Good governance for nutrition in the Philippines: Elements, experiences, and lessons learned 2006 PDF

International Union of Nutrition Sciences/International Nutrition Foundation (IUNS/INF) prize winner lecture Good governance for nutrition in the Philippines: Elements, experiences, and lessons learned Florentino S. Solon Abstract tion pro...

International Union of Nutrition Sciences/International Nutrition Foundation (IUNS/INF) prize winner lecture Good governance for nutrition in the Philippines: Elements, experiences, and lessons learned Florentino S. Solon Abstract tion program, given changes in political and economic circumstances, are summarized. Malnutrition is a multifactorial problem that needs a multisectoral solution. This article reviews the role of good governance in nutrition programs, citing the Phil- Key words: Food fortification, governance, legislation, ippines as an example. In the Philippines, these efforts malnutrition, micronutrient malnutrition, nutrition, are reflected in the partnership between the public and Philippines private sectors in the establishment of the country’s capability in research, policy-making, and program implementation. The establishment of the different public Introduction institutions engaged in research and policy-making is discussed, highlighting the role of political will through Malnutrition goes beyond a mere head count of legislation. The evolving tasks of the nutrition program malnourished children and women. The incidence are discussed by citing the tasks in two eras. In the 1970s, of malnutrition is generally attributed to a variety of the challenges were limited national nutrition data, man- social and economic factors adversely bearing on the power, tools, and health infrastructure. The public and human condition. It is such a multifaceted problem private institutions were able to respond by legislating that to confine its solutions to setting up “intervention national nutrition surveys and dedicated nutrition work- schemes” (preventive and curative measures) for the ers in each village. The challenges in the current era are affected group would be, as it were, just scratching the improved implementation of health programs, given the surface. Coping with malnutrition means getting to the devolution of health services, and the gathering of an evi- roots of the social and economic conditions that bring dence base to further strengthen and refine the strategies it about. It means shaping national policy and planning of supplementation, fortification, breastfeeding, and food a deep and comprehensive long-term program to meet security. In responding to these challenges, multisectoral nutrition needs. This allows other circumstances of solutions and collaboration are critical in providing an deprivation to be addressed that implicate, in turn, a evidence base to formulate policy. The role of the private host of other factors in the socioeconomic system. sector, with the Nutrition Center of the Philippines used The multiplicity of factors in nutrition program work as an example, is that of a supportive and collaborative evidently requires a corresponding multidisciplinary partner in good governance. Finally, the lessons learned and multisectoral approach. This requires a unifying from the past decades of implementing a national nutri- element in the form of strong leadership at various levels of operation to achieve results. On the whole, it is believed that a national nutrition program cannot make The author is affiliated with the Nutrition Center of the much headway without a political will that draws much Philippines, Taguig City, Philippines. of its strength from the active support of the highest A version of this paper received the 2005 IUNS/INF International Nutrition Award, presented at the 18th Interna- national leadership. The interplay of developmental tional Congress of Nutrition in Durban, South Africa, 19-23 elements would be too complex to fuse into a viable September 2005. program without top-level good governance, which Please address queries to the author: Florentino S. Solon, should be replicated at the local level. President and Executive Director, Nutrition Center of the Philippines, Villamor Interchange, South Superhighway, Governance is the process of decision-making and Western Bicutan, Taguig City 1630 Philippines; e-mail: ncp- implementation. Good governance allows participa- [email protected]. tion by both men and women, respects the rule of law, Food and Nutrition Bulletin, vol. 27, no. 4 © 2006, The United Nations University. 343 344 F. S. Solon and enforces full protection of human rights. Equity, lishment of a systematic assessment of the nutritional transparency, and responsiveness to all stakeholders problems in the communities. The second was the are required in good governance. Good governance establishment of a policy-making body to direct and mediates to reach broad consensus. Effectiveness, coordinate the efforts of the different agencies and sec- efficiency, and accountability are key requirements of tors. The third was the partnership between the public good governance. and the private sectors which is now increasingly seen as a valid model for pushing the research and program agenda in the field of nutrition and tropical diseases. Structure of the Philippine government The fourth was the health and political infrastructure through which programs are translated into action. The 1987 Constitution returned the Philippines to a Selected events and key legislation are summarized presidential system with a bicameral legislative body in table 2, showing the development of institutions, and an independent judiciary. The national govern- human resources, and policies in nutrition. ment has three branches: the executive, the legislative, and the judiciary. The local government units (LGUs) have a three-tier structure (table 1). The province is the Food and Nutrition Research Institute largest LGU. The municipalities and the cities are in the same tier, but the cities have a larger share of internal In the first half of the 20th century, there were no revenue allotment. The municipalities are always com- national nutrition surveys or national nutrition plan- ponents of the province; however some cities may be ning. In 1947, the Philippine Institute of Nutrition independent of the province. The barangay or village (PIN) was created to be the clearinghouse for nutrition is the smallest local administrative unit, with at least data under the Office of the President. The PIN eventu- 2,000 inhabitants. Thus, cities and municipalities all ally became the Food and Nutrition Research Institute have barangays administratively subordinate to them. (FNRI), which was established as the principal govern- The country’s 76 million inhabitants are distributed ment research institute for food and nutrition. in more than 40,000 villages. Each LGU is headed by a democratically elected official and has an elected legislative body that enacts ordinances and resolutions National Nutrition Council and appropriates funds for managing the LGU affairs. The Local Government Code of 1991 (Republic Act In 1971, the Nutrition Food and Agricultural Council 7160) transferred the responsibility for health services under the Department of Agriculture was created and (among other things) to the LGUs. At the same time, tasked to coordinate all nutrition and food activities the LGUs were given the power to raise local revenues, of both the government and the private sector. to borrow, and to determine types of expenditures. The Nutrition Act of the Philippines in 1974 was a The devolution of health services, like a double-edged milestone in the history of Philippine nutrition. sword, offered opportunities for improved allocation of This law made nutrition a priority concern of the gov- resources and local decision-making but also initially ernment and mandated that the nutrition program be suffered from logistical difficulties. It is against this implemented by all agencies concerned in nutrition in backdrop that the current national nutrition program an integrated fashion. The law also created the National operates. Nutrition Council (NNC), the highest policy-making and coordinating body for nutrition. The NNC has a governing board composed of 10 of the President’s History cabinet members and 3 private-sector representatives appointed by the President. Until recently, the chairman How did food and nutrition planning in the Philippines of the governing board has always been the Secretary evolve? The current national program for nutrition is of the Department of Agriculture. The chairmanship a product of several key forces. The first was the estab- has been transferred to the Secretary of Health by a presidential executive order. TABLE 1. Government structure in the Philippines The NNC formulates policies and strategies; coordi- nates the planning, monitoring, and evaluation of the LGU LCE No. of LGUs nutrition program; and facilitates the release of funds, Province Governor 79 as well as requests for grants and loans by governmental City Mayor 114 and nongovernmental organizations. The NNC secre- Municipality Mayor 1,496 tariat is headed by an Executive Director who super- Village Barangay captain 41,945 vises the 17 regional offices operated by a Regional LGU, Local Government Unit; LCE, Local Chief Executive Nutrition Program Coordinator who conducts advo- Source: National Statistics Office. cacy and coordinates the monitoring and evaluation of Good governance for nutrition in the Philippines 345 TABLE 2. Summary of selected legislation related to Philippine nutrition* Public- and private-sector institutions Year Area Law Remarks 1947 Creation of the Philippine Associa- The PAN was critical in the formation of the tion of Nutrition (PAN) PIN, which eventually became the FNRI 1947 Creation of the Philippine Institute Executive Order No. 94 of Nutrition (PIN) 1958 Reorganization of the PIN into RA 2058 the Food and Nutrition Research Center (FNRC) 1959 Creation of the Nutrition Founda- The NFP is a private organization conceived tion of the Philippines (NFP) to help the government in promoting better 1975 Reorganization of the FNRC into nutrition for Filipinos the Food and Nutrition Research Institute (FNRI) 1971 Nutrition Food and Agricultural Executive Order No. 285 The NFAC was the forerunner of the NNC. Council (NFAC) The NNC was established as a policy- 1974 National Nutrition Council (NNC) Nutrition Act of the making body through the Nutrition Act of Philippines (PD No. 491) the Philippines (PD 491) 1974 Nutrition Center of the Philippines The NCP is a private, nonstock, nonprofit (NCP) organization that is engaged in research and program development in nutrition Manpower Year Area Law Remarks 1977 Creation of Barangay Nutrition PD No. 1569 The BNS was a pilot project by the NCP in Scholars (BNS) cooperation with the Government. This was later institutionalized through this law 1995 Incentives for Barangay Health RA 7883 This law recognized the value of village Workers health workers by giving incentives for vol- unteerism Nutrition policy Year Area Law Remarks 1986 Breastfeeding EO 51 The issuance of executive orders and enact- 1992 Breastfeeding RA 7600 ment of legislation related to nutrition are a 1995 Salt iodization RA 8172 result of the multisectoral consultation and 2000 Food fortification RA 8976 coordination that was made possible by the Nutrition Act of the Philippines * Executive orders emanate from the executive branch of the government unit. Republic Acts are laws enacted by the Congress of the Republic of the Philippines. Presidential Decrees were used during the period when the Philippines was under martial law. the plans and programs in their respective LGUs. Letter Philippine Nutri-Foods Corporation (PNFC) devel- of Instruction 441 was issued by the President in 1976 ops and sells micronutrient-fortified complementary to designate lead agencies for the delivery of particular and supplementary foods and nutrition-related items nutrition interventions. used by government agencies and nongovernmental organizations in food assistance programs. The NCP Publishing Corporation (NCPPC) develops nutrition Nutrition Center of the Philippines information and educational materials designed for the different target audiences of the NNC national nutri- The Nutrition Center of the Philippines (NCP) was tion education program. established in the same year as the NNC. The NCP is The relationship of the NNC and other government a private, nonprofit organization whose mandate is to agencies with the NCP can be considered a model of mobilize nongovernmental resources, conduct research, public–private partnership. The contribution of the and develop nutrition program models in support of NCP as a private partner of the NNC can be seen in the Philippine nutrition plan and program. The NCP the different aspects of the design and development is not funded by the government. Income-generating of the national and local government nutrition pro- subsidiary corporations help sustain the NCP. The grams and projects, and in its research that supports 346 F. S. Solon the formulation of legislation for nutrition. The NCP’s weight children and nutrition changes recorded on a nonbureaucratic form of governance has been advan- growth-monitoring chart. In the process, Opera- tageous in relating its function to all levels of the tion Timbang awakened the community’s awareness of government agencies, international organizations, and nutritional problems, and participation in solving these academic institutions. problems was enhanced. In 1977, the NCP was selected as an associated Early on, one practical problem with Operation institution of the United Nations University (UNU). Timbang was the availability of a standard weighing Together, the UNU and the NCP have provided scale in the barangay. This problem encouraged inno- advanced training in community-based planning and vation. The NCP developed a bar-type weighing scale management of nutrition programs to UNU fellows (“barscale”). The Department of Health (DOH) vali- chosen from developing countries of Asia, Africa, and dated and field-tested the barscale and recommended Latin America. it for field use together with the Salter scale. Opera- tion Timbang as institutionalized by the NNC is now conducted once a year. Nutrition surveys Operation Timbang is a nationwide barangay-driven assessment effort, and the results give a profile of At the beginning of the national nutrition effort, nutritional status at the village level. In the barangay, information on the national nutrition situation was families with underweight children are identified and not available. There were no national nutrition surveys targeted for delivery of vital nutrition services. At to guide policy makers. The FNRI conducted the first the policy level, these data allow the planners to rank National Nutrition Survey in 1978. The FNRI is the the region, provinces, municipalities, and barangays research and nutrition assessment arm of the Depart- according to the prevalence of underweight among ment of Science and Technology, a member of the preschool children. NNC. The national nutrition surveys have been con- ducted every 5 years since 1978. Thus, there have been six national nutrition surveys conducted from 1978 to Local nutrition organizations 2003. The FNRI has also conducted regional nutrition surveys of anthropometry, dietary, and biochemical The strategy of the national nutrition program is the indicators that cover one region per year. The survey establishment of an active organizational structure at results are analyzed, interpreted, and fed back to the all levels of operation. Whereas the NNC is responsible NNC governing board and, more importantly, to the for national-level planning, there are regional, provin- LGUs and the public through multimedia. The findings cial, municipal, and barangay nutrition committees of the national survey serve as a guide for planners composed of individuals from government and the and programmers to identify the regions and even the private sector. These committees are headed by the provinces and populations that are most at risk for highest political leaders in the respective LGUs. On protein–energy and micronutrient malnutrition. Like- the premise that the solution to malnutrition should wise, these series of regional surveys, together with the begin in the home, the organizational effort starts with findings of the FNRI’s special studies and of research the policy maker closest to the family, the barangay of other sectors, were the basis of the NNC’s first captain. The barangay captain is vested with two vital national nutrition policy and the Philippine Nutrition powers, executive and legislative. These can be used at Program (PNP). In the early 1970s, the PNP identified the village level to facilitate the implementation of the protein–energy malnutrition, vitamin A deficiency, nutrition program. anemia, and iodine-deficiency disorders as the main The barangay has been pinpointed as the focal nutrition problems to be addressed. point of planning and implementation of the nutrition program. The municipal mayors and the nutrition committees, assisted by a designated municipal nutri- Operation Timbang tion action officer, plan, coordinate, and manage the nutrition programs of the respective barangay. Both the In the 1970s, there was clearly a need to start a nation- municipality and the barangay have a share of internal wide movement to create awareness of the nutrition revenue allotment as a source of income, as well as problem and the accompanying solutions at the vil- social development funds of which a certain percentage lage level. The government and nongovernmental may be used for social projects, including health and organizations organized a mass weighing of preschool nutrition projects. The municipal and barangay local children in every village of the country. Operation Tim- chief executives (LCEs) and their respective legislative bang (which means “weighing”) aimed to determine bodies have discretion on the amount to be allocated the weights of preschool children so that immediate for such purposes in their areas. nutrition assistance could be given to the under- As mentioned earlier, the devolution of services Good governance for nutrition in the Philippines 347 to the local administrative units provided for by the pregnant and lactating women are anemic. Vitamin A Local Government Code gives greater autonomy and deficiency, a key contributor to mortality and morbid- responsibility to the LGUs. It is therefore important ity in children, continues to be present in roughly 4 out to strengthen local nutrition planning and program- of 10 children, despite twice-yearly vitamin A supple- ming under the leadership of the local government mentation. These rates have not declined substantially executives. over the decades, and in one age group (infants), they have slowly increased. However, iodine status showed encouraging progress over 10 years, with a significant Manpower for nutrition and health reduction of iodine deficiency among schoolchildren according to urinary iodine levels. In addition, the To mobilize the people of the community to accept country continues to undergo serious political and and practice good nutrition, a properly selected and economic changes and is burdened by debt and natural well-trained cadre of volunteers is necessary. The NCP disasters that adversely affect efforts to maintain the conceptualized, developed, and piloted a program nutritional status of the population. that trained barangay-based nutrition workers called barangay nutrition scholars (BNS) to be the nutrition movers in the barangay. The BNS are carefully selected Medium-term Philippine Plan of Action volunteers from the barangay who undergo intensive for Nutrition training in the delivery of practical nutrition services: monitoring the growth of preschool children, com- On the basis of the results of the FNRI National Nutri- munication of simple nutrition messages to parents, tion Survey, the NNC Secretariat, together with the particularly pregnant and lactating women, and timely Technical Committee, formulated the Medium-Term delivery of food and pharmaceutical supplements to Philippine Plan of Action for Nutrition (MTPPAN), targeted women and children. After the NCP piloted the country’s framework to improve the quality of the BNS project with the LGUs, the NNC scaled up the life of the population through better nutrition and BNS project to be implemented nationwide through a improved health. The Plan serves as a reference law (see table 2) providing a BNS in every barangay. for national program planners, policy makers, private About 22,000 BNS are now serving the country. and nongovernmental organizations, and funding The BNS is further strengthened by another vol- agencies. The devolved government agencies provide unteer, the barangay health worker (BHW). These the LGUs with operational guidelines of the detailed volunteers render primary health-care services, includ- essentials of the program components. The MTPPAN ing nutrition, in a cluster of 20 to 30 households in 2005–10 program strategies are focused as follows: every barangay. As an incentive to volunteerism, a infants and children 1 to 3 years old, adolescents, and law enacted in 1995 grants the BHWs hazard and pregnant and lactating women are priority targets; subsistence allowances, educational programs, civil areas with high rates of malnutrition and poverty are service eligibility, and preferential access to loans (see priority targets for intensive nutrition services; food- table 2). These benefits go to more than 200,000 BHWs based interventions focus not only on production and in the country. consumption of nutrient-rich and fortified food, but also on exclusive breastfeeding and use of nutrient- dense complementary foods to ensure food security; Nutrition situation and the nutrition program is complemented by other development interventions. For many years, the country has addressed the same The strategies are applied in the development and problem of malnutrition in its various forms. In 2003, implementation of the core programs: home, school, the sixth National Nutrition Survey found that 3.5 mil- and community food production; food fortification; lion preschool children were underweight, a prevalence food assistance; micronutrient supplementation; and of 27%. The prevalence had been reduced only by less nutrition education. than one percentage point per year for the previous 10 years. Thirty percent of preschool-aged children Food-based intervention were stunted. Among children 6 to 10 years of age, the prevalence of underweight was 27% and the prevalence The MTPPAN places food production measures as of stunting was 36%. one of the priority programs within the provisions of Anemia and vitamin A deficiency continue to afflict the Agriculture and Fisheries Modernization Act of a substantial proportion of vulnerable Filipino children the Department of Agriculture, in which alleviation of and women. The trends are alarming. Among children, poverty and social equity, food security, rational use between one-third (preschoolers and schoolchildren) of resources, sustainable development, and empow- and two-thirds (infants) are anemic. Four out of 10 erment of people are the important principles. The 348 F. S. Solon NCP introduced a food production project called controlled trial among schoolchildren in four rural Food Always in the Home (FAITH) for people to schools. After a 6-month intervention that provided grow organic, chemical-free vegetables and fruits and each child with 60 g of either fortified or nonfortified raise small animals at home. The project particularly pandesal daily, the number of children with inadequate stressed community and home food security and tar- liver stores of vitamin A was reduced by 50%. Since geted families with underweight preschoolers. A self- the government policy is to fortify wheat flour with instructional manual for FAITH has been developed to vitamin A and iron, the NCP proceeded to conduct a be used in the barangay. Although the MTPPAN has stability study on wheat flour fortified with iron alone adopted FAITH as one of the food-based strategies, or in combination with vitamin A. The study showed the NCP will investigate the efficacy and effectiveness that both vitamin A and iron were stable in wheat flour of the home food production intervention in improv- and its products (unpublished data). ing the nutritional status of the household’s vulnerable The results of the rice and wheat flour fortification members. studies were used as a basis for the Philippine Food The government’s policy of promoting fortification Fortification Law (see table 2), which was fully imple- of processed food with vitamin A and iron has achieved mented in November 2004. The President declared good compliance from manufacturers. This policy was November 7 Food Fortification Day to be observed preceded by the NCP’s first randomized, controlled nationwide every year. trial that demonstrated the efficacy of vitamin A–forti- fied margarine [14, 15]. This study provided evidence Food assistance that vitamin A fortification of an oil-based consumer product was effective. The results were then readily The government food assistance program has a long translated into action by using them as advocacy tools history of implementing various supplementary feed- for promoting the benefits of fortified food products. ing schemes to rescue and rehabilitate malnourished To promote fortified food products, the margarine children. This provides windows of opportunity for was awarded a stamp of recognition from the DOH innovative food formulations of calorie-dense and and the words “accepted by the DOH” were placed on nutrient-adequate standard recipes for supplementary the label. From this initial stamp evolved the Sangkap and complementary feeding of infants and preschool- Pinoy (meaning Filipino or indigenous ingredients) aged children. In addition, the feeding activity (includ- seal, a mark of recognition from the government of a ing assistance during disasters) serves as an entry point properly fortified, high-quality food product. Today, 71 for conducting health and nutrition education and processed food products are fortified with vitamin A other complementary activities. , although only the margarine has had an efficacy The MTPPAN gives priority to providing identi- trial and only about 6 of these fortified products are fied underweight young children aged 6 to 24 months frequently used. with supplementary food containing one-third of the The good response by manufacturers of processed recommended energy and nutrient intake (RENI) for food to the food fortification policy encouraged the a period of 120 days. Given the limited budget of the government to promote the policy further with the government, it has become necessary to prioritize ultimate aim of fortifying staple foods: rice with iron, populations for interventions. School-aged children in wheat flour with iron and vitamin A, cooking oil with grades 1 and 2, with priority given to the underweight, vitamin A, and sugar with vitamin A. are likewise given supplementary food (breakfast or The food industry identified two main issues. First, morning snack) in school to alleviate their hunger, the technology of food fortification should fit easily accelerate their school performance, and improve their into the production process. Second, the micronutri- nutritional status. Pregnant women are supposed to be ents added to the staple food should be stable, cause no screened to identify those who are wasted or stunted organoleptic changes, and be efficacious. or have a history of giving birth to a low-birthweight The government, through the FNRI, developed and infant, and these women are given priority for supple- transferred the technology of fortification of cooking oil mentary food assistance. and sugar with vitamin A to the food industry. The For three decades, the NCP, through its subsidiary FNRI developed the technology of fortification of rice PNFC, has formulated and processed high-calorie, with iron. An efficacy trial showed that consumption of high-protein, and vitamin A–fortified foods as supple- iron-fortified rice improved iron status. Bioforti- ments to family foods and as complementary foods for fied rice has also been shown to be effective. breastfed children. The Nutri-Pak is a product consist- In 1995, the NCP conducted a wheat flour fortifica- ing of rice blended with a legume and skimmed milk tion study that showed substantial retention of vitamin and containing a separate 15-g packet of edible oil for- A in flour and pandesal (wheat bun) without any orga- tified with vitamin A. The Nutri-Pak was awarded the noleptic changes. Two years later, the efficacy of vita- Sangkap Pinoy seal by the DOH. There are six varieties min A–fortified pandesal was assessed by a randomized, of Nutri-Pak, which are widely used by national and Good governance for nutrition in the Philippines 349 local governmental and nongovernmental organiza- ommending a three-times-yearly schedule of vitamin A tions for community or institutional feeding. Other supplementation while the FNRI conducts a controlled PNFC products include biscuits and noodles made field study of this schedule. The vitamin A supple- from wheat flour fortified with vitamin A and iron, mentation program targets lactating women for the and powdered, vitamin A–fortified whole milk flavored high-dose capsule every 6 months, whereas pregnant with cocoa. women are supplemented with 10,000 IU tablets daily The government considers breastfeeding and com- or twice weekly from the fourth month of pregnancy plementary feeding a food-based intervention. To until delivery. The NCP position is that targeting promote and protect breastfeeding, the government has pregnant mothers for vitamin A supplementation is adopted a national code of marketing for breastmilk not necessary. substitutes and supplements and enacted legisla- The iron supplementation policy and program are tion to promote rooming-in and breastfeeding targeted to infants, preschool and school-aged children, (see table 2). The campaign also focuses on promoting adolescents, and pregnant and lactating women. The exclusive breastfeeding for the first 6 months, followed NCP conducted a government-funded study to deter- by the introduction of family foods or fortified comple- mine the effectiveness of weekly iron supplementation mentary foods that provide the nutrients children need among rural children without deworming in areas of while they continue breastfeeding. light helminth burden. The DOH, assisted by the WHO Regional Office for the Western Pacific, con- Micronutrient supplementation ducted a study of iron–folic acid supplementation of Filipino women of reproductive age and showed that The problem of clinical and subclinical vitamin A defi- iron status was significantly improved in both pregnant ciency in the Philippines has long been emphasized in and nonpregnant women who took the supplement studies in Cebu [26–29]. Supplementation of children weekly for at least 6 weeks. Another study, funded under 6 years of age with high-dose vitamin A capsules by the DOH, was conducted by the NCP to determine (200,000 IU) has been in place in the country for 13 the effectiveness of a redesigned iron supplementation years. The increase in vitamin A deficiency reported delivery system in reducing the prevalence of anemia in the national surveys of 1993, 1998, and 2003 has in pregnant women. The system was effective in reduc- compelled the government to investigate the reason ing anemia and increasing the number of prenatal that this alarming trend continues despite nationwide visits and the proportion of pregnant women with biannual supplementation (with an average coverage adequate prenatal visits. It also led to an increase of 80%). An early study in the Philippines that com- in the proportion of pregnant women taking iron sup- pared supplementation every 6 months, fortification, plements and an almost twofold increase in the mean and home food production found no improvement in percent compliance of the pregnant women with iron the vitamin A status of supplemented preschool-aged supplementation. children, and it recommended that children should A manual for the village health workers which receive supplementation every 3 to 4 months. The documented the features of the redesigned iron sup- International Vitamin A Consultative Group (IVACG) plementation delivery system for pregnant women and recommends an interval of 4 to 6 months. the steps of how it was implemented was developed by The FNRI used the results of the 1998 National the NCP. The NCP, together with the DOH, will field Nutrition Survey to study the effect of the vitamin A test the manual before scaling it up for nationwide supplementation program on subclinical vitamin A application. deficiency among preschool children. The study The current government universal salt iodization found that the reduction in deficiency by high-dose program started with UNICEF, and the DOH assisted vitamin A capsules was limited and did not persist a nationwide survey of salt producers conducted by the for 6 months, particularly in areas of high prevalence, NCP. Information was collected on salt production and and that in less severely affected areas the effect of the consumption, methods and facilities for production capsules was greater among stunted than among non- and marketing, price, transport, and storage facilities. stunted children. The authors suggested that in areas The results of the survey served as the main basis for with a high prevalence of vitamin A deficiency, a three- the salt iodization law (see table 2). Most salt is times-yearly schedule is warranted, and that in areas of sold in the community exposed in open heaps. Some low prevalence, stunted children detected by screening salt is repackaged in low-density polyethylene. The should receive vitamin A capsules more frequently. Bureau of Food and Drugs (BFAD) under the DOH We must bear in mind that the greater justification prohibits the sale of iodized salt in an open heap. The for vitamin A supplementation rests on the effect of BFAD and the NCP conducted a study to compare the community-based supplementation on child mortality stability of iodized salt sold in open heaps with that rather than on biochemical indicators alone. of salt sold repackaged in plastic. The iodine levels The MTPPAN, on the basis of the FNRI study, is rec- of salt sold by both methods were within allowable 350 F. S. Solon levels after one month of exposure under simulated educate and change behavior. Conducted by the NNC market conditions. The BFAD is now studying a and Manoff International, the study involved the use modification of the salt iodization standard and review- of 60-second messages broadcast by commercial radio ing the guidelines for implementation of the law. The three to four times daily for one year. The study found National Nutrition Survey found that the percentage of an increase in the number of mothers who adopted the households using iodized salt rose from 25% in 1998 to new behavior of enriching porridge with oil, fish, and 56% in 2003. Iodine status also improved remarkably, vegetables. with a reduction in the prevalence of iodine deficiency The NCP Nutri-Bus Project was a mobile and among schoolchildren from 35% in 1998 to 11% in comprehensive system organized in 1978 to provide 2003 according to measurements of urinary iodine support to the barangay health and nutrition work- excretion levels. ers. Shown on the bus were videotapes on health and The DOH, the NNC, and nongovernmental organi- nutrition using communication techniques to change zations jointly developed a micronutrient supple- or modify the behavior of targeted vulnerable groups, mentation guide for the use of LGUs, particularly the especially pregnant and lactating women and their health units, containing information about the targets, preschool and school-aged children. The vehicle pharmaceutical preparation, form, and doses of the contained Nutri-Pak supplies, seeds and seedlings of supplements as well as the procedures for procurement vegetables for distribution to target populations, and of the supplements. food prescription pads. A series of evaluative studies on the Nutri-Bus project Nutrition education was carried out from 1979 to 1981 in the province of Leyte to measure changes in knowledge, attitudes, The NNC policy requires member agencies to actively and nutritional status of program beneficiaries. The pursue nutrition information, education, and com- results of the 1979 study showed that mothers in vil- munication (IEC) campaigns directed to priority lages exposed to more video showings were 55% more groups. The NCP introduced innovative measures likely to describe complete meals, 73% more likely to needed to reach remote areas and widely scattered name Nutri-Pak (the high-calorie, high-protein food targets. A few examples of public–private partnership supplement) as a good snack, and 71% more likely to are cited below. give specific descriptions of Nutri-Pak. The 1981 study The teacher–child–parent (TCP) approach, designed showed that the levels of knowledge among mothers by NCP and institutionalized by the Department in 1979 were being maintained. Between 1979 and of Education, integrates health and nutrition in the 1981, the level of moderate and severe malnutrition elementary school curriculum. Messages are con- among children decreased by 17 percent and the level veyed between the school and the home by the child. of normal nutrition and mild malnutrition increased A key feature of the TCP approach is a set of manuals by 12 percent. each of which covers a specific program area in the A very important development in the country’s curriculum. The manuals contain the nutrition and health and nutrition education effort is the active health messages that are presented as lesson plans for involvement of the broadcasting and advertising indus- the schoolteacher. With its impressive track record, tries. An example is the cooperative venture between TCP was chosen as one of the innovative components the NCP and the J. Walter Thompson Company (Phil- of Educational Technology for Basic Education of the ippines), one of the top advertising companies in the Education for All Program of the Philippines for the country. decade 1991–2000. The venture involved the production of 15 30-second Several materials were developed by the NCPPC television spots on food values and sources for a nutri- for the use of health workers at various levels. Highly tion awareness campaign. Aired over Philippine televi- illustrated manuals explaining the important aspects sion in 1984, the project immediately became one of the of community health and nutrition were developed most popular public service campaigns to hit the televi- for village-based health and nutrition workers and sion screen. Entitled “Pagkaing tama sa abot kayang translated into six major Philippine languages. A refer- halaga” (roughly translated as “right food, within ence manual for physicians covers topics on assessment reach”), the project was conceptualized by J. Walter and management of nutritional disorders. A food pre- Thompson with technical input from the NCP. scription pad containing illustrated instructions with In 1984, the NCP–J. Walter Thompson nutrition recommended amounts for preschoolers, pregnant campaign won the Catholic Mass Media Award for and lactating mothers serves as an innovative tool for Best Public Service TV Advertisement, and in 1985 it dietary advice. won the award for the Best Public Service Radio and The Mass Media Nutrition Education Study (1975) TV Advertisement (after the television spots had been in Iloilo Province demonstrated the power of radio to produced as radio plugs and aired nationwide). At the Good governance for nutrition in the Philippines 351 Asian Advertising Congress in Bangkok, Thailand, Lessons learned the campaign won the silver medal of the Max Lewis Memorial Challenge Award. The following lessons have been learned from experi- In 2000, the Nutritional Guidelines for Filipinos ence with nutrition in the Philippines: was prepared by a technical group of government and The Nutrition Act of the Philippines and other laws non-government organizations. This revision of were the key to the sustainability of the nutrition pro- the 1990 Dietary Guidelines for Filipinos contains grams for three decades. 10 messages to promote good health through proper Public–private partnership, involving international nutrition. and UN agencies and industries, adds great value to all aspects of the nutrition program. Transparency in national nutrition survey results Monitoring and evaluation triggered actions from executive and legislative bodies, nongovernmental organizations, international coopera- The MTPPAN provides that the NNC conduct annual tors, and the media. plan and program assessment called the Monitoring Over the years, local leadership may change, as well and Evaluation of Local Level Plan Implementation as nutrition workers. But good nutrition plans and (MELLPI) to determine the efficacy and effectiveness programs driven by the community and the family of the nutrition plans and programs implemented at the remain. local level. In assessing the progress of the programs, The results of well-designed local studies that show the MELLPI identifies their strengths and weaknesses evidence of either efficacy or effectiveness of an inter- to help guide any remedial actions to be taken. vention program being proposed or carried out provide The NNC is also the focal agency in the country for scientific bases for decision makers to support the the Food Insecurity and Vulnerability Information sustainability of the program. and Mapping System (FIVIMS), whose function is to Barangay health and nutrition workers, with ade- collate, assemble and analyze vital data for measuring quate capacity-building, can effectively deliver health and monitoring food insecurity and vulnerability and and nutrition services in the community. to disseminate information about which areas are food- Good governance in nutrition can withstand threats insecure or at risk for food insecurity. and constraints from changes in national leadership and political and socioeconomic upheavals. 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