exist in the programs and 3) what
effect do such relationships between stakeholders have in the outcome of the programs.
A comparative analysis of these cases clarifies the effect of the different network on the
TB control programs.
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Table 4-5 Questionnaire to the organizations Survey items Objects
1
1
What is the present situation of TB in Manila and the
Philippines?
WHO, RJPI, DOH,
CANOSSA, ICAN
2
2
What kind of TB control programs have you
managed?
WHO, RJPI, DOH,
CANOSSA, ICAN
3
3 What is your role on the TB control program?
WHO, RJPI, DOH,
CANOSSA, ICAN
4
4 Who are involved in the programs?
WHO, RJPI, DOH,
CANOSSA, ICAN
5
5
How do you grasp the progress and disadvantages of
the TB control programs?
WHO, RJPI, DOH,
CANOSSA, ICAN
6
6
What relationships between the stakeholders exist in
the programs? /
How can TB control programs establish relationships
between the stakeholders?
RJPI, DOH, CANOSSA,
ICAN
7
7
What kind of difficulties did you have when you were
cooperating with the stakeholders?
RJPI, DOH, CANOSSA,
ICAN
8
8
What effect do such relationships between
stakeholders have in the outcome of the programs?
RJPI, DOH, CANOSSA,
ICAN
9
9
What kind of new association do you want to
cooperation with in future?
RJPI, DOH, CANOSSA,
ICAN
1
10
What are the future challenges about the TB control
programs?
WHO, RJPI, DOH,
CANOSSA, ICAN
Source: Made from questionnaire
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Table 4-6 Questionnaire to the inhabitants
Survey items
1 What is the present situation of TB in Manila and the Philippines?
2 Are there TB patients close to you?
3 If you suffer from TB, what will you do?
4 What is your daily life like?
5 Did you know about TB before you participate in NGO’s activities?
If so, when and where did you learn about TB?
6 How did you come to participate in the activities by NGOs?
7 How often do you contact with Canossa’s staff members?
8 What do you think is needed to treat TB?
Source: Made from questionnaire
4.5.1.2 Study object
There are briefs of study objects.
(a) “The TB control project in socio-economically underprivileged urban area in metro Manila, The Philippines. ‘Stop TB para sa Lahat’ PhaseⅢ”
This project has many stakeholders, but our study focused on three organizations (RJPI,
DOH, CANOSSA) that contributes to this project and could visit,
(ⅰ) RIT/JATA Philippines, Inc (RJPI)
Japan-Anti TB Association (JATA) has been providing human resources, technical
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assistance and project management on NTP project with JICA since 1992. The project
had finished in 2007, JATA established RJPI in 2008, and continue TB control programs
in the Philippines. RJPI has conducted the TB control programs with establishing the
network between NGOs, inhabitants organizations and public/private medical
organizations in the urban poor areas.
(ⅱ) Department Of Health(DOH)
DOH is the governmental organization and important health organization in the
Philippines. DOH has a responsibility to ensure the access to basic public health
services of the Filipino through providing quality health and medical services
constantly.
DOH instituted the National TB control Programs (NTP) that is public promises for
TB. NTP has worked out in public health center and hospital.
(ⅲ) CANOSSA
CANOSSA is catholic health center in Tondo, Manila where called urban poor area.
CANOSSA set out improving the community health by helping particularly poor and
patients.
(b) “Community-based Rehabilitation Project on Health and Livelihood”
(ⅰ) I-CAN Foundation Philippines, INC (ICAN)
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ICAN is established to improve children well-being in Japan in 1994. ICAN has
conducted education, medical care and increasing the livelihood. Our study takes up the
TB control program in Community-based Rehabilitation Project on Health and
Livelihood from 2007 to 2010.
(ⅱ) PICO
PICO is the cooperative association organized in ‘Community-based Rehabilitation
Project on Health and Livelihood’ by ICAN. PICO aims the inhabitants to make income
not collecting govern dumpsite but sustainable way.
PICO’s members were 80 Community Health Volunteers in 2008. PICO’s activities
are independent of ICAN’s activities like daycare, job training, pharmacy etc. All staffs
are allotted several parts. Each part holds the annual meetings. The meetings held
semimonthly, the leaders of several parts report and discuss about the activities and
management of funds. PICO is monitored by ICAN. But ICAN will transfer the
project to PICO. Instead of ICAN, PICO will conduct the project.
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4.5.2 Case study
4.5.2.1 “The Tuberculosis Control Project in Socio-Economically Underprivileged
Urban Area in Metro Manila, The Philippines. ‘Stop TB para sa Lahat’ PhaseⅢ”
This project started PhaseⅠ in 2008, PhaseⅡ in 2009 and PhaseⅢ in 2010. Then this
project had finished in 2011. Our study takes up the phaseⅢ.
This project conducted by RJPI aims to decrease mortality and prevalence rate by
2015 in Tondo, Manila and in Payatas, Quezon where are known as the urban poor areas.
And this project targets on improvement access to quality DOTS by 2010. Therefore,
RJPI set some indexes including the treatment success rate of new smear-positive is not
less than 85% in project areas, the registration rate of new smear-positive in the project
areas, increasing the case detection of new smear sputum by non-governmental medical
organizations like NGOs in project areas. The main activities are providing quality
DOTS service, establishing the network between the stakeholders and empowerment
through advocacy. RJPI established the referential system between the DOTS centers
and referential organizations. The main system is; the organization that found the new
patient hand over the referential form to go to DOTS centers, and the patient go to the
DOTS center. The patient gets a diagnosis by the sputum smear test. If the patient was
smear-positive, they start the treatment.
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And RJPI integrates the report from diagnosis to treatment to grasp the process from
diagnosis to treatment.
The following is the results of interview to the several organizations’ staffs. To the
question “What is the present situation of TB in Manila and the Philippines”, RJPI,
DOH and Canossa answered the Philippines is 9th of 22 high-burden countries of TB,
TB is the 6th cause of death in the Philippines. The stakeholders in this project are
WHO, global funds, DOH, CHD, health centers, RJPI, hospitals, clinics and NGOs.
RJPI monitors the partners by quarter. At which time, RJPI brings the local
governmental staffs to look the present situations, promotes understanding toward TB.
If the referential system did not work out, RJPI arranges a face-to-face meeting called
‘Tapatan’ for the concerned parties. The concerned parties check the referential systems
in the meeting. As a result, they became to refer smoothly. Therefore RJPI holds the
workshops. At the workshop, the delegates of several partners report them activities. To
the question “What kind of difficulties did you have when you were cooperating with
the stakeholders”, DOH answered political commitment, funds, human resources, and
community involvement. RJPI answered that the problem is health-seeking behavior.
Canossa was badly off human resources, but Canossa did not have the difficulties. To
the question “What effect do such relationships between stakeholders have in the
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outcome of the programs”, CANOSSA’s CHV answered “I took the effort to detect the
new TB patient” and “I got to know about what is possible for me to eliminate TB. To
the question “What kind of new associations do you want to cooperation with in future”,
RJPI answered church organizations. WHO, DOH, RJPI, Canossa answered active case
finding as the future challenges.
Table 4-7 Answer from WHO, DOH, RJPI and CANOSSA
1
Q: What is the present situation of TB in Manila and the Philippines?
A:
WHO: Estimate number of TB (all forms) is 1.9 million. Estimate number of deaths
due to TB is 260,000 in the Western Pacific.
DOH: The Philippines is 9th of 22 high-burden countries, 3rd in the Western Pacific
Region. And TB is the 6th cause of prevalence and mortality in the
Philippines.
RJPI: The Philippines is 9th of 22 high-burden countries. TB is the 6th cause of
mortality. The Philippines reached the Global targets of 70% Case Detection
Rate and 85% Success rate in 2006. There is the issue of Local Variance
Persists.
CANOSSA: The Philippines is 9th of 22 high-burden countries. TB is the 6th cause
of mortality.
2
Q: What kind of TB control programs have you managed?
A:
WHO: WHO don’t make a commitment to the individual projects outside the field
of the pilot projects.
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DOH: TB-DOTS in jails/prisons, indigenous populations, elderly, urban poor,
Public-Private Mix DOTS, community-based DOTS, CATCH-TB Project
and TB-LINC Project.
RJPI: ‘TB Control and Prevention Project in Socio-Economically Underprivileged
Areas in Metro Manila, the Philippines’
CANOSSA: Management of information and supply, DOTS, examine by
microscope
3
Q: What is your role on the TB control program?
A:
WHO: Collecting dates、policy making, providing technical assistances
DOH: Formulate plans, policies, to standards, advocate, implementation of oversee
programs, provide technical or assistance, monitoring, evaluating and
information analysis
RJPI: establishing the referral network, building the relationships between the
stakeholders, providing technical assistances, training, monitoring
CANOSSA: documentation, provision of information, implementing DOTS,
diagnosis with microscope
4
Q: Who are involved in the programs?
A:
WHO: international organizations, governments, NGOs
DOH: international organizations, Local Government Units, Private sectors
RJPI: DOH, CHD, NGOs, hospitals, health centers, clinics, volunteers, health
workers
CANOSSA: RJPI, JICA, health center, DOH. NGOs, MHD, PhilCAT, CHVs
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5
Q: How do you grasp the progress and disadvantages of the TB control programs?
A:
WHO: Exchanging information with each governments
DOH: No answer
RJPI: monitoring quarter, workshop, tapatan
CANOSSA: visitation, seminar/training, meetings, evaluation
6
Q: What relationships between the stakeholders exist in the programs? /
How can TB control programs establish relationships between the stakeholders?
A:
DOH: No answer
RJPI: No answer
CANOSSA: increasing the facilities.
7
Q: What kind of difficulties did you have when you were cooperating with the
stakeholders?
A:
DOH: Less political commitment, Issues on resources (Financial and human
resources), Health-seeking behavior, Less community involvement
RJPI: health seeking behavior
CANOSSA: Nothing. But mention to one, lack of human resources.
8
Q: What effect do such relationships between stakeholders have in the outcome of
the programs?
A:
DOH: decreasing the prevalence rate, 80% Case Detection Rate of new
smear-positive, treatment success rate of 90%
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RJPI: implementation the TB control programs.
CANOSSA: increasing the information, improving the treat programs, collaboration
with other NGOs, creating incentives.
9
Q: What kind of new association do you want to cooperation with in future?
A:
DOH: No answer
RJPI: church organizations
CANOSSA: all organizations (particularly private medical)
10
Q: What are the future challenges about the TB control programs?
A:
WHO: active case finding, addressing the risk populations.
DOH: Finding more and finding fast the TB cases, Addressing “difficult” and
“costly” groups of cases, Introducing, adopting and sustaining the new tools
for diagnosis, Addressing limited human resources, particularly at
implementing levels, Balancing partner’s support with their contribution to
the Program
RJPI: addressing the risk population, active case finding, obtaining consent from
patients and communities.
CANOSSA: active case finding, protect health workers against TB, diffusion of
knowledge.
Source: Made from questionnaire
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4.5.2.2 “Community-based rehabilitation project on health and livelihood”
This project has the targets that the inhabitants sustain adequate health environment
personally, go forward localizing the health project. ICAN strengthened grouping the
inhabitants, and established a cooperative association. ICAN gives the management of
health project to the cooperative association. ICAN supports PICO function as the main
actor of not only health program but improvement of livelihood program. This study
focuses on TB control program in the health program.
The following is the results of interview to ICAN staff. To the question “what is the
present situation of TB in Manila and the Philippines”, ICAN answered the numbers of
death by TB are 75 people per day in the Philippines. TB is the 6th cause of death in the
Philippines. The inhabitants answered TB is spread in the area, bias to TB and lack of
knowledge. The main TB control programs are supply of milk and supplement, health
education, home visitation and feeding. ICAN’s roles of the TB control programs are
coordinating assignment with the health center and superintendence of PICO. The
stakeholders in this project are health centers, health services bureau, JICA and Orione
foundations. It can be said that the grass-roots TB control program is conducted.
Because PICO consists of inhabitants, conducts the meetings with patient monthly and
does home visitation, health education. To the question “What kind of difficulties did
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you have when you were cooperating with the stakeholders”, ICAN answered lack of
medicine and human resource, constant change of the health center staffs. To the
question “What kind of new associations do you want to cooperation with in future”,
ICAN answered government and private sectors. To the question “What are the future
challenges about the TB control programs”, ICAN answered case finding as soon as and
funds. PICO could not conduct the enough TB control programs by limiting of times
and funds at present.
ICAN has held the monthly meetings named Barangay TB Management Council
(BTBMC) in 2011 to share the information. The participants are barangay chairman,
health centers, NGOs conducting the TB control programs, doctors in Payatas. Then, the
new TB control programs are designed
Table 4-8 Answer from ICAN
1
Q: What is the present situation of TB in Manila and the Philippines?
A: The number of deaths due to TB stands at an average of 75 Filipino
everyday. Diagnosed as curable, it ranks 6th among the top leading
causes of mortality and morbidity in the Philippines. DOH reported
a decrease in the number of mortality due to TB from 38.2 deaths
per 100,000 populations to a rate of 31 per 100,000.
2
Q: What kind of TB control programs have you managed?
A: Supplemental feeding, milk and multivitamins supplement, health education
session, house visit.
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3
Q: What is your role on the TB control program?
A: Coordinate with Bgy. Health Center. Orient and talk to patient and their
family members, Provides tasks and supervise CHV in-charge, monitors
records and medicines, follow-up patients.
4
Q: Who are involved in the programs?
A: The treatment partners, Bgy. Health Center, CHV, JICA, JATA, Orione
foundations, PICO
5
Q: How do you grasp the progress and disadvantages of the TB control
programs?
A: No answer
6
Q: What relationships between the stakeholders exist in the programs? / How can
TB control programs establish relationships between the stakeholders?
A: Visit and coordinate with organizations, joining conference and seminars,
partnership with Quezon City Health Office, monthly meeting with TB
patient, house visit with treatment partner, health education with the patient.
7
Q: What kind of difficulties did you have when you were cooperating with the
stakeholders?
A: No enough supply of medicines, lack of health staff and health facilities,
transition of staff, schedule or availability of the patient for the medication
and appointment for laboratory test, financial limitation on laboratory fees and
transportation, misinformation or lack of about TB, social stigma on people
with TB, different priorities, never give-up vices like smoking and drinking
alcohol that will hinder the effect of medicines.
8 Q: What effect do such relationships between stakeholders have in the outcome
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of the programs?
A: Having a confidence
9 Q: What kind of new association do you want to cooperation with in future?
A: Government and private agencies.
10
Q: What are the future challenges about the TB control programs?
A: Increase rate of MDR-TB, lack of funds from LGU for diagnosis and
treatment of TB, more trainings on management of TB program.
Source: Made from questionnaire
4.5.3 Consideration
In this section, we explain the answer of three research questions and the sum of our
research. Before that, it states that there is the difficulty of treating network that we
can’t see. It takes long time to bother what can it be said between organizations in
cooperate. Should just know each organization? Should measure frequency to contact
between institutions? And so on. What was very useful in this study are interview and
questionnaire for persons concerned with the project. Based on the information
provided from persons concerned with the project and the contents that were
investigated in Japan, we want to inspect what kind of influence a network had on TB
control program.
First, here we clarify the research question 1) who are involved in the programs and
how are they involved? Through the study in Japan and field survey, we could get so
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much information. About the case of RJPI, we could survey in Japan what kind of
stakeholders is concerned before field survey. And among the field survey, we surveyed
actual situation. About the case of ICAN, we surveyed most in Philippines and after
returning Japan because there was no time to spent survey before going to Philippines
for convenience of appointment. But, because this case is comparatively small, we met
various stakeholders in the Philippines and we could get so much information.
In the both cases, we learned that there are not only medical organizations but also
many related stakeholders while there are differences of stakeholder’s number. In the
case of RJPI, Global funds, WHO, central/local governments, health centers, health
service bureaus, public/private clinics, inhabitants and so on are related as stakeholders.
In the case of ICAN, Global fund, WHO, central/local government, health center, health
service bureau, public/private clinic, inhabitants, CHVs and so on are related as
stakeholders, too. Each case can be seen to cooperate with DOH that centre government
gives medicine and local government join the case. But there are differences between
the numbers of related stakeholders while each case relates similar stakeholders. In the
case of RJPI, RJPI is being professional for the role of coordination, which acts as an
intermediary between government and local institutions. There is cooperation system
include local coordination institutions. On the other hand in the case of ICAN, ICAN
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also cooperates with government, and more, ICAN acts as an intermediary between
institutions and supports the activity of PICO. ICAN works in a wide range of areas.
Most of previous studies in section4 explain the importance of cooperate with various
institutions on the recently projects of TB control and health. For example, A
Mushtaque R Chowdhury (1999) says the importance that local NGOs involve in TB
control programs. Atun, Weil, Eang and Mwakyus (2010) say that private organizations
including the NGOs became cooperate with the government and the outcome of the
treatment would spreads. This trend can be seen in global TB control programs by
WHO and in the National TB control Program by DOH in the Philippines. And, on
National TB program in Cambodia, Bangladesh, Ethiopia, Pakistan, Zambia and so on,
various organizations actual relates to TB control program, which is WHO, foreign
government, central /local government, public/private clinic, NGOs, inhabitants,
community and so on. The point is the existence of private clinic. According to previous
study of Zambia, it is clear that private clinic has important place in TB control program.
Kawahara says the importance too. But it could say not to enough emergence of private
clinic on the each case we surveyed.
Second, we clarify the research question 2) what relationships between stakeholders
exist in the programs? Especially, through the interview and questioners for local people
205
in the Philippines, we could get so much information. In the case of RJPI, the system to
deal with various problems is already established, which government inspects the field
with NGO staff and RJPI coordinates the meeting if there is problem. RJPI organizes
the workshop to share information regularly. And CANOSSA, we visited to in the field,
make a home visit to TB patient who didn’t come to office to take medicine. CANOSSA
supports continually DOTS. RJPI gives equipment and material based on JICA. DOH
also gives facility and materiel for free. In the case of ICAN, there is meeting to share
information. In addition, since September 2011, the staff of the local public health
center, NGO which actives for rerated TB, doctors in the area and so on gathers and
conducts a meeting for sharing information to think about the TB problem of the vast
area.
In others, the activity for development of human resources to CHVs is carried out in
the both cases, too. In the previous study of Zambia as we explain in 4.4.2, the necessity
of sharing information in such a meeting and the development of human resources is
expressed to effect. Ishikawa states that it is effective in TB control program that there
is a coordination organization in a network. In addition, it is said the importance of
development of human resources in a case. Because according to lonnorth (2010), it
cannot be said that all has enough quality in the private medical organization.
206
Finally, we clarify the research question 3) what effect do such relationships
between stakeholders have in the outcome of the programs? The answer here sum
comprehensively based on working papers, interview and questionnaire on the field
survey. In both cases, the number of the case detection and treatment success increase,
and it can be said to be effective TB control program. And a network of stakeholders is
how affected this, at first, point worth making is the case detection of patient. All
institutions where we interviewed stated that the most important problem is the case
detection of patients. DOH has realized to need local community and the NGO rooted in
the community in order to detect patient, and the importance is explain in the global TB
strategy by WHO. Because most of the poor do not go to the hospital as has been
understood above from the investigation of Kawahara in the previous study and an
interview to WHO on the spot. Therefore it is difficult to detect the TB patient who is
the poor with special needs. About this, RJPI is going to detect more patients by
carrying out a project with local NGO. In addition, it is possible to put cooperation with
more NGOs or the private medical organization. ICAN moves the weight of the activity
of the TB control program at the organization called PICO by inhabitants. As explain
the previous study of Bangladesh and Zambia, in this way, poor develop confidence in
the TB control program and TB control program become more effective. In addition, by
207
interview on the field survey, it was found that this activity adds incentive to spread this
more and contribute to cure a patient more for CHVs who are same poor. In this way,
the effect of TB control programs is not only treatment success rate and case detection
rate are increase as outcomes of TB control programs but also a wide variety effect.
As observed above, it is effective for TB control program to cooperate with various
stakeholders. Following is a summary of what has been researched about both cases and
what has been compared with previous studies. Both cases have a similarity that there
are various stakeholders from the international organization to inhabitants and they
share information by having a meeting regularly in that. Both cases have activity of
personal training, too. Both cases have been effective as TB control program.
Meanwhile, as difference, both cases have difference of the effect and width of the
activity from a difference of the number of the collaboration organizations. And, both
cases have coordinator but the way of coordination is difference. The entry situation to
the TB control program by the private medical organization is different too.
4.6 Conclusion
In this sections summarize what we had discussed so far and explain the conclusions of
our study.
In the 1990s, especially aggravated the spread of TB in developing countries, WHO
208
has recommended DOTS which is the most effective TB control program. By the grace of
DOTS, the TB situation in the world was much improved, but the high prevalence of TB
was still a serious situation in the 22 high-burden countries of TB. Thus the new Stop TB
Strategy was announced in 2005. This strategy, targets an individual patient, those close
to the patient, family, and neighbors that based on DOTS have set to work on the issue. In
addition, activities involving health workers are urged to enhance cooperation. The turn
out of being close to an individual patient or TB control had important works with many
stakeholders from this strategy. So our study is devoted to stakeholders among
networking, and a survey conducted for the two cases have been in cooperation with
various stakeholders in the Philippines. Our study visited their cooperation organizations,
conducted surveys and interviews. It follows from the results found in previous study and
field survey in the Philippines. This includes previous study dealing with importance of
WHO and foreign governments, the country's central or local governments, public and
private medical organizations, NGOs, local inhabitants and their community involvement
in a variety of global TB control and meeting between their organizations to exchange
information or coordinate network formation with various stakeholders. In addition,
studies about two projects that were conducted in cooperation with organizations in
various sectors like previous study, and meetings for those various stakeholders were
209
conducted. These things were common throughout the previous study and case studies. In
both projects, DOTS has increased the number of patients with successful detection and
treatment of TB, can be said is valid. Both projects have received the drugs and
equipment such as provided free of charge for those that interact with government and
other organizations. From previous study, TB cooperation between the organizations
made a greater impact by working to win high credibility about TB control from being
involved with inhabitants themselves, and by increased numbers of patients with
successful detection and treatment. These previous studies were also found to be common
throughout the case. Using different networks in TB control, the difference in effect size
and spread of activity that has been the same effects is presented. This factor, involving
various stakeholders, coordination between the partners and development of human
resource were common in the previous study and case study.
On the other hand, the difference in the case study and previous study was whether
or not the network was contained in private organizations. In previous studies,
participation in private hospitals was stated to be critical. From this, future work in the
Philippines is the entry of private hospitals, and entry to TB control programs that is
considered to contribute to improve a case detection rate.
From the above, relationships between stakeholders, said to be a valid approach to
210
TB control. It is important to cooperate with all organizations involved in the treatment
of TB found in laboratory diagnosis. Organizations to distribute throughout the country
for TB control system, authority to oversee the medication and treatment of inhabitants,
and organizations that mediate respective roles of various stakeholders have been
measured together. Our study has hope in the opportunity to think about the problems
of TB in the Philippines, plus developing countries.
211
References
Abmad N. (2003), Voice of Stakeholders in the Health Sector Reform in Bangladesh,
World Bank.
Atun, R. D. (2010), Health-system strengthening and tuberculosis control, THE LANCET,
Vol 375, 2169-2178.
Chowdhury, A. M. (1999),Success with the DOTS strategy, THE LANCET, Vol 353,
1003-1004.
Grange, m. J. (1999), Paradox of the global emergency of tuberculosis, THE LANCET,
Vol 353, 996.
Ishikawa N, K. M. (2007), kekkaku kara mieru ningen no anzenhosyou(Human Securith
with a View of TB Control Projects), Japan International Cooperation Agency
Research Institute.
Kawahara, K. (2008), Philippine kyouuwakoku no hokeniryoujijyou to
iryouhokenjijyou(Health Situations and Medical Insuarance System of the
Philippines), Iryo To Shakai(medical care and Society), 18(2), 189-204.
LönnrothK. G. Castro, J. M. Chakaya, L. S. Chauhan, K. Floyd, P. Glaziou and M. C.
Raviglione.K.,. (2010), Tuberculosis control and elimination 2010–50: cure,
care, and social development, THE LANCET, Vol 375, 1824-1829.
Ministry of Foreign Affrica of Japan. (2012), International Cooperation, Retrieved from
Official Development Assistance:
http://www.mofa.go.jp/mofaj/gaiko/oda/doukou/mdgs.html
Mori, T. (2009, 11 15),wagakuni no kekkaku taisaku no genjyou to kadai 12 kekkaku
taisaku no aratana senryaku (Our country TB control of situation and problems
aThe new TB control Strategy-Stop TB Partnership),
nihonkousyuushi(Japanese Society of Health), 56(11).
212
Partnership, Stop TB. (2011, 12), kekkaku ni tsuite (About TB), Retrieved 10 2010, from
Stop TB Partnership: http://www.stoptb.jp/about/dots/
Raviglione, C. M. (2002, 3), Evolution of WHO policies for tuberculosis control,
1984-2001, THE LANCET, Vol 359, 775-780.
Styblo, K. (1989). Overview and epidemiological assessment of the current global
tuberculosis situation with an emphasis on control in developing countries.
OXFORD JOURNAL.
Tao, Y. (1997), kekkaku ha ima (Today's TB), Bungei Sya.
The Department of Health. (2005), The NTP Manual of Procedures, DOH.
United Nations. (2010), The Milleunnium Development Goals Report 2010, United
Nations.
WHO. (1994), Framework for effective TB control, WHO.
WHO. (1998), Global TB Control-WHO Report 1998, WHO.
WHO. (2002), Community Contribution to TB Care: an Asian Perspective, WHO.
WHO. (2002), Global TB control-surveillance, planning, surveillance, WHO.
WHO. (2009), Global TB Control-epidemiology, strategy, financing, WHO.
YamadaN. (2005), HIV/AIDS projects to kyoudousita chiiki DOTS no arikata-Zambia
Lusaka City no torikumiyori-DOTS: Service extension to communities in
conjunction with HIV/AIDS Control Project(JICA) in Lusaka, Zambia: A
observation report, Journal of Amori University of Health and Welfare, 6(3),
309-314.
Analysis and Conclusion
Seoungho Kim
215
Analysis
As referred to in the introductory chapter, this study focused on stakeholder cooperation
and education in the four themes (mother and child care, sanitation, nutrition, infectious
disease). In this chapter, we analyze the four themes based on the two focuses.
Stakeholder cooperation
First of all, we analyzed the effectiveness of peer education in chapter 1, which observes
the field of maternal and child health. In order to conduct peer education, international
organizations like UNFPA planned the program, public sector like schools and regional
government engaged in adopting the program, and NGOs provided education. Various
stakeholders were involved in the execution of peer education, and they contributed to
improving access to reproductive health by leveraging their strengths. In the Philippines,
which has the same situation indicated in the previous studies of stakeholder cooperation,
government and NGO were involved in the field of maternal and child health. They plan
to improve the situation by coping with barangays and local communities.
In the next place, sanitation facilities are pubic goods. However in the current
situation, it is difficult to distribute sanitation facilities throughout the country just by the
public sector. Therefore, supports from private sector are important for the distribution to
216
the poor. Efforts in adopting appropriate technology with the high regard for low cost and
cost-benefit are required in order to disseminate facilities throughout the country. In the
Philippines, private sector, like NGOs, and public sector, including the Department of
Education and regional government, plan to improve the sanitation situation by coping
with schools and communities. Public sector is beneficial in financial assistance,
distribution of supplies, and school education. By comparison, private sector makes effort
to diffuse sanitation facilities using low-cost and appropriate technology to schools and
communities.
Next, we discussed the possibility of private-public partnership in the nutrition field
in chapter 3. We looked into cooperation among stakeholders, for example government
and companies, companies and NGOs, and government and NGOs. Although PPAN,
taken up in 3.4, is a governmental policy implemented by NNC, companies and NGOs
related to nutritious issues also work in the plan. Filipino government gets technical and
financial assistance from foreign capitalized companies like Ajinomoto. On the other
hand, it supports local companies for nutritious improvement by tax reduction and
technical assistance. Whereas the previous studies refers to the importance of cooperation
between government and NGOs based on literature and hearing, it did not research the
actual relationships.
217
Last of all, in the field of infectious disease, tuberculosis is a particular disease which
requires surrounding recognition of tuberculosis for its solution, as it was expressed in the
previous research. Also, cooperation among various stakeholders including public sector,
private hospitals, and NGOs deeply rooted in the region is crucial for the solution. As it
was referred in the previous research, NGOs have close relationship with local
communities and assume significant role in tuberculosis treatment, which necessitates
lasting supervision. Therefore, the government assimilates tuberculosis countermeasure
into its policy and tries to tackle tuberculosis issues with supports of private hospitals,
NGOs and local communities. Through on-the-spot investigation in the Philippines,
importance of both public and private sectors was clarified.
Education
Firstly, the approach called peer education, which we have dealt in chapter 1, is an
educational approach for improving maternal and child health. As you may notice from a
speculation of the fourth research question, peer education not only improved the
knowledge of its participants, but also changed their awareness and actions. Since
environment sensitive to sexual issues exists in the Philippines, familiarity is a huge
advantage of peer education and it enhanced the effectiveness of education. Thus,
education holds significant potentiality and it is an important key for the problem solving
218
in the field of maternal and child health, as it was seen in the previous studies. On the
other hand, we could also hear opinions that improving access to health services is the
most urgent issue. We have recognized that more comprehensive approach is
indispensable.
In addition, education is an important issue in the field of sanitation. Through our
study, we verified that formation of hygienic habit via education is considerable, as it was
expressed in the previous studies. Various stakeholders conducted hygienic education in
schools and communities in order to form hygienic habit. Moreover, enlightenment
activity to the people concerned with diffusing sanitation facilities promotes development
in sanitation awareness of citizen and stakeholders. It also leads their participation to
projects to diffuse sanitation facilities and contributes to the solution of sanitation
problems.
Furthermore, education also assumes substantial role in nutritious improvement. As it
is referred in previous studies, lack of nutritious knowledge causes unbalanced nutrition
intake and consequently induces malnutrition. In order to resolve inadequate knowledge,
education is necessary. As we have seen the possibility of improving recognition
concerned with nutrition through case analysis of 3.2.3.3 in chapter 3, nutritious
improvement project and advancing visibility of nutrition is essential in the field of
219
nutrition.
Lastly, it is true that approaches from government, hospitals and NGOs are critical to
spot and treat tuberculosis, but citizens also need to understand what tuberculosis is and
put efforts in medical treatment. To do so, education and advocacy campaigns dealing
with health and diseases within the community are required. Through these activities,
knowledge of the citizens improves, as it was mentioned in the previous studies.
220
Conclusions
This research pays attention to relationships among stakeholders and education. Based on
the on-the-spot investigation, it examines and analyzes the four topics in the field of
health and sanitation: maternal and child health, sanitation, nutrition and infectious
diseases.
Ahmad(2003), a preceding study which focuses on child health, reproductive health
(RH), and countermeasures of infectious disease among various health and sanitation
problems in Bangladesh and analyzes those topics based on the opinions of stakeholders,
is referred to in this research to set the topics and focuses. We researched into maternal
and child health, sanitation, nutrition, and infectious diseases to improve the health and
sanitation problems.
As for the focal point 1, relationships among stakeholders, we referred to
Ferranti(2004), which is about the roles and partnerships of public and private sectors.
This preceding study describes that both public and private sectors have their roles in the
field of health and sanitation and cooperation between them is important. Concerning the
second focus, education, we referred to World Bank (2005), which insists that education
is important to improve health and sanitation issues, and explains the methods of health
221
and sanitation education in developing countries.
According to the preceding studies, this thesis takes up the four topics: maternal and
child health, sanitation, nutrition and infectious diseases. The problems related to these
topics are very serious in the Philippines. Mainly because of the influence of religion, the
national framework of RH is needed to cope with the RH problem. The low diffusion rate
of sanitary facilities is a severe sanitation problem in the Philippines. Moreover, hunger
and micronutrient deficiencies exist and tuberculosis is still common. Urgent action is
necessary to overcome these problems.
In this way, we paid attention to relationships among stakeholders and education in
maternal and child health, sanitation, nutrition, and infectious diseases, and carried out
analysis in each chapter. Through the on-the-spot investigation, we found out that peer
education improves the knowledge of RH and changes the action and behavior of people.
As for sanitation, we focused on diffusing sanitary facilities and making the practice of
using them through education. In the Philippines, the roles of the private sector to
improve and diffuse sanitary facilities are essential because the government cannot
diffuse sanitary facilities on its own. Furthermore, it is necessary to adopt the habit of
using them. Education is the key to improve the situation. Regarding nutrition, we
focused on public-private partnership for nutritional improvement of the Filipinos. There
222
are various forms of cooperation between public and private sectors and both sectors
direct their energies to improve nutrition. About infectious diseases, we discussed the
possibility of cooperation among stakeholders in measures for tuberculosis through the
two case studies. The various stakeholders are involved in the tuberculosis control
program, such as the governmental organizations, the organizations which observe the
patients to take the drug, those who connect each stakeholder, and local communities.
Each of them has its own role and the cooperation between them is important.
The focal point 1, relationships among stakeholders, is proved to be essential for
improving health and sanitation problems. Various stakeholders are working together and
utilizing each advantage to improve the situation. Peer education as a method to improve
the access to RH was examined in the maternal and child health issue. In the research, the
examples of peer education in schools and communities provided together by
international organizations, governments, and NGOs were observed. About sanitation, it
was difficult for the public sector to diffuse sanitary facilities on its own due to financial
restrictions, so the technologies of the private sectors largely NGOs, such as the low cost
technology, are needed. The importance of public-private partnership in nutritional
improvement was shared among governments, companies, and NGOs and various
nutritional improvement projects were carried out. The possibility of improving the state
223
of infectious diseases through the partnerships of the central and local governments,
private hospitals, and NGOs was also investigated. As mentioned in Ferranti (2004),
which is related to the first focus, relationships among governments, private companies,
NGOs, and communities is the key for development in developing countries. Of course,
there is a limitation. For example, lack of awareness by governments and differences in
objectives between organizations are the common problems among four topics. The
solutions for these problems could be further researched.
The focal point 2, education, could make people realize the problems of health and
sanitation. Peer education was effective not only for the adolescents but also for a wide
range of age groups involving twenties. The improvement of knowledge and the positive
changes of action and behavior were observed. Sanitation education changes the
behaviors of local people and makes the stakeholders aware of the need of sanitary
facilities, which leads to their diffusion. The problems of the misunderstanding of
fortified food and the lack of knowledge are serious, so nutrition education should be
offered. Since the lack of knowledge on tuberculosis prevents complete recoveries, the
improvement of knowledge on infectious diseases is the key. Therefore, as stated in
World Bank (2005), the importance of education and its positive effects were proved.
However, this research had limited time and case studies. The on-the-spot
224
investigation was only two weeks long and the target areas were limited in Metro Manila
and its suburbs. The number and range of visited international organizations,
governmental organizations, companies, NGOs, schools, and communities were also
limited. We also researched into just the small parts of each topic. Maternal and child
health has other problems such as the approaches to improve the health of pregnant
women and infants. As for sanitation, this research could not go further into the work of
companies to diffuse sanitary facilities. About nutrition, the work of NGOs and domestic
companies, and nutrition problems in communities were not clear.ly observed In the
research of infectious diseases, although most of the patients are in the lower class,
enough interviews with them were not conducted. In conclusion, this research does not
cover the whole health and sanitation problems in the Philippines. Therefore, it is difficult
to generalize the research result. The further research involving more study cases,
detailed examination, and comparative analysis is needed.
225
References
Ahmad, N. (2003). Voices of Stakeholders in the Health Sector Reform in
Bangladesh : Building Capacity for Reform. In A. S. Yazbeck, & D. H. Peters
(Eds.), Health Policy Research in South Asia (pp. 369-400). Washington,
D.C.: World Bank.
Ferranti, D. (2004). Public and Private Roles in Health: Theory and financing
patterns. In P. Musgrove (Ed.), Health Economics in Development (pp.
35-76). Washington, D.C.: World Bank.
The World Bank. (2005). Improving health, nutrition, and population outcomes in
Sub-Saharan Africa : the role of The World Bank. Washington, D.C.: World
Bank.
Appendixes
Schedule for Field Survey
in the Philippines in 2011
Visiting List
229
Schedule for Field Survey in the Philippines in 2011 HAYASHI Seminar, Chuo University, Tokyo, Japan
DATE AM PM
28-Aug (Sun)
Flight PRO431 (Terminal 2)Narita to Manila Oxford Suites
Durban Corner P. Burgos Streets, Makati City 1200,Philippines PHILIPPINE AIR LINE 9:30
- 13:10
29-Aug (Mon)
Asian Development Bank(ADB) (8:30-13:30)
<Ms. Harumi Kodama>
Headquarters: 6 ADB Avenue, Mandaluyong City
1550, Metro Manila, Philippines
30-Aug (Tue)
The Philippine Center for Water and Sanitation (PCWS)
(14:00-17:00)
< Ms. Lyn N. Capistrano>
Penthouse 3, Minnesota Mansion267 Ermin Garcia Street,
Cubao1102 Quezon City
31-Aug (Wed)
Food and Nutrition Research Institute (FNRI)
(8:30-11:30)
University of the Philippines Diliman
<Dr. MARIO V. CAPANZANA>
(14:30-18:30)
DOST Compound, Bicutan, Taguig City
U.P. Campus, C.P.Garcia Avenue, Quezon City
230
DATE AM PM
31-Aug (Wed)
United Nations Population Fund
(10:00-)
< Ms. Arlene Calaguian Alano> 30th Floor, Yuchengco Tower 1
RCBC Plaza, 6819 Ayala Avenue
1229 Makati City
01-Sep (Thu)
Canossa (local NGO) (13:30- 17:00)
<Sister Eline Pascaldo>
E.Jacinto St., Magsaysay Village, Tondo, Manila
02-Sep (Fri)
Health Human Resource Development Bureau Department of Health
UNICEF Philippines
(8:30-12:00)
<Ms. Jackeline Acosta、 Ms. Dinna Sane >
<Mr. Timothy Grieve>
San Lazaro Compound, Sta. Cruz, Manila
31st Floor, Yuchengco Tower,Rizal Commercial B anking Corporation (RCBC)
Plaza, Ayala Avenue corner Gil Puyat Avenue, Makati City,
Philippines
03-Sep (Sat)
Family Planning Organization of the Philippines(FPOP)
(9:00-12:00) National office
I-CAN Foundation Philippines, INC
<Mr. Gessen Rocas> <Ms. Yukiyo Nomura >
50 Doña Hemady St. New Manila, Quezon City 1112
Philippines
38 Don Doroteo Street, Don Enrique Heights, Brgy Holly Sprits, Quezon City, Metro
Manila, the Philippines
231
DATE AM PM
04-Sep (Sun) Internal Meeting
05-Sep (Mon)
Olongapo City Hall / UNFPA Field Office WASH meeting
<Dr. Angel Umali > <Mr. Timothy Grieve>
Rizal Ave, Olongapo City
Usec Quijano's Office Department of Education
4F Bonifacio Bldg., DepED Complex, Meralco Ave., Pasig City
Philippines
06-Sep (Tue)
Japan Anti-Tuberculosis Association (JATA)
(9:30-11:10)
Cent for Advanced Philippines Studies(Caps)
<Ms. Mami Kon> <Mr. Dan Lapid> 1853 Tayuman Road, Manila,
Metro Manila, Philippines 120-A K-8th Street, East Kamias,
Quezon City, Philippines 1102
07-Sep (Wed)
Family Planning Organization of the Philippines(FPOP)
(9:00-15:00)
AJINOMOTO PHILIPPINES CORPORATION
(14:00-17:00)
<Mr. Gessen Rocas>National office <Ms. Ecille Go>
50 Doña Hemady St. New Manila, Quezon City 1112
Philippines
331 Sen. Gil J. Puyat Avenue, Makati City
Bagong Ilog elementary School.
<Ms. Irene Mercado>
Bagong Ilog Elementary School, Bagong Ilog, Sgt.L.Pasua, Pasig City, Metro Manila, Philippines
232
DATE AM PM
08-Sep (Thu)
World Health Organization(WHO)
<Dr. Kenji Amamoto>
Western Pacific Regional Office PO Box 2932 (United Nations Avenue)
1000 Manila, Philippines
09-Sep (Fri)
Flight PRO432 Manila to Narita
PHILIPPINE AIR LINE
14:30 – 19:55
233
Visiting List
Maternal and child Team
Place: UNFPA National Office Date:2010/08/31
Interviewee(s):Ms. Arlene Calaguian Alano/Mr.Mario Balibago/
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of peer education project
Contents :
■ To get detailed information of peer education projct
■ To get information of present situation about RH of the Philippines
Place: Family Planning Organization of the Philippines National
office Date:2010/09/03
Interviewee(s):Mr. Gessen Rocas/Mr.Brayant Gonzales
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of the peer education project
Contents:
■ Presentation of the YES4YES Project
■ Interview with Peer Educators and Youth Volunteers
■ Interview with Youth Clients
234
Place: The Olongapo City Date:2010/09/05
Interviewee(s):Dr. Angelito Umali
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose:
■ To know the experience of peer education in Olongapo City
■ Visit to UNFPA Field Office
■ Briefing at Dep. Ed Division Office
■ Field Visit: Kalalake National High School School-based Teen Wellness Center
and ALS Center
■ Field Visit: Barangay Banicain Community-based Teen Wellness Center
■ Field Visit: Social Ddevelopment Center(VAWC Referral Center)
■ Courtesy Call and Dialogue with mayor James Gordon Jr.
Contents:
■ Q&A session with school faculty and peer educators(students)
■ Meeting with Village Officials and Out-of-school youth
■ Interactive disucussions with the facility social workers and youth residents
■ Q&A session with Mayor on RH Programs in the city
Place: FriendlyCare Clinic Date:2010/09/06
Interviewee(s): Ms.Lourdes A.Manuel
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose: To get information of the peer education
Contents:
■ Presentation
■ Interview
■ Inspection of a facility
235
Place: Family Planning Organizationof the Philippines Pampanga Clinic Date:2010/09/07
Interviewee(s):Mr.Brayant Gonzales Group: Maternal and child health Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita Purpose: To get information of the peer education Contents: ■ Interview Youth Clients, Peer Educators, Volunteers and Service Providers
Place: WHO Pacific Regional office of the Philippines Pampanga
Clinic
Date:2010/09/08
Interviewee(s): Dr.A.Kaptiningsih
Group: Maternal and child health
Interviewers: Moe Sasaki/Kimihiro Kato/Moe Suzuki/Ayako Shukuya/Shokei
Yunoshita
Purpose:
■ To get information of present situation of RH
Contents: Presentation and interview
236
Water and Sanitation Team
Place: JFE Engineering Corporation Date:2011/05/24
Interviewee(s): Mr. Hideaki Noma
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To learn about water treatment system in the Philippines
Contents:
■ To get information of sewage system in the Philippines
■ To get some knowledge the difficulty of installing sewage system
Place: Philippines Center for Water and Sanitation Date: 2011/08/30
Interviewee(s): Ms. Lyn N. Capistrano, Mr. Apol T. Jimenez, Mr. Percival M. Abad
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To get information of WASH
Contents:
■ To learn what the low cost technology is
■ To learn how important relationship between stakeholders is
Place: Asian Development Bank Date:2011/08/29
Interviewee(s): Mr. Alan Baird, Ms. Harumi Kodama
Group: All Team Members
Interviewers: All Team Members
Purpose: To get information of sanitation situation in the Philippines
Contents:
■ To learn about present situation of sanitation facilities in the Philippines
■ To get some knowledge of appropriate technology
■ To find out the situation of Pasig river
237
Place: Department of Health Date: 2011/09/02
Interviewee(s): Mr. Rolando
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To learn the policy of the Philippine government.
Contents:
■ To learn about the national policy of water and sanitation
■ To get information of national budget of water and sanitation
Place: UNICEF Philippines Date: 2011/09/02
Interviewee(s): Mr. Timothy Grieve
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To get information of WASH in schools
Contents:
■ To learn the present situation about water and sanitation in the Philippines
■ To find out that advocacy campaign is effective to spread water supply and sanitation
facilities
Place: WASH meeting Date: 2011/09/05
Interviewee(s): Mr. Timothy Grieve, Mr. Melf Kuehl
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To get information of WASH in schools.
Contents:
■ To learn what kind of toilet is the best for schools
■ To learn how to make such facilities
■ To get the various specific examples of criteria for constructing sanitation facilities
238
Place: Center for Advanced Philippines Studies Date: 2011/09/06
Interviewee(s): Mr. Dan Lapid, Ms. Lilia GC Casanova
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To get information of Ecological sanitation toilets.
Contents:
■ To get the various specific examples of the way of making fertilizer using ECOSAN
■ To learn about advocacy campaign
■ To learn how important ECOSAN is
239
Place: Bagong Ilog elementary School Date: 2011/09/07
Interviewee(s): Ms. Irene Mercado
Group: Water and Sanitation Team
Interviewers: Momoe Kinebuchi, Naoki Ikeda, Fumie Nakajima, Yuya Hayashi
Purpose: To learn about sanitation education and how to make facilities.
Contents:
■ To learn how important to use proper technology is
■ To get information of sanitation education
■ To see its facilities
■ To interview the pupils and the teachers
Place: World Health Organization Date: 2011/09/08 Interviewee(s): Dr. Kenji Amamoto, Dr. Nobuyuki Nishikiori, Ms. Mien LingChong,
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To learn about the present situation
Contents: ■ To learn what behavior change is ■ To get information of sanitation situation in the Philippines
Place: Oji Nepia Co. LTD Date:2011/10/24
Interviewee(s): Ms. Eiko Ohori, Mr. Takashi Saito
Group: Water and Sanitation Team
Interviewers: All Team Members
Purpose: To get information about 1000 toilets Project
Contents:
■ To learn sanitation situation in East Timor
■ To get information of awareness program
■ To learn how to support for East Timor
240
Food and Nutrition Team
Place: Asian Development Bank Date:2011/08/29
Interviewee(s): Mr. Gerard Servais
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of Public Private Partnership strategies to improve nutrition
problems
Contents:
■ To learn about how to improve nutrition problems
■ To get some knowledge of Public Private Partnership
Place: Food and Nutrition Research Institute Date:2011/08/31
Interviewee(s): Ms. Czarina Martinez
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of nutrition condition and practicing to improve nutrition
problems in the Philippines
Contents:
■ To learn about present situation of nutrition condition in the Philippines
■ To get information of PPP practing to improve nutrition problems
241
Place: Department of Health Date:2011/09/02
Interviewee(s): Ms. Maria Lourdes A. Vega
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of nutrition condition and practicing to improve nutrition
problems in the Philippines
Contents:
■ To learn about present situation of nutrition condition in the Philippines
■ To get information of PPP practicing to improve nutrition problems
Place: Ajinomoto Philippines Corporation Date:2011/09/07
Interviewee(s): Ms. Helen Q. Lim, Mr. Andrew D. Ong, Mr. Kazuki Tsumagari
Group: Food and Nutrition Team
Interviewers: Seoungho Kim, Manabu Ito, Miyuki Ito, Keisuke Tagawa, Kana Togo,
Mizuki Hayashida
Purpose: To get information of practicing to improve nutrition problems in the
Philippines
Contents:
■ To get detailed information of practicing to improve nutrition problems
■ To get detailed information of the nutrition improvement project cooperated with
FNRI
242
Infection disease Team
Place: Japan Anti-Tuberculosis Association(JATA) Date: 2011/06/03
Interviewee(s): Mr. Akihiro Ohkado, Ms. Mami Kon, Ms.Yuriko Oda
Group: Infection Disease Team
Interviewers: Infection Disease
Purpose: To get information about TB and the TB project. Contents:
■ To get information about TB.
■ To get information about TB control program.
■ To get answer about our questioner.
Place: Canossa Health and Social Center Foundation,Inc. Date: 2011/09/01
Interviewee(s): Sister Eline Pascaldo
Group: Infection Disease Team
Interviewers: All team members Purpose: To get information about situation of TB and the project. Contents:
■ To get information about a TB control program.
■ To visit Smokey Mountain.
■ To get answer about the relationships with other agencies.
Place: RIT/JATA Philippines INC. Date: 09/06/2011
Interviewee(s): Ms. Mami Kon
Group: Infection disease Team
Interviewers: All team members
Purpose: To get information about situation of TB and the project.
Contents:
■ To get information about a TB control program.
■ To get information about a present situation of TB in the Philippines.
■ To get answer about the relationships with other agencies.
243
Place: I-CAN foundation Philippines, INC. Date: 09/03/2011
Interviewee(s): Ms. Yukiyo Nomura/Staffs/Inhabitant
Group: Infection Disease Team
Interviewers: All team members
Purpose: To get information about situation of TB and the project. Contents:
■ To get information about a TB control program.
■ To get answer about the relationships with other agencies.
■ To get interview with staffs and inhabitants.
Place: WHO-WPRO Date: 09/08/2011
Interviewee(s): Dr. Nobuyuki Nishikiori
Group: Infection disease
Interviewers: All team members
Purpose: To get information about situation of TB and the project.
Contents:
■ To get information about a TB control program.
■ To get answer about the relationships with other agencies.
■ To get information about a present situation of TB in the world.
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Postscript
Just a year ago, on February, 2011, our study has started. The time has passed so
quickly but it was the best and the deepest year in our lives. I am sure that, for 21
members here, all of what we have experienced this year is worth it.
The major characteristic of our study is that it focuses on one big theme “health
and sanitation”. Seniors of Hayashi seminar had set a theme to suit their interests
like education, environment, business and so on in their studies. But this year,
every student studied with “health and sanitation” at the basis, in order to connect
four teams deeply and sophisticate the study as a whole. However, since the way of
the study has changed, we constantly stumbled from the beginning. Thinking back
now, we got here taking a lot of time and such a long way round. But it is definite
that the time we have spent to think brought us many great things.
In addition, since there are unique 21 members in this seminar, we often got
into arguments. Owe we could get to finish, I think that there was passion of going
for the best and sence of responsibility fulfilling own role to all of us.
Finally, we would like to express our deepest appreciation to all of the people
who supported our study, especially, to Professer Mr. Hayashi who warmly
watched over us throughout the year. Prizing our autonomy, he allowed us to
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decide everything. It must have been easier for him to give us directions, but he
didn’t daresay. He always watched over us patiently beside us. We feel great
pleasure that we could study with him. Thank you very much.
And I would like to tell 21 members who have been studying together, “You
worked so hard. Well done.”
Miha Matsubayashi
Representative, Hayashi seminar in 2011
Chuo University, Tokyo, Japan
28 January 2012