Network Marketing Philippines Study

Document Sample
Network Marketing Philippines Study Powered By Docstoc
					Nutrition Section
UNICEF New York
June 2009




     Infant and Young Child Feeding Programme Review



            Case Study: The Philippines




                                                       i
                                         Acknowledgements
This case study is part of a review of infant feeding programmes which was conducted as a joint effort
between UNICEF’s Nutrition Section and the Academy for Educational Development (AED), in order to
understand the factors that influenced breastfeeding programme outcomes, distil general lessons learned
from the experience of these countries and make recommendations for programming on infant and young
child feeding. The review included detailed individual case studies from six countries, as well as a
consolidated report which draws upon these case studies. The six countries are Bangladesh, Sri Lanka,
Uganda, Benin, the Philippines and Uzbekistan, chosen to represent a range of regions and diverse
scenarios in terms of breastfeeding programming efforts and outcomes.

On the part of AED, the review was led by Luann Martin. Ann Brownlee visited the Philippines and
prepared this country case study report.
UNICEF/Manila management and technical staff, including Marinus Gotink (Section Chief, Health and
Nutrition), and Elham Monsef (Nutrition Specialist) provided very useful guidance throughout the visit
and Martha B. Cayad-an (Health Specialist) was extremely helpful in sharing her experience and wisdom
from many years working with DOH and UNICEF breastfeeding and IYCF programmes. Leila Jusay and.
Robin Cook provided very professional and thoughtful logistical support. Interviewees at WHO, within
the DOH, Dr. Jose Fabella National Medical Centre, breastfeeding NGOs, hospitals, universities, and
professional associations were generous in sharing their experiences and suggestions. And finally, all the
respondents above, and other stakeholders gave extremely useful suggestions for future programming
during a productive working meeting on the final day. The photo on the cover was supplied by Arugaan.
The Nutrition Section at UNICEF headquarters – Nune Mangasaryan, Christiane Rudert, Mandana Arabi,
David Clark and Julia Krasevec, provided technical inputs and oversight during the review process, as
well as during the preparation and finalization of the country case study reports.

Funding for the case studies was provided by UNICEF, USAID through the Africa’s Health in 2010
Project, and AED.




                                                                                                        ii
                                                               Table of Contents

Acknowledgements....................................................................................................................................i
Acronyms and abbreviations .................................................................................................................. iii
Executive summary...................................................................................................................................v

1. Introduction ..........................................................................................................................................1
2. Country profile .....................................................................................................................................1
        2.1 Demographic, health and nutrition indicators .........................................................................1
        2.2 Trends in breastfeeding rates ...................................................................................................2
3. Key findings of the review....................................................................................................................4
        3.1 IYCF situation assessments and challenges ............................................................................4
        3.2 Programme coordination and mobilization of partners ...........................................................6
        3.3 IYCF policies, plans and programmes ....................................................................................8
        3.4 Key components of the breastfeeding and IYCF programmes .............................................10
        3.5 Integration strategies and cross-cutting issues .......................................................................18
        3.6 Resources invested ................................................................................................................19
        3.7 Sustainability, replication and scale-up .................................................................................20
4. Discussion ...........................................................................................................................................22
        4.1 Accomplishments and areas for improvement .......................................................................22
       4.2 Factors contributing to programme results ............................................................................23
       4.3 Lessons learned and innovations ............................................................................................24
5. Recommendations ..............................................................................................................................24


Annexes: ................................................................................................................................................29
1. Materials reviewed .............................................................................................................................30
2. Key informants and interview schedule .............................................................................................35
3. Milestones in the Philippines IYCF Programme ...............................................................................39
4. Lessons learned and innovations ........................................................................................................45
       The Milk Code struggles .............................................................................................................45
       The Philippines’ Mother Baby Friendly Hospital Initiative.........................................................49
       Community-based breastfeeding program of Barangay Pembo, Makati City ............................52
       Comprehensive nutrition programme for nutritionally depressed barangays
             in Cebu City ........................................................................................................................57




                                                                                                                                                              iii
Acronyms and abbreviations
AO-          Administrative Order
AHMP         Accelerated Hunger Mitigation Project
AusAID       Australian Agency for International Development
BASICS       Basic Support for Institutionalizing Child Survival Project
BF           Breastfeeding
BF/IYCF      Breastfeeding/infant and young child feeding
BFAD         Bureau of Food and Drugs
BFHI         Baby-friendly Hospital Initiative
BHW          Barangay Health Worker
BNS          Barangay Nutrition Scholar
BUNSO        Balikatan at Ugnayang Naglalayong Sumagip sa Sanggol
CDC          Centers for Disease Control
CfB          Children for Breastfeeding
CHD          Center for Health Development
CPC          Country Programme for Children (UNICEF)
DOH          Department of Health
ECOP         Employment Confederation of the Philippines
EO           Executive Order
Fabella      Dr. Jose Fabella Memorial Hospital
FAO          Food and Agriculture Organization
GOP          Government of the Philippines
Hilots–      Traditional birth attendants
HIV/AIDS      Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
HOMS         Hospital Operations and Management Service
HRBAP        Human rights based approach to programming
IBFAN        International Baby Food Action Network
IEC          Information, education and communication
IMAP         Integrated Midwifery Association of the Philippines
IMCI         Integrated Management Childhood Illness
IRR          Implementing Rules and Regulations
IYCF         Infant and young child feeding
LGU          Local Government Unit
MBF          Mother-Baby Friendly
MBFHI        Mother-Baby Friendly Hospital Initiative
MCH          Maternal and child health
MDG          Millennium Development Goals
MICS         Multiple Indicator Cluster Surveys
MTCT         Mother to child transmission (of HIV)
MTR          Mid Term Review
NCDPC        National Center for Disease Prevention and Control
NCHP         National Center for Health Promotion
NCP          Nutrition Center of the Philippines
NDHS         National Demographic and Health Survey
NGO          Non-Governmental Organization
NNC          National Nutrition Council
PhilHealth   Philippine Health Insurance Corporation
PhP          Philippine Peso
PIR          Programme Implementation Review
PMTCT        Prevention of mother to child transmission (of HIV)



                                                                                 iv
POGS        Philippines Obstetric and Gynecological Society
PPS         Philippine Pediatric Society
RIRR        Revised Implementing Rules and Regulations
TOT         Training of trainers
TRO         Temporary Restraining Order
TUCP        Trade Union Congress of the Philippines
TWG         Technical Working Group
UNDP        United Nations Development Programme
UNICEF      United Nations Children’s Fund
UNICEF/NY   UNICEF/New York (Headquarters)
UP          University of the Philippines
USAID       United States Agency for International Development
VCCT        Voluntary confidential counseling and testing
WABA        World Alliance for Breastfeeding Action
WBW         World Breastfeeding Week
WHO         World Health Organization




                                                                 v
Executive summary
The review
This case study is one of six in a review of the contributions of UNICEF and its partners to infant and
young child feeding (IYCF) programmes. The Philippines study involved a review of relevant documents
and a visit to Manila between July 14 – 18, 2008 which included interviews with 22 key informants1 and a
stakeholder workshop. UNICEF/NY requested that this review focus, for the most part, on breastfeeding
and key indicators related to this practice. It was decided, for the Philippines, that the review would cover
the last 15 years.
Overview of breastfeeding and IYCF programming
The Department of Health (DOH), UNICEF and other partners began to actively promote breastfeeding in
the early 1980s, with the National Movement for the Promotion of Breastfeeding established in 1983. The
Milk Code (Executive Order (E.O). 51) was signed by President Cory Aquino in 1986. A couple of years
later the DOH prepared a draft Five Year Plan (1988-1992) for Breast-feeding Promotion in the
Philippines and in 1992 the Senate approved the Rooming-in and Breastfeeding Act, which served as the
legal basis for the Mother Baby Friendly Hospital Initiative (MBFHI). The MBFHI served as the
“centerpiece” breastfeeding programme in the 1990s, with over 1,400 hospitals, a full 83% of those
targeted2, certified. However, as UNICEF/NY moved on to other initiatives in the late 1990s
UNICEF/Philippines shifted its focus to other issues. MBFHI had remained somewhat dependent on
external funding, rather than being institutionalized fully within the national health system. The
reorganization at the DOH in the late 1990’s decreased managerial capacity and support for MBFHI,
compliance at accredited hospitals slipped, and training and assessment activities sharply decreased.
Other breastfeeding promotion and protection initiatives deteriorated at this time as well, as
responsibilities were segmented, while the formula companies continued to step up their marketing
campaigns and infiltrate the media, professional groups and government agencies. The economic situation
in the 1990’s and early 2000’s was reasonably good, possibly leading to a belief among national leaders
and, to some degree, its partners, that malnutrition would “take care of itself”. Awareness of the dangers
of formula feeding and breastfeeding benefits was at a low point, with a lack of evidence-based advocacy.

The development and endorsement of the “Global Strategy for IYCF” by the World Health Organization
(WHO) and UNICEF in 2002 served as a strong impetus for countries to revitalize and expand their IYCF
programmes. The UNICEF and WHO country offices in Manila advocated for the adoption of the Global
Strategy for IYCF and preparation of a national strategy and in 2005 the “National Policies on Infant and
Young Child Feeding” were issued and a very comprehensive “Philippine National Plan of Action on
Infant and Young Child Feeding (2005-2010) completed. Key BF/IYCF programmes and activities
undertaken in the last few years have included:
o   Strengthening the Milk Code. After five years of struggle in the 1980s to get a national Milk Code
    adopted to implement the International Code of Marketing of Breast-milk Substitutes, it was finally
    signed into law in 1986. In the mid 1990s the DOH appointed a Milk Code Task Force and tried to
    enforce strict implementation of its provisions until 2000, when a Health Secretary with close ties to
    the milk companies revised the regulations in their favor. In 2004 the push to close the loopholes
    began again, with many drafts of Revised Implementing Rules and Regulations (RIRR) prepared and
    active lobbying against their adoption by the companies. The DOH, along with dedicated
    breastfeeding advocacy groups and technical support from UNICEF and WHO, waged an intense
    struggle over the next three years for adoption of the RIRRs, with a daunting set back, when the


1
  One additional interview was conducted by phone with the former Country Representative, Dr. Alipui, currently based at
UNICEF New York.
2
  There were 1798 hospitals/maternities in the Philippines, according to the UNICEF BFHI Report for 2005/6.


                                                                                                                           vi
       Supreme Court issued a Temporary Restraining Order (TRO) to halt implementation of the RIRR,
       after pressure from the companies and even the US Chamber of Commerce. Eventually in 2007, after
       creative and forceful lobbying on the part of the breastfeeding advocates, including demonstrations
       and active participation in public inquiries and a court hearing, with UNICEF and WHO using their
       “brands” to support the DOH, the TRO was lifted and all but 3 of 57 RIRR provisions allowed. While
       this was a major victory, much work must be completed to insure that a sustainable monitoring and
       enforcement system is put in place.
o      Revitalizing MBFHI. After very successful and energetic implementation of the MBFHI in the
       1990s, compliance began to slip, for the reasons described earlier. In the early 2000s there was little
       training or assessment activity. Following adoption of the Global Strategy for IYCF and development
       of the Philippine’s National Plan of Action for IYCF, a retrospective study was commissioned by
       UNICEF to review past MBFHI achievements and determine what slippage in compliance had taken
       place. The study indicated that the backsliding was substantial. As a result, new guidelines for
       implementing MBFHI were prepared, using the newly revised global BFHI materials as a basis. In
       2006 UNICEF supported a MBFHI Assessors Course, with participants including programme
       managers and licensing officers based at DOH Centers for Health and Development at regional levels
       and staff from PhilHealth. About 160 were trained nationwide. In 2007 an Administrative Order on
       the “Revitalization of MBFHI” was issued. Work has begun to retrain staff in all the target hospitals,
       providing them with “Certificates of Commitment” while they work to achieve “mother friendly
       criteria” and mount other hurdles. Hospitals were given two years, until 2010, to become accredited
       as “mother-baby friendly”. UNICEF helped to encourage an innovative agreement with the Philippine
       Health Insurance Corporation (PhilHealth), which will require that hospitals wanting PhilHealth
       accreditation (and thus financial support) will first need to be designated “mother-baby friendly”.
o      Re-energizing IYCF training and education. In the 1990s training hospital staff to implement the
       “Ten Steps” of MBFHI was the major focus of BF/IYCF capacity building, with some training at
       community level and within the pre-service educational system for health professionals. By the late
       1990s, capacity building efforts related to breastfeeding and child survival shifted to the Integration
       Management of Childhood Illness (IMCI) and other initiatives. In October 2005 WHO/Geneva and
       UNICEF/NY conducted one regional TOT for the Integrated Course on IYCF Counseling3 in the
       Philippines. UNICEF then supported TOT courses on IYCF in selected regions and Training on IYCF
       Counseling in its 19 CPC 6 provinces. An estimated 200 trainers from national, regional and
       provincial levels were trained and about 500 health implementers were trained in CPC 6 areas4. A
       Lactation Management Course was supported by UNICEF in 2006 targeting health personnel of
       selected medical centers and regional hospitals, with about 120 staff trained. By the end of 2006, with
       assistance from the President’s Accelerated Hunger-Mitigation Project (AHMP) an estimated 13,000
       volunteers and successful breastfeeding mothers were trained/oriented/organized to provide support
       to other breastfeeding mothers. The AHMP has also provided substantial resources for IYCF, with a
       cascade of training that is slated to target almost 24,000 participants by the end of 2008. In addition,
       some work is beginning to rejuvenate the efforts to strengthen pre-service education, and strategies
       for integrating nutrition content into elementary education are being considered.
o      Organization of media campaigns. Breastfeeding promotion in the media began in the early 1980s,
       with the establishment of the National Movement for the Promotion of Breastfeeding and a media
       campaign to accompany the effort to pass the Milk Code. Advocacy through the media slowed in the
       late 1990s, along with other breastfeeding initiatives. The DOH, UNICEF and various NGOs have
       recently been quite active in promoting BF/IYCF via various media channels, with a wide range of
       posters, articles, videos, and radio and TV spots produced and aired, including a widely-screened
       documentary called “Formula for Disaster”. The communications section of UNICEF actively and
3
    The Integrated Course focuses on breastfeeding, complementary feeding and HIV/AIDS.
4
    CPC 6 covers only19 out of 81 provinces and only 5 highly urbanized cities.


                                                                                                            vii
    creatively supported the Government in Code advocacy efforts, greatly increasing awareness of the
    issues involved among politicians, health workers and the general community.
o   Increasing community-based promotion and support. Through the years, the DOH and UNICEF
    have worked on community level nutrition strategies, starting in 1981 with a “Barangay Nutrition
    Scholar (BNS) Project” that aimed to place village level nutrition workers (volunteers selected by the
    local Barangay Captains) in each of the 30,000 barangays (villages or districts). UNICEF’s CPC 5
    (from 1999 – 2003) established 2,200 health and nutrition posts with barangay health and nutrition
    workers who were tasked with breastfeeding support, among other duties. These posts are still
    understaffed, however, with only 30% currently having barangay health workers. In the current CPC
    efforts are being made to train peer counselors and foster establishment of breastfeeding support
    groups. AHMP is working on this as well. WHO has supported and documented work with barangay
    Pembo, Makati City, to develop a mother and baby friendly community, which is now being
    replicated. In addition, efforts to strengthen breastfeeding support in the workplace have been
    initiated, with the DOH, WHO and UNICEF working to develop pilot mother baby friendly
    workplaces.
Key findings
The National Demographic and Health Surveys (NDHS) in 1993, 1998 and 2003 have provided the best
data on trends related to IYCF practices for the period covered by this review. The reports indicate that
exclusive breastfeeding, the key indicator, increased for children < 6 months of age from 1993 to 1998
(from 25% to 37%) but then decreased in 2003 (down to 34%). Early initiation of breastfeeding is one
key practice that has improved with all three surveys, rising from 36.6% infants starting within the first
hour (for births in the 3 years preceding the survey) in 1993, and then 40% in 1998 and 52.9% in 2003.
UNICEF’s 2007 Sub-Regional Multiple Indicator Cluster Survey, which covers only the CPC 6 areas,
found that exclusive breastfeeding for children < 6 months of age was only 18%, much less than the
national average, with rates in the disadvantaged cities much lower than in the rural areas. There is much
to be done, since UNICEF’s CPC plan proposes a 30% increase in these rates.
The description of breastfeeding and IYCF programming, above, summarizes the accomplishments of the
key IYCF initiatives. Sustainability has been one of the most difficult challenges faced by these
initiatives, and thus development of viable strategies for monitoring and maintaining gains achieved is
one of the key foci of planners at this time.
Recommendations
Recommendations stemming from the field visit, in summary, include the following:
Policies, plans and programme management. The national IYCF programme is on the way to
revitalization but management, supervision and coordination will need to be greatly strengthened if it is to
have the desired impact. Full time staff members are needed both for overall IYCF programme
management and for the MBFHI, as well as comparable staff at regional levels. Coordination of the many
IYCF activities undertaken by DOH, AMPH, UNICEF, the NGOs and other organizations needs to be
strengthened to insure the most efficient use of resources. The National Plan of Action for IYCF needs to
continue producing yearly implementation plans, with clear assignment of responsibilities, budget and a
functional evaluation system, if the National Plan is to have the desired impact. The National Plan should
be reviewed in preparation for the assessment in 2010 and planning for2010-2015.
The Milk Code. Now that the Revised IRR has been approved, it is critical not to lose the momentum
gained, as continued diligence is needed to insure that the Code is adequately monitored and enforced. A
“lay” version of the Supreme Court’s rulings should be developed, with clear guidelines for what is
permissible and not and how Code violations will be monitored and penalized. The composition and work
of the Inter-Agency Committee on the Code should be reviewed to insure that it is strong and active, the



                                                                                                        viii
Code monitoring tool should be finalized, and multi-sectoral monitoring teams capacitated and supported
at all levels.
Maternity protection and workplace actions: UNICEF and its partners should encourage the
government to propose legislation mandating longer maternity leave and other entitlements in line with
the ILO Maternity Projection Convention No. 183. In addition, UNICEF should continue its collaboration
with NGOs to encourage additional employers to adopt MBF practices, such as providing breastfeeding
rooms and breaks and crèches or child care for infants being exclusively breastfed, with certification of
workplaces as “MBF workplaces”. Promotion of MBF public places should continue as well. Hopefully
the “Expanded Breastfeeding Act” mandating the establishment of lactation stations in the workplace and
public places will be passed, adding government support for these efforts.
Communications. A media campaign, with periods of intense advocacy in support of breastfeeding,
should continue, to counter advertising pressure from the milk companies. In addition, the DOH should
explore, in collaboration with UNICEF and other partners, further development of a comprehensive
communication strategy for IYCF, building on lessons learned from the successful communications work
related to the Code.
The Mother Baby Friendly Hospital Initiative. As mentioned above, a full-time manager for the
MBFHI and other health system training should be identified within the DOH, in addition to a full-time
manager for the IYCF programme as a whole. This would free up the staff at the Fabella Training Center
to concentrate on training and assessment. Further work is needed to decentralize these activities, with
training teams identified at regional, provincial and lower levels, and a well-functioning system
developed for training and supervising them. The strategies for training hospital staff should include
follow-up to ensure that the new knowledge and skills are converted into relevant actions in the maternity
services. Systematic orientation of policy-makers and hospital administrators should be undertaken, with
the new BFHI Course for Decision-makers one possible resource for this effort. A special effort should be
made to strengthen internal monitoring of the certified hospitals, with periodic checks, using the new
BFHI Monitoring Tool or something similar, to determine whether compliance is continuing. The system
for recertification should follow standard guidelines and should be cost-effective, as unbiased as possible,
and sustainable – i.e. institutionalized within the standard quality control and supervisory procedures of
the health system. Finally, once this system is in place, authorities should ensure that the agreement with
PhilHealth requiring MBFHI designation for PhilHealth certification is enforced.
Training and education. A more systematic approach to IYCF capacity building is needed, with a
sustained system for follow-up support, mentoring and monitoring put in place, including strategies for
dealing with staff “turnover” and offering needed refresher training. Development of a systematic
initiative to strengthen the IYCF content in the pre-service curricula of medical, nursing and midwifery
schools should continue, as it would be the best way to ensure a sustained improvement in health
professionals’ IYCF-related knowledge and skills. Consideration should be given, as well, to ensuring
that basic, proven healthy family practices, including those related to IYCF, are integrated into the
curricula for primary and secondary schools
The community. Increased efforts are needed to promote, protect and support optimal IYCF practices at
community level, including phased expansion of lay/peer counseling on IYCF in barangays and further
fostering of mother support groups, with the aim of achieving scale in all 42,000 barangays. Promising
pilot projects such as the peer counseling system being implemented in Makati and other cities and
provinces should be considered for further scale-up. Consideration should be given to the
recommendation by the former UNICEF Representative5 of a strategy for strengthening the current BHW
system, in which BNSs and BHWs are selected/appointed by the Barangay Captains to serve as
volunteers at the Captains’ discretion. Local authorities could be encouraged to pay these volunteers, who

5
    Dr. Nicholas Alipui


                                                                                                           ix
would focus on health promotion, while the DOH, with support from various partners, could supply one
additional paid BHW in each barangay, who would focus treatment, and remain, even with changes in
local barangay leadership.
UNICEF’s role. UNICEF has played a very active and effective role in the last few years in helping to
revive critically needed programmes and focus new approaches on IYCF promotion, protection and
support. It should continue to play a very active role in mobilizing new partners, advocating continued
development of policies supportive of IYCF, fostering development of needed programmes and tools,
helping to build the capacity of regional and local training and resource centers, assisting the DOH in
developing a strong system for mentoring and supervising cadres trained, and taking interventions at
community level to scale through advocacy for Government polices and plans and leveraging other
partners to contribute. In addition, UNICEF should contribute to a continued effort to strengthen national
Code monitoring capacity and support the establishment of a sustainable system for monitoring and
enforcing the Code, assist with the design and implementation of an evidence-based comprehensive
communication strategy, and provide technical assistance with planning for IYCF support in difficult
circumstances, such as emergencies and HIV. The human rights-based approach to programming
(HRBAP) and gender equity should be considered in all its efforts, with added focus on developing the
capacity of “rights holders” such as parents, caregivers and children, in addition to “duty bearers”, such as
organizations and health workers but also parents and caregivers. Finally, a key focus of its work with the
DOH and other partners should be to identify, test, and foster adoption of sustainable approaches, as well
suited as possible to withstand the challenges of working in a devolved system with a high rate of staff
turnover.




                                                                                                           x
1. Introduction
This case study is one in a series of six in a study commissioned by the United Nations Children’s Fund
(UNICEF) to review the contributions of UNICEF and its partners to infant and young child feeding
(IYCF) over the past few years. The other countries studied include Bangladesh, Benin, Sri Lanka,
Uganda, and Uzbekistan. The aim of the IYCF review was to: 1) better understand the contextual and
programmatic factors that led to the changes in selected countries; 2) assess the contributions by different
actors, including UNICEF, to the area of IYCF during the period when the change in breastfeeding rates
occurred; 3) develop a series of innovations, good practices and lessons learned to improve future
programming, and 4) identify ways of overcoming challenges to improved practices. UNICEF/NY
requested that this review focus, for the most part, on breastfeeding and key indicators, such as exclusive
breastfeeding, related to this practice. It was decided, for the Philippines, that the review would cover the
last 15 years, since the trend data of interest came from the 1993, 1998 and 2003 National Demographic
and Health Survey (NDHS) reports.
The development of the case study for the Philippines involved review of relevant documents, a field visit
between July 14 – 18, 2008 to Manila, and analysis of the information and data obtained during the visit
(See documents reviewed in Annex 1). The field work included interviews of 22 key informants,
involving staff from UNICEF, the World Health Organization (WHO), the Department of Health (DOH),
and various partners such as non-governmental organizations (NGOs), professional associations, and
collaborating health facilities and universities (see Itinerary in Annex 2). Dr. N. Alipui, former UNICEF
Representative for the Philippines was interviewed by phone in UNICEF/New York (NY) as well.
In addition, a 6 hour workshop was held on the final day of the visit, which focused on a review of IYCF
trends and working groups on IYCF policies and legislation, the Milk Code and breastfeeding advocacy,
the Mother Baby Friendly Hospital Initiative (MBFHI) and pre-service curricula, and IYCF at community
level. Each group worked to identify the key milestones and accomplishments in its focus area, the
challenges and how they have been addressed, strategies for sustainability and what has worked, lesson
learned, and recommendations for the future. The workshop ended with group reports and finalization of
recommendations.

2. Country profile
2.1 Demographic, health and nutrition indicators
The Philippines is a country of over 7,000 islands, with about 4,000 of them inhabited. It has a population
of over 88 million (SOWC 2009), with about half living in rural areas. The Gross Domestic Product
(GDP) per capita was US$963 as of 2004. 30% of the population was below the poverty threshold as of
2003, down from 39.9% in 1990, with the country on its way to the Millennium Development Goal
(MDG) of 19.95% by 2015 (UNICEF annual report, 2007). However, the ratio of poorest to wealthiest is
increasing, from 1.9 in 1998 to 3.1 in 2003 (Countdown 2015 Philippines). Adult literacy is quite high in
the Philippines, with 83.8% functional literacy (Child Survival Profile). However, the MDG of achieving
universal primary education is not on track, with a 66.5% elementary completion rate in 1990, up to only
68% in 2005/6 and yet a target of 81% in 2015 (UNICEF annual report, 2007). The Human Development
Report (2008) rates the Philippines as 102 out of 179 countries, with a human development index (HDI)
of .745, which takes into account life expectancy, access to education (literacy and school enrollment) and
standard of living. HIV adult prevalence (15-49 years) is less than .1%.
The under-five population in the Philippines is over 11 million (SOWC 2009), with an under-five
mortality rate per 1000 live births of 28, down from 62 in 1990 and thus well on its way to reaching the
MDG target of 21 in 2015. The infant mortality rate is 23, down from 57 in 1990, with an MDG target of
19. The prevalence of malnutrition among children under five, as measured by the percentage moderate
and severe underweight, was 28% (SOWC 2009), down from 34.5 in 1990, with a goal of 17.25 for 2015.



                                                                                                            1
(UNICEF annual report, 2007). Intensive work is necessary, however, if these key targets are to be met by
2015.

The data on breastfeeding is not as         Table 1. Philippines Profile
encouraging, with exclusive                 Indicator                                                   Data
breastfeeding of infants under 6 months     Demographic indicators
of age, the key indicator, rising from      Total population (millions)                                  88.0
26% in 1993 to 37% in 1998, but then        Population under 5 (millions)                                11.1
decreasing again, to 34% in 2003.           Urban population (%)                                          64
Exclusive breastfeeding rapidly declines    Total fertility rate                                          3.3
with infant age, from 52.5% at under 2      Mortality indicators
months, to 35.4% at 2-3 months and          Under-five mortality rate                                     28
only 16.1% at 4-5 months (2003              Infant mortality rate                                         23
NDHS). The prevalence of breastfeeding      Neonatal mortality rate                                       15
was 87% in 2003, with urban children        Nutrition indicators
less likely to be breastfed than rural      Low birthweight (%)                                           20
(82% compared with 91%). Home               Moderate and severe stunting (%)                              30
deliveries accounted for 56.5% of all       Moderate and severe wasting (%)                                6
births (2006 Family Planning Survey),       Moderate and severe underweight (%)                           28
with 63.5% of the babies delivered by       Infant feeding indicators
non-skilled birth attendants (such as       Exclusive breastfeeding (< 6 months) (%)                      34
“hilots”, other members of the family       Breastfeeding with comp. foods (7-9 months) (%)              63.9
and friends). Breastfeeding initiation      Health indicators
within one hour increased slightly from     Adult HIV prevalence (15-49 years)                           <0.1
35.6% in 1993 to 40.7% in 1998 and          Antenatal care coverage (%)                                    88
then jumped to 54% in 2003. Use of          Home deliveries (%) (FPS 2006)                               56.5
formula and feeding bottles was still a     Population using improved drinking water sources (%)           93
problem in 2003, with 23.9% of mothers      Population using adequate sanitation facilities (%)            78
reporting formula feeding and 31.2%         Human development indicators
reporting use of bottles with nipples for   Human development index (HDI) value                         0.745
infants 4-6 months of age. The continued    Life expectancy at birth (years)                             71.0
high rates of moderate and severe           Adult literacy rate (ages 15 and older) (%)                  92.6
stunting (30%) and low birthweight          Gross school enrollment (%)*                                 81.1
(20%) (SOWC 2009) highlight the need        Gross Development Product per capita (PPP US$)**          $5,137
for greater attention to improving          *Combined primary, secondary, and tertiary gross enrollment ratio
maternal nutrition and complementary        ** Purchasing power parity
feeding.                                    Sources: The State of the World’s Children 2009, UNICEF; DHS
                                            Report 2003; Human development indicators:
                                            http://hdr.undp.org/en/statistics/
2.2 Trends in breastfeeding rates
The NDHS reports from 1993, 1998 and 2003, as mentioned above, provide the best data on trends
related to key IYCF practices over the period covered by this review. A few key results from the three
surveys are summarized below.

As Table 1 illustrates, exclusive breastfeeding increased from 1993 to 1998 and then decreased in 2003
half way to 1993 levels. Use of plain water with breastfeeding decreased slightly from 1993 to 1998 and
then increased dramatically from 1998 to 2003 while use of supplements (including formula) continued to
decrease in all three surveys.




                                                                                                           2
                                                    Table 1
   Year of NDHS                          Breastfeeding (BF) status for children age < 6 m.
                             Not               Exclusive                 BF                     BF
                             BF                   BF               + plain water           + supplements
          1993               20.3                 25.4                  10.9                    43.5
          1998               23.4                 37.0                   8.9                    30.7
          2003               19.7                 33.5                  18.4                    28.5


Table 2 shows similar trends for exclusive breastfeeding as Table 1, for both sets of ages under 6 months,
with the practice decreasing in 2003. Use of infant formula stayed the same or increased for all three age
sets from 1993 to 1998 and then decreased for all ages in 2003. Use of bottle with nipple for ages 0-3
months decreased for all three time periods, but for ages 4-6 and 7-9 months increased from 1993 to 1998
and then decreased in 2003.Thus, while exclusive breastfeeding decreased in 2003, interestingly, the use
of infant formula and bottles with nipples decreased as well.
                                                    Table 2
 Year of                                  Type of foods received by child’s age
 NDHS              0-3 months of age               4-6 months of age                 7-9 months of age
              Only      Infant     Using     Only       Infant     Using        Only      Infant     Using
             breast- formula       bottle   breast- formula        bottle     breast- formula        bottle
              milk               w/nipple    milk                 w/nipple      milk                w/nipple
   1993       40.6       24.5       32.8      13.0       27.9       28.7         3.1       26.6       30.9
   1998       57.7       24.8       30.2      21.5       30.1       38.2         1.3       35.4       46.6
   2003       50.0       17.4       26.2      15.2       23.9       31.2         1.1       26.9       29.9
The area graphs on the following age provide a full visual snapshot of the infant feeding patterns and
trends in the Philippines: As the lighter blue sections of the area graphs illustrate, the problem of giving
water in addition to breast milk in the first six months has been increasing, while provision of other non-
milk liquids in addition to breast milk has decreased.
Figure 1




                                                                                                               3
Early initiation of breastfeeding is one key practice that has improved with all three surveys, rising from
36.6% infants starting within the first hour (for births in the 3 years preceding the survey) in 1993, and
then 40% in 1998 and 52.9% in 2003.
Median duration of any breastfeeding was 14.1 months in 1993, 12.8 months in 1998 and 14.1 in 2003.
Duration of both any breastfeeding and exclusive breastfeeding was generally inversely related to
education in all three surveys, higher if the mother was assisted by a traditional midwife than if she was
assisted by a medically trained worker, and higher if rural than urban.
The 2007 Sub-Regional MICS, as mentioned earlier, covers only the CPC 6 areas, but provides
interesting insights concerning these more disadvantaged areas. Exclusive breastfeeding among children
0-5 months of age was only 18.4% (much lower than the 33.5% found nationally in 2003), and for the 5
CPC 6 cities was even lower, at an average of 7.5%. Children not breastfed at all was higher in these
areas (21.6%) than nationally in 2003 (19.7%) and much higher in the CPC 6 cities (38.8%). It will be
important to look at the trends if future Sub-Regional Surveys cover the same or quite similar areas.

3. Key findings of the review
3.1 IYCF situation assessments and challenges
Needs assessments
The Philippines has faced a number of daunting challenges through the years, as the struggle to improve
IYCF practices has continued. The issues faced in the area of health and nutrition, as well as other sectors,
have been clearly described in the needs assessments and situation analyses of UNICEF and other
partners in recent years. UNICEF, for example, produced a very detailed “Philippines Situation Analysis”
in 2007, covering issues related to all its focus areas, including Health and Nutrition and IYCF. The
various five year “Country Programme for Children” (CPC) plans and mid-term reviews all include
assessments of needs and the problems yet to be solved, to set the stage for actions proposed for the next
programme phases. Breastfeeding and IYCF have been featured in the recent CPCs, with an emphasis on
the fact that “exclusive breastfeeding” is one of the indicators where the trends are not encouraging and




                                                                                                              4
progress is needed. Many of the annual UNICEF Philippines reports provide useful snapshots of
challenges the organization and country have been struggling with in particular years.
The BASICS6 project’s “Newborn health in the Philippines: a situation analysis” (2004) provides some
useful insights on newborn health and nutrition, with a section on breastfeeding. UNICEF has
commissioned studies on breastfeeding practices in two of its CPC 6 areas in 2004/2005, to provide
improved understanding of cultural aspects of infant feeding practices.
IYCF evaluations and reviews
Only a few evaluations and reviews have provided results directly relevant to IYCF. The key population-
based data concerning IYCF practices has come from the NDHS, the most recent being in 1993, 1998 and
2003. Another NDHS was completed in 2008 and is currently being analyzed, with results due out soon.
These surveys have been a good source of comparative data over time on key indicators such as early
initiation, exclusive breastfeeding, bottle-feeding, complementary feeding and breastfeeding, and
breastfeeding duration. One caveat concerning trend analysis is that the “24 hour recall” question
concerning liquids and foods children receive was changed substantially between the 1998 and 2003
surveys (see Q. 445 in 1998 and Qs. 492 and 493 in 2003 for a comparison), thus making it impossible to
be certain that changes in rates based on this question are due to changes in practices. UNICEF’s Multiple
Indicator Cluster Surveys (MICS) also provide some data, although earlier MICS did not focus on
breastfeeding. The Sub-Regional MICS conducted in 2007 does provide IYCF data, but was focused only
on the CPC 6 areas and so could not be compared with the NDHS data for an analysis of trends.
In addition, the Retrospective Study on MBFHI (2006) provides useful data related to that initiative based
on surveys in almost 100 hospitals. The two mid-term reviews for the CPC 5 and 6 and the annual
UNICEF country reports, as well as data from other programmes such as AMHP and the Makati and
Cebu City community initiatives, provide information on IYCF-related accomplishments and some
limited data on changes in practices. In 2007 an IYCF Program Implementation Review meeting was
held, and the presentations by various stakeholders provide additional perspectives on both
accomplishments and on-going challenges. Finally, in 2008 a mid-term assessment of the Philippine Plan
of Action for Nutrition 2005-2010 was completed, which included lots of data on IYCF-related
accomplishments.

Problems and challenges faced
Breastfeeding practices and their effects. As described in the country profile above and in more detail
in the review of IYCF indicators later, poor infant feeding practices remain a key problem. WHO experts
in the Philippines estimate that 19% of the deaths of children under five years of age can be attributed to
inappropriate feeding practices, including formula feeding7. Recent Lancet studies report that
breastfeeding is the single most effective preventive intervention to save children’s lives, and that
practices such as early initiation, exclusive breastfeeding for 6 months, and appropriate complementary
feeding and sustained breastfeeding for up to two years can prevent over 75% of deaths in early infancy
and 37% of deaths in the second year8. Infants 0-5 months old who are not breastfed have a 7 fold
increased risk of dying from diarrhea and 5 fold increased risk from pneumonia than infants who are
exclusively breastfed9. (Philippine Situational Analysis 2007, p.11). For the Philippines, it is estimated
that 16,000 infants die each year from not being breastfeed. It is estimated that the poor (living with less
than USD $1/day) spend up to 30% of their income, unnecessarily, on formula. US$10 million is spent


6
  Basic Support for Institutionalizing Child Survival Project
7
  This is in line with the estimates in the Child Survival Series article, “How many child deaths can we prevent this year?”, Jones
et al., The Lancet, Vol 362, July 5, 2003.
8
  WHO Collaborative Study Team on the role of breastfeeding on the prevention of infant mortality. Effect of breast-feeding on
infant and child mortality due to infectious disease in less developed countries: a pooled analysis. Lancet, 2000, 355: 451-455.
9
  Jones G et al. How many child deaths can we prevent this year? Lancet 2003; 362:65-71.


                                                                                                                                  5
yearly for hospitalization, health consultations and medicines for illnesses due to formula-feeding (WHO
and UNICEF presentation).
As chronicled in the needs assessments above, a number of challenges have slowed the development
goals the Philippines has set for itself, as well as desired improvements in the specific area of IYCF:
o   Economic and political challenges. A study by the Asian Development Bank of poverty in the
    Philippines found that the sustained economic growth experienced from 2000 to 2003 was not pro-
    poor and that the national figures mask large regional and provincial differences, with rural poverty
    higher than urban. While only half of the population is rural, a full 80% of the nation’s poor live in
    these areas. The Philippines, in addition, has one of the highest rates of income inequality in Asia,
    with patronage policies and endemic corruption greatly slowing the ability of the government to make
    the changes, including those related to infant and young child feeding, needed to assist the most
    disadvantaged. (UNICEF report, 1999).
o   Emergencies and disasters. The Philippines experiences a very high number of natural disasters,
    with a large number of major typhoons, mud-slides and volcanic eruptions causing wide-scale
    devastation and disruption of the economy, and some of the most disadvantaged areas being the worst
    effected. Insurgency and political instability have also taken their toll, with low and mid-level
    intensity armed conflict for over 40 years, which has numerous consequences for the rights and health
    of children and their families. It is especially important to guard good IYCF practices in emergencies.
    Well-intentioned but poor feeding policies, including wide-scale use of infant formula donations,
    have caused problems in the past (2007 Situation Analysis). The government revised its policy on
    infant formula donations in 2008. The updated policy upholds the international policy on infant
    formula distribution during emergencies.
o   Rapid turnover and emigration of health care staff. The rapid turnover of trained and experienced
    health personnel due to transfers and out migration has exacerbated existing capacity deficits in the
    areas of health and IYCF, negating past training investments, especially in the absence of effective
    mechanisms for transfer of skills when experienced workers leave. The Philippines is the major
    exporter of nurses to the world and only second to India for physicians (CPC 6 plan). Low
    government salaries and the low priority given to health care delivery have contributed to this serious
    “brain drain” with rural and hard to reach areas most affected.
o   Administrative problems and the challenge of devolution. The health care delivery system and
    IYCF programming has experienced a lack of stability through the years, due to a political system in
    which a shift of leadership at the top means a change in the administration of the DOH, changing
    priorities and, in some cases, changing structures. One of the biggest challenges for health care
    delivery and, as a result, for efforts to improve IYCF practices, has been the process of devolution,
    which began in 1991 and adversely affected the performance of the health system by fragmenting the
    various levels. Earlier, the central government was tasked with the delivery of basic services to
    children, before this responsibility was devolved to local governments. The local government units
    (LGUs) have often been unable or unwilling to maintain pre-devolution expenditures for health.
    Delivery of health and nutrition services at the local level, including IYCF, is particularly challenging
    because it is heavily politicized. The barangay health workers and barangay nutrition scholars are
    appointed by the Barangay Captains and approximately 50% of these grass roots providers change
    every time the Barangay Captains change due to elections, with a resultant rapid loss of workers with
    needed skills and experience.
    UNCEF itself has faced challenges in finding an effective planning process for this devolved system.
    Twenty four focal areas needing work plans approved by the governing council in each province and
    6 sectoral programmes planned and implemented through 17 projects have led to over 400 annual
    work plans for the focus areas, plus national and regional level annual work plans (UNICEF 2006
    annual report). UNICEF is in the process of working to streamline this daunting process. A review of


                                                                                                            6
    these plans for this case study found that the quality of the IYCF-related portions of these plans varied
    greatly, with many quite minimal in scope.
The next sections of the report address the response to these challenges.

3.2 Programme coordination and mobilization of partners
Mobilization and coordination of key partners and stakeholders has been an important aspect of the
country’s efforts to improve IYCF practices.
The Government of the Philippines, as expected, plays the leading role, with a National IYCF
Management Committee within the DOH, co-chaired by the Undersecretaries for Health Operations and
for External Affairs. The Committee’s members include the Directors or alternatives from key DOH
centers and bureaus, as well as Dr. Jose Fabella Memorial Medical Center (Fabella) which has been
designated as the IYCF national training institution.
A National IYCF Technical Working Group has been created to provide technical assistance to the DOH
in planning, coordination, monitoring, evaluation and research. It includes representatives from the
Government, NGOs, and international organizations.
Health and nutrition system entities involved in the programme are wide-ranging, from the National
Nutrition Council (NNC) and the Food and Nutrition Research Institute (FNRI), the Health Development
Centers (HDCs) at various levels, to hospitals, lying-in clinics, health centers and health and nutrition
posts at the barangay level. The National Nutrition Council (NNC) has taken the lead on the Accelerated
Hunger Mitigation Project (AHMP), which now has substantial IYCF components.
Government institutions including various multi-sectoral, functional committees, and the Leagues of
Provinces, Cities, Municipalities and Barangays have also been asked to be active stakeholders. The
Department of Interior and Local Government is tasked to mobilize local councils for the protection of
children to prioritize IYCF in their plans.
Key international and national organizations providing support for the IYCF programme include UNICEF
and WHO, with their country offices taking the lead, and regional and headquarter colleagues providing
additional assistance when needed. Other international groups, such as the World Alliance for
Breastfeeding Action (WABA), the International Baby Food Action Network (IBFAN), the International
Lactation Consultant Association, ICDC, Baby-Milk Action, La Leche League International, and the
Academy of Breastfeeding Medicine have played a supportive role in initiatives such as the struggle to
enforce the Milk Code, strengthen breastfeeding support in workplaces, and other activities. The Nutrition
Center of the Philippines has provided solid technical support, training materials, and pilot project
leadership in the area of nutrition for over 30 years. The Trade Union Congress of the Philippines (TUCP)
and Employment Confederation of the Philippines (ECOP) have played an active role in facilitating
workplace strategies supportive of breastfeeding employees. The Philippine Health Insurance Corporation
(PhilHealth) has been a valuable partner in an innovative strategy to require MBFHI designation as a
criterion for PhilHealth accreditation.
Donor organizations and projects have provided additional financial and technical resources. The
Australian Agency for International Development (AusAID) has been very supportive in the past and will
provide substantial resources to deepen nutrition and IYCF programming in selected UNICEF CPC
provinces. Manoff International, Wellstart International and the Academy for Educational Development
provided technical support for nutrition and lactation management training in the past.The Partners for
Health Child Survival Program of Pearl S. Buck International included breastfeeding support in its
community-based programme in the southern Philippines, BASICS II undertook a large child survival
project focused on newborn health, including breastfeeding, and the LINKAGES project did some work
on the lactation amenorrhea method (LAM), all with support from United States Agency for International
Development (USAID).


                                                                                                           7
Partnerships with non-governmental organizations (NGOs) have served to energize and greatly extend the
power and reach of key IYCF strategies, such as those to enforce the Milk Code, provide breastfeeding
support in the workplace and support and protect breastfeeding in the community, among others. IBFAN
Philippines (Arugaan), a network of NGOs providing mother-to-mother support, has been an active and
effective breastfeeding advocate for years, providing support for working women, and organizing child
care crèches. It played an important role in the recent Milk Code struggles, by mobilizing more than 100
NGOs to form the Save the Babies Coalition for this purpose. Children for Breastfeeding, and its partner,
Nurturers of the Earth, have been very active and effective recently in mobilizing children and women to
support breastfeeding, to advocate for Milk Code enforcement, and to participate in media events. Faith-
based organizations, such as the Catholics Bishops Conference of the Philippines, have joined some of the
advocacy efforts as well.
Professional societies such as the Philippine Pediatric Society (PPS), the Philippines Obstetrics and
Gynecological Society (POGS), the Philippine Midwives Association (PMA), the Integrated Midwifery
Association of the Philippines (IMAP), the Philippines Nursing Association (PNA) and the Association of
Philippines Medical Colleges have been asked for technical support and advice, with some members more
supportive than others. Universities such as the University of the Philippines (UP) and its Philippine
General Hospital (PGH) often provide research and technical assistance. And, finally, some commercial
partners such as Proctor & Gamble have sponsored nutrition activities.
As will be seen in the programme descriptions below, UNICEF, WHO, the DOH and other leading IYCF
organizations have actively worked to mobilize their partners. The assistance of these partners has been
extremely valuable, although there have been some “growing pains” and dissention among partners at
times, particularly when the Milk Code struggles became heated. A 2006 UNICEF study on NGOs and
civil society organizations found that these partners appreciated the “critical enabling and technical value”
that UNICEF was able to provide to their organizations, giving them added status and ability to achieve
their goals. They felt, however, that more could be done by UNICEF to strengthen the capacities of the
NGO/civil society organizations, further energize the partnerships, and thus increase their ability to
provide needed assistance, especially for the severely disadvantaged (UNICEF annual report 2006).

3.3 IYCF policies, plans and programmes
The DOH, UNICEF and other partners began to actively promote breastfeeding in the early 1980s, with
the National Movement for the Promotion of Breastfeeding established in 1983. The Milk Code
(Executive Order (E.O). 51) was signed by President Cory Aquino in 1986. A couple years later the DOH
prepared a draft Five Year Plan (1988-1992) for Breast-feeding Promotion in the Philippines and in 1992
the Senate approved the Rooming-in and Breastfeeding Act, which served as the legal basis for the
Mother Baby Friendly Hospital Initiative (MBFHI). The MBFHI served as the “centerpiece”
breastfeeding programme in the 1990s (see details in MBFHI section below). However, as UNICEF/NY
moved on to other initiatives in the late 1990s UNICEF/Philippines shifted its focus to other issues.
MBFHI had remained somewhat dependent on external funding, rather than being institutionalized fully
within the national health system. The reorganization at the DOH in the late 1990s decreased managerial
capacity and support for MBFHI, compliance at accredited hospitals slipped, and training and assessment
activities sharply decreased. Other breastfeeding promotion and protection initiatives deteriorated at this
time as well, as responsibilities were segmented, while the formula companies continued to step up their
marketing campaigns and infiltrate the media, professional groups and government agencies. The
economic situation in the 1990’s and early 2000’s was reasonably good, possibly leading to a belief
among national leaders and, to some degree, its partners, that malnutrition would “take care of itself” with
a rise in the standard of living. Awareness of the dangers of formula feeding and breastfeeding benefits
was at a low point, with a lack of evidence-based advocacy.




                                                                                                           8
The development and endorsement of the “Global Strategy for IYCF” by WHO and UNICEF in 2002
served as a strong impetus for countries to revitalize and expand their IYCF programmes. UNICEF
Philippines had worked with the Government and other partners to launch the Child-Friendly Movement
in 1999, and the 1999-2003 UNICEF Fifth Country Programme for Children (CPC 5) included some
breastfeeding support, for example, as a component of IMCI and the Enhanced Child Growth Project.
UNICEF and WHO advocated for the adoption of the Global Strategy for IYCF and preparation of a
national strategy and in 2004 an IYCF task force was created. In 2005 the “National Policies on Infant
and Young Child Feeding” (Administrative Order (A.O.) 2005-0014) was issued and a very
comprehensive “Philippine National Plan of Action on Infant and Young Child Feeding (2005-2010)”
completed. Both the Policies and the Plan address the key targets in the Global Strategy, with the Global
Strategy and accompanying documents such as the IYCF Assessment Tool used extensively by the
consultant that helped with the drafting. The Plan focuses on six mother-child friendly settings (health
facilities, work places, schools, public places, communities and homes, and industry) and employs four
strategies to reach each of these places:
     o Develop policies and standards
     o Improve systems for effective IYCF
     o Mobilize stakeholders to IYCF
     o Involve families and communities to promote and adopt IYCF
After the Program Implementation Review (PIR) last year, a yearly implementation plan was drafted.

The Medium-Term Philippine Plan of Action for Nutrition 2005-2010, which is being managed by the
National Nutrition Council, includes a substantial IYCF component as well. For example, the plan targets
the revitalization of MBFHI, testing a model of organizing and maintaining effective community support
groups for breastfeeding in urban areas and organizing these groups in over 100 barangays, developing
“demonstration” mother-baby friendly workplaces, conducting training of trainers and trainings for large
numbers of health workers and volunteers on breastfeeding, setting up breastfeeding stations in malls,
revising the Implementing Rules and Regulations (IRR) of the Code, holding a number of meetings and
conferences for political leaders, medical practitioners and NGOs, among others, airing TV and radio
plugs on breastfeeding, producing and distributing nutrition education and communication materials to
health centers, schools and other public places, and coordinating World Breastfeeding Week. It focuses
on complementary feeding, supplementary feeding and nutrition education as well. The National Plan
targets marginalized families and areas with high levels of undernutrition, food-poverty, and poverty. The
updated Plan of Action for 2008-2010 mentions that wide coverage will be a main concern as opposed to
piloting and limited coverage, and specifies that protection of optimum IYCF in disaster situations will be
a special concern. It does not mention HIV and infant feeding.

UNICEF’s Sixth Country Programme for Children (CPC 6), which covers 2005-2009, has included some
IYCF activities, starting in its second year, with an increased emphasis on “disparity reduction” and thus
more concentrated efforts in disadvantaged barangays. The activities planned vary, as the DOH, each of
the Centers for Health Development, focus areas and regions prepare their own Action Plans. Activities
listed include, for example, IYCF advocacy at provincial and local levels, training of health workers and
BHWs on IYCF and counseling, MBFHI training, assessment, reassessment and certification,
establishment of breastfeeding mother support groups and “mother baby friendly” communities, Code
monitoring, airing of IYCF-related radio and TV spots, sponsoring of World BF Week celebrations and
campaigns, distribution of IEC materials, provision of breastfeeding support in the workplace, and
integrated monitoring of IYC and other child survival activities. Some plans have very few IYCF
activities and others quite a number. More than half are listed as “unfunded”. One of the CPC’s goals is to
increase exclusive breastfeeding rates for children less than 6 months of age by 30% by 2009. The
templates for the action plans for CHDs and focus areas ask for baseline and target data for this indicator,
but most of the plans have not provided this information. The extent to which focus areas and barangays
plan and implement comprehensive IYCF programmes varies greatly, due to the “devolved” system, but



                                                                                                            9
the focus on IYCF programming within CPC 6 has increased substantially in the last few years (see
details in sections below).

WHO’s “Country Cooperation Strategy, Philippines/WHO 2005-2010” has very little emphasis on IYCF,
although WHO staff have been active collaborators in various IYCF initiatives.

Throughout the process of “revitalization” of BF/IYCF in the last four years or so, UNICEF has played a
key advocacy role on many fronts. UNICEF made the case for strengthening the Milk Code and IYCF
programming by highlighting decreasing exclusive breastfeeding rates as reported in the NDHS, the
results of the MBFHI review which showed that substantial slippage in compliance, and widespread use
of infant formula, the country’s number one imported commodity. It provided technical support for the
development of the IYCF Policies and Plan of Action and supported a consultation “write shop” where
guides on the establishment of five breastfeeding/healthy places were drafted. In the last few years it
played a critical advocacy role for the Milk Code (see section below) and lobbied actively at policy level
for stronger mother and child friendly nutrition programmes, with an emphasis on BF/IYCF, at the first
National Conference of Nutrition Stakeholders in the Philippines (Manila April 2006).

The President’s Accelerated Hunger-Mitigation Program (AMHP), launched in 2007 and implemented by
the NNC is providing a boost to IYCF. Encouraged by advocacy for IYCF at the Nutrition Stakeholders
Conference, NNC has incorporated key IYCF activities into the “Promote Good Nutrition” component of
the AMHP, including training and support for IYCF at community level and assistance for MBFHI
training of trainers in its priority areas. In addition, an “Expanded Breastfeeding Act”, which would
mandate the establishment of lactation stations in the workplace and public places and integration of
breastfeeding education into the school curricula was proposed by Senator Cayetano and passed by the
Senate. The Act is currently stalled in the House. The Bicameral Committee needs to meet and finalize
the Act, which then would need the signature of the President to make it into law.

Milestones related to policies and plans and the key components of the breastfeeding and IYCF
programmes described below are presented in Annex 3.

3.4 Key components of the breastfeeding and IYCF programmes
The Milk Code
The efforts to successfully regulate breast milk substitutes began in the Philippines more than 25 years
ago, with two intense struggles over time. In 1981 the International Code of Marketing of Breast-milk
Substitutes was adopted by the World Health Assembly. That same year the Philippines’ national Code
was drafted, but it took 5 years of forceful advocacy before it was signed into law, with NGOs led by the
National Coalition for the Promotion of Breastfeeding, later named BUNSO, lobbying for its passage. In
1986 BUNSO staged a street march of breastfeeding mothers and babies together with community
leaders, doctors, lawyers and church leaders in front of the offices of four milk companies. Breastfeeding
mothers participated in discussions concerning the Code. The Philippine Code of Marketing of
Breastmilk Substitutes (E.O. 51) --The “Milk Code” -- was finally signed into law later that year.
Throughout the next twenty years the DOH and other government agencies, in collaboration with NGOs
and international agencies, struggled to give the Milk Code “teeth”, through its Implementing Rules and
Regulations (IRR) and efforts to monitor and enforce them. Meanwhile formula companies continued to
find ways to more aggressively advertise and promote their products. In 1994 the Milk Code Task Force
was formed and the following year proposed stringent implementation of its restrictions. Then in 2000 the
IRR was revised in favor of the milk companies. A controversial Administrative Order issued by Sec. of
Health Romualdez allowed milk manufacturers to engage in activities such as breastfeeding education,
and production and development of materials on breastfeeding. When a representative from the milk
companies was invited to be a member of the National Breastfeeding Technical Working Group (TWG)



                                                                                                        10
in 2000 ,UNICEF decided to no longer attend. (Currently the National IYCF TWG does not have any
milk companies or associates as members and UNICEF is active again.)
In 2004 the struggle to close the loopholes began to
heat up again, with 12 drafts of Revised
Implementing Rules and Regulations (RIRR) for
the Milk Code prepared by the Task Force over the
next couple years, while the milk companies and
their allies actively lobbied against adoption. In
2005 30 partners from government and NGOs were
trained on monitoring the Milk Code by resource
persons from ICDC10 in Malaysia, code monitoring
courses were held at regional and local levels, and
then a major seminar on advocacy for the new IRR
was held for the NGOs, all with UNICEF support.
Finally, in 2006 the Revised Implementing Rules
and Regulations (RIRR), which provided clear
guidance on how the National Milk Code could be
enforced, were signed by the Health Secretary. This was just the beginning of the battle, however. After
the signing, the companies filed a petition to the Supreme Court to annul and set aside the RIRR,
challenging the validity of a number of its provisions and applying for a Temporary Restraining Order
(TRO). The Supreme Court initially rejected the request for the TRO. A month later the Court changed its
initial decision and granted the TRO, a few days after a letter was received from the US Chamber of
Commerce by President Macapagal-Arroyo, warning of “the risk to the reputation of the Philippines as a
stable and viable destination for investment” if the RIRR was not re-examined.11
Both before and after the TRO was granted the
Philippines saw a period of intense advocacy for
breastfeeding and the RIRR by the DOH, with support
from UNICEF, WHO, Children for Breastfeeding,
Save the Babies Coalition led by Arugaan, and many
other local and international breastfeeding advocates
such as WABA and IBFAN. The UNICEF
Representative, Dr Nicholas Alipui, played a
catalyzing role in this effort and key WHO staff were
very active. The UNICEF/NY legal officer for the
Code, David Clark, gave valuable support, as well.
Skilled use of data by UNICEF, WHO and its partners
was a critical part of the advocacy efforts. Drafts of
the IRR were discussed in a public hearing and the Senate, the House and Malacanang held public
inquires on the Milk Code. Around the time of the oral argument at the Supreme Court, over 249 related
print reports appeared in local newspapers and there were 81 TV news reports on the subject. UNICEF’s
video, “Formula for Disaster” was widely popular, with over1000 copies distributed, some
internationally. It is estimated that the milk companies had over 100 million USD available for formula
promotion (2006 Neilsen) while the DOH only had 60,000 USD for breastfeeding promotion (2006
budget), but the advocates were able to capture the attention and support of the media, the public, the
politicians and the justices (UNICEF annual report 2007).


10
  International Code Documentation Center, a member of the IBFAN network
11
  “Pharmaceutical and Health Care Association of the Philippines vs. Health Secretary Francisco T. Duque III et al.”, ICDC
Legal Update, January 2008.


                                                                                                                             11
Finally, in October 2007 the Supreme Court lifted the TRO and affirmed the RIRR, except for 3 of the 57
provisions. The provisions disallowed included a total ban on advertisements, promotion and
sponsorships by formula companies and administrative sanctions and fines in case of violations of the
Code. The rest of the RIRR was declared “reasonable regulation of an industry which affects public
health and welfare” and on closer look, it was determined that the DOH could still “cause the prosecution
of the violators” of the Code and provide penalties upon conviction. The RIRR allows the DOH to require
strict labeling of covered products, allows for oversight to extend to breast milk substitutes intended for
children over 12 months of age, and many other important tools for regulation.
Thus, a very important victory was achieved in the “Milk Code struggles” which, at the same time, served
to sensitize the press, the public, and the politicians to the importance of breast milk and energize the
efforts to implement IYCF programmes throughout the country. However, the battle to enforce the Milk
Code is far from over. An Inter-agency Committee has been tasked with monitoring and enforcement of
the Code. Vigilance is needed at all levels of society, if the Code is to be effectively monitored and
violations noted and penalized. The DOH will need support from the international agencies, the health
system and NGOs at all levels, to succeed.
The Mother Baby Friendly Hospital Initiative (MBFHI)
In the Philippines a little less than half of the deliveries (43.5%) are institutional – with the remaining
taking place at home. The country was one of the first to demonstrate the impact of “rooming-in” in
maternity services, with the pioneering work of Dr. Natividad Clavano at Baguio General Hospital in the
mid 1970s, including “revolutionary” changes at the hospital such as closing the hospital nursery,
rooming the babies with their mothers, and limiting formula use. These measures led to an increase in
breastfeeding in the maternity wards from 40.5% to 87.1% and impressive decreases in morbidity and
mortality (with diarrhea episodes reduced by 94% and death among clinically infected babies reduced by
95%) (Clavano 1982).
Dr. Jose Fabella Memorial Hospital (Fabella), the largest maternity hospital in Manila, started rooming-in
for normal vaginal deliveries in 1979 after training by Dr. Clavano. In 1985 medical/nursing teams from
Fabella began to receive intensive training in lactation management by Wellstart International, a WHO
Collaborating Centre, with 9 staff trained over a period of about 7 years. By the late 1980s Fabella had
closed the newborn nurseries and totally phased out the use of formula, with breastfeeding and use of
expressed milk even in the neonatal intensive care unit. In 1989 Fabella was recognized officially by the
DOH as a “Rooming-in Facility”. That same
year, Dr. Gonzales, Medical Director at Fabella,
calculated that each year his hospital had saved
6.5 million pesos (310,000 USD), a full 8% of
its annual budget, as a result of not having to
pay for a full scale nursery – figures that helped
convince other hospital administrators that
rooming-in was cost-effective. In 1991 Fabella
was designated as the National Lactation
Management Training Center, and later helped
set up a regional training center in Cebu.
In 1991 the global Baby Friendly Hospital
Initiative (BFHI) was launched and in early
1992 the Philippines participated in the “Master
Trainers and Assessors Workshop” and served
as one of 12 “starter” countries. The Rooming-in and Breastfeeding Action (RA7600) of 1992 provided
the legal mandate for the Philippines’ Mother Baby Friendly Hospital Initiative (MBFHI), which got
underway in 1993.



                                                                                                         12
The Initiative was very active in the early years. Wellstart International provided lactation management
education (LME) for breastfeeding professional both within the Philippines, at a Regional workshop in
Bali and in the US. A “Sister Hospital Scheme” was launched in 1994, with government medical centers
tasked to assist their private hospital partners to become mother and baby friendly. Over 78 MBFHI
courses were given at Fabella and other training sites for over 4,000 trainees by 1996, with support from
the DOH, UNICEF and USAID. Courses were provided for local administrators and policy makers as
well. The hospital became internationally known and hosted and trained teams from a number of
neighboring countries. Strong progress was made in hospital designation in the mid to late 1990s under
the leadership of Dr. Margarita Galon at the Hospital Operation and Management Service (HOMS)/DOH,
with 139 hospitals designated Mother-Baby Friendly (MBF) in 1993, 667 in 1995, and 909 in 1997,
reaching a peak in the late nineties, when the DOH had certified 1,427 or 83% of the 1,713 targeted
hospitals12.
In the late nineties and early 2000s compliance began to slip as UNICEF/NY decreased its support for
BFHI, the Government of the Philippines (GOP) “re-engineering” resulted in the transfer of key
professionals who had been managing the MBFHI to unrelated positions, UNICEF Philippines and DOH
support lessened, and pressure from the formula companies continued to mount. A very simplified tool to
assess the MBFHI-certification status of hospitals was incorporated into the licensing activities of the
DOH thereby further short changing the assessment process. A one day MBFHI Programme Review and
Evaluation was held in 2000 to discuss strategies for sustainability and to prevent backsliding among
accredited hospitals, but little was done for several years. In 2006 UNICEF supported a retrospective
study on the MBFHI by the University of the Philippines in 15 regions and 98 hospitals, which revealed
that only:
     o 52% of the participating hospitals had lactation coordinators
     o 63% of the mothers were assisted in initiation of breastfeeding within half an hour
     o 52% of post-partum mothers were assisted to breastfeed and maintain lactation
     o 43% of hospital personnel did not allow food or drinks other than breast milk
     o 28% of the health facilities fostered the establishment of breastfeeding support groups
         (Revitalization of MBFHI, A.O. 2007-0026, p.2).
There was high compliance with Steps 1, 7, and 9 (breastfeeding policy, rooming-in and no pacifier use),
fair compliance with Steps 2 through 6 (staff training, antenatal education, early initiation and no use of
formula), and low compliance with Steps 8 and 10 (feeding on demand and fostering of mother support
groups). Some of the barriers included lack of awareness of heads of facilities of their accreditation, lack
of budgetary support for training and monitoring, inadequate information, education and communication
(IEC) materials, inadequate training and knowledge of staff, inadequate monitoring, poor commitment
and cooperation of some staff, unregulated marketing by the milk companies, and lack of active MBFH
task forces.
In 2006 UNICEF shared the revised global WHO/UNICEF BFHI materials with partners at national and
regional levels and worked with the DOH to develop technical guidelines on MBFHI. In 2006 UNICEF
also supported a MBFHI Assessors Course, with participants including programme managers and
licensing officers based at DOH Centers for Health and Development at regional levels and staff from
PhilHealth. About 160 were trained nationwide. In 2007 the DOH issued an Administrative Order on the
“Revitalization of MBFHI” (AO 2007-0026). This set of guidelines had, as objectives, to revitalize the
MBFHI, with a new emphasis on enforcing the Code, providing mother-friendly care, establishing
linkages with primary health care facilities and community support groups, and ensuring the hospital as a
MBF workplace. The guidelines designated a management structure at various levels with Fabella
remaining the National IYCF Training Center. An accreditation process was agreed upon, including self
assessment, issuance of a Certificate of Commitment for 2 years, and training as needed on the 10 Steps,

12
     There were 1798 hospitals/maternities in the Philippines, according to the UNICEF BFHI Report for 2005/6.


                                                                                                                 13
mother-friendly care, HIV, and infant feeding in emergencies. Reassessment will follow with
accreditation for sustained implementation, and a required annual MBFHI report to the Center for Health
Development (CHD). One important innovation was the integration of the MBFHI within the PhilHealth
accreditation system, requiring hospitals to be MBF before receiving PhilHealth accreditation. (See
Annex 4.)
Starting in 2007 Fabella began to actively assist with reassessment and training, and is being asked to
conduct a number of regional training of trainer (TOT) courses for hospitals in all priority areas, with
support from the President’s Accelerated Hunger-Mitigation Program.
BF/IYCF training and education13
Training of hospital staff on breastfeeding and implementation of the “Ten Steps” within the MBFHI has
been a major part of the focus of BF/IYCF capacity building. In addition, other ICYF training activities
have been held within the health system, at the community level, and within the pre-service educational
system for health professionals. In the 1990s training in MBF at the hospital level and strengthening of
service providers in the field on breastfeeding counseling was undertaken with support from the DOH,
UNICEF and USAID. Regional Baby Friendly Speakers Groups were organized to provide technical
assistance to service providers and barangay health workers were trained to support breastfeeding
mothers. In 2003 the Handbook, Integrated Management of Pregnancy…Childbirth, Postpartum and
Newborn Care, which includes breastfeeding management, was produced by the DOH for the Philippine
setting, with support from UNICEF and other donors and then provided to trained health workers. In
October 2005 WHO/Geneva and UNICEF/NY conducted one regional TOT for the Integrated Course on
IYCF Counseling14 in the Philippines. UNICEF then supported TOT courses on IYCF in selected regions
and Training on IYCF Counseling in its 19 CPC 6 provinces. An estimated 200 trainers from national,
regional and provincial levels were trained and about 500 health implementers were trained in CPC 6
areas15. A Lactation Management Course was supported by UNICEF in 2006 targeting health personnel
of selected medical centers and regional hospitals, with about 120 staff trained.
By the end of 2006, with assistance from the President’s Accelerated Hunger-Mitigation Project (AHMP)
an estimated 13,000 volunteers and successful breastfeeding mothers were trained/oriented/organized to
provide support to other breastfeeding mothers. The AHMP supported 3 TOTs for the Integrated Course
on IYCF Counseling for 86 participants. By April 2008 almost 9,000 participants in 83% of the targeted
municipalities and barangays had been trained on IYCF, using the Integrated Course and Pabasa sa
Nutrisyon16, developed by the Nutrition Center of the Philippines (NCP) with the help of the Fabella
Training Center. The trainees included municipalities, city and barangay17 implementers, including
BHWs and barangay nutrition scholars (BNSs), and hospital-based implementers and clinicians. The
AMHP is planning that over 75% of its focus barangays will be covered by IYCF training with help from
Fabella, with almost 24,000 participants targeted by the end of 2008. In addition, the target for lactation
management training in 2008 for priority one, two and three areas is over 2,000.
Through the years, there have been periodic recommendations that the lactation management and IYCF
content in the curricula in medical, nursing and other health science schools be strengthened, as coverage
of the topic is often very limited, with little or no clinical practice. As early as 1985 a Manual on Infant
Nutrition with emphasis on breastfeeding was prepared by the NCP for the Association of Philippine
Medical Colleges (APMC), with the participation of well respected faculty of key medical schools, and

13
   A list of IYCF training materials and courses is provided in Annex 1: Materials Reviewed.
14
   The Integrated Course focuses on breastfeeding, complementary feeding and HIV/AIDS.
15
   CPC 6 covers only19 out of 81 provinces and only 5 highly urbanized cities.
16
   Pabasa sa Nutrisyon is a nutrition information/education strategy, consisting of 10 interactive learning sessions, provided by
BHWs, BNSs or cluster leaders, under the supervision of public nurses and midwives for mothers and other household members.
(IYCF Action Plan, p. 32) It integrates breastfeeding and complementary feeding into some of the sessions but, according to
UNICEF, the preparation of a separate module on breastfeeding would be useful.
17
   The smallest administrative division in the Philippines, the native Filipino term for a village, district or ward.


                                                                                                                              14
was used for about five years. Use was not wide-spread, most likely because instructors are responsible
for developing their own curricular content.
Recently efforts to introduce additional practical content on IYCF have continued. Academics in some
key schools have added practical IYCF-related content to their courses and clinical sessions on an
individual basis and some work has been done to propose additional content, for example, in the APMC
handbook. The National Plan of Action on IYCF (2005-2010) proposes that medical, nursing and
midwifery colleges and universities both strengthen their IYCF curricula and provide short postgraduate
lactation courses. A major effort has been launched to insert Integrated Management of Childhood Illness
(IMCI) into pre-service curricula, with the IMCI module integrated in the curricula of 22 medical, 60
nursing and 45 midwifery schools. This initiative might provide some useful lessons. Some breastfeeding
content is provided within the IMCI modules, but it needs strengthening, and consideration is being given
by UNICEF to this issue.
Recently a model chapter, “Infant and young child feeding: Model Chapter for textbooks for medical
students and allied health professionals”, has been finalized and published by the World Health
Organization, which could provide very useful content for pre-service education on this topic.
Finally, some efforts have been made to integrate nutrition content into elementary education. The
Nutrition Center of the Philippines developed a School Guide for Teaching Proper Nutrition, for grades 1
– 6, which focuses on malnutrition but might be supplemented with IYCF related materials. The National
Plan of Action for IYCF recommends that breastfeeding be included in elementary education, and a
focused initiative is needed to bring this to fruition. (See Annex 1, “Training Materials”, for a list of key
IYCF-related education and training materials.)




Communication
Breastfeeding promotion in the media began in the early 1980s, with the establishment of the National
Movement for the Promotion of Breastfeeding. As described in the section on the “Milk Code”, efforts on
the part of NGOs to lobby for the passage of the Philippines National Milk Code in this same period
included a number of advocacy and promotional activities. In 1992 World Breastfeeding Week (WBW)
was first celebrated world wide, with coordination by WABA and the endorsement of UNICEF, WHO
and the Food and Agricultural Organization (FAO). It has been celebrated at various venues in the
Philippines since that time, with extra media attention
to breastfeeding issues during that week, but
observance weakened in the late 1990s. It was given
added importance when the President issued a
proclamation in 2005 for a week long WBW
celebration every first week of August, helping to
ensure stronger participation of both government and
NGOs.
Both the DOH and UNICEF have been actively
involved in promoting BF/IYCF via various media
channels, with a wide range of posters, articles, videos,
and radio and TV spots produced and aired. (See the
IEC section of Annex 1 for a list of key materials.)
Much of the media support was initiated to provide
support for the Milk Code and the RIRR (see section
above), with the DOH, the NGOs, UNICEF and WHO
encouraging coverage. IEC materials have also been


                                                                                                          15
developed and distributed by UNICEF focused on reviving the breastfeeding culture in the workplace and
community, and behaviour change communication materials on IYCF have been distributed in the focal
areas. In 2006-2007 UNICEF helped develop and implement the national communication campaign on
breastfeeding (“The Miracle of Breastfeeding”) and developed and disseminated over 50,000 posters in
English and Tagalog. Messages included, for example, guidance on the value of colostrum and early
initiation, positioning and attachment, why breastfeeding is best for mom and baby, and how to express
milk. Some of the messages were based on data gathered through KAP studies. With its increased budget
this year, the DOH has funded a number of the IEC materials and the World Breastfeeding Week
Celebration.
Two media achievements were spearheaded by Children for Breastfeeding (CfB), with the Philippines
achieving the Guinness World Record in Simultaneous Breastfeeding in a Single Site (3,541
breastfeeding mothers in Manila) during WBW 2006 and then CfB partnering with WABA on
Synchronized Breastfeeding Worldwide to achieve the Guinness World Record in Simultaneous
Breastfeeding in Multiple Sites (with16 countries and 10,000 mothers) during WBW 2007. UNICEF
contributed to the production of a “Baby Crawl” video filmed at the Fabella, which features a newly
delivered baby instinctively looking for the breast, rooting and latching for his first breastfeed.
As mentioned in the Milk Code section, UNICEF commissioned a documentary “Formula for Disaster” in
2007 which highlighted the risks of artificial feeding and the negative effects of unethical marketing
practices on breastfeeding.
Thus the communication section of UNICEF has substantially increased its efforts and capabilities to
support IYCF advocacy and promotion efforts in the last 3 years, in collaboration with the DOH, WHO
and various NGO partners. UNICEF is currently working with WHO, DOH and other stakeholders to
develop a multi-year communication strategy using the Communication for Behavioral Impact (COMBI)
methodology. A group of 25 people from the various stakeholders were trained in COMBI last
November. A final plan for the multi-year communication strategy will be ready by mid-2009.
Community-based promotion and support
Community level volunteer workers. As early as 1981 UNICEF was working on community level
nutrition strategies, with a “Barangay Nutrition Scholar Project” for village level nutrition workers, which
had the goal of training and deploying one in each of 30,000 barangays. Growth monitoring was one of
the key activities at this level in the early years. Within the CPC 5 (1999 – 2003) 2,220 health and
nutrition posts were established with barangay health and nutrition workers, volunteers with minimal
honoraria from the LGUs. These barangay based workers are expected to closely follow-up mother-infant
pairs from pregnancy through child birth and their infants’ early years. They are assigned to do
breastfeeding promotion and support, among
other tasks. The Barangay Captains, elected by
popular vote, appoint the BHWs and BNSs.
The programme is nationwide/at scale but is
dependant on local politics as far as
implementation. The health and nutrition (H &
N) posts throughout the country are under-
staffed at present, with only 30% of them
currently having BHWs, and with these
workers receiving their last full training about 5
years ago. As mentioned earlier, there is about
50% turnover among the volunteers, with each
round of elections for Barangay Captain every
three years. During the CPC 6 (2005 – 2009)
there has been some added emphasis on



                                                                                                         16
strengthening BHW capabilities in selected disparity barangays and UNICEF is providing the funding for
training newly appointed BHWs/BNSs on an annual basis.
Peer counselors and support groups. As mentioned in the section on training, IYCF “training of
trainers” at various levels, down to the community, has been revived in recent years, with the DOH, the
AHMP, Fabella’s National Training Center, UNICEF and WHO involved in various initiatives.
Following training, one key focus has been the training of peer counselors and fostering of breastfeeding
support groups. Breastfeeding support groups, for example, were established in 103 barangays in 24 focus
areas under CPC 6 with support from “Children for Breastfeeding” during 2005-6 (UNICEF annual report
2006).
Model breastfeeding communities. The DOH and other partners have begun to advocate for the
establishment of “model breastfeeding communities”, with a number of complementary features,
including ordinances for Milk Code enforcement, and health workers, birth attendants, peer counselors
and support groups able to monitor, support and encourage appropriate infant feeding. The model
communities would be mother and child friendly in their workplaces and public places as well.
Several innovative community-based pilot programmes with a focus on IYCF are currently underway.
The cities of Caloocan, Makati and Taguig recently passed City Resolutions or Ordinances in line with
recommended feeding practices of the DOH and WHO. They have worked to create breastfeeding rooms,
monitor and report Milk Code violations, train workers, promote breastfeeding and establish community
support groups to aid pregnant and new mothers with IYCF problems. A model for a community-based
breastfeeding programme and community support groups was implemented in Barangay Pembo by
Makati City in 2005, in collaboration with the Makati Health Department, and with technical and
financial support from WHO. It utilizes peer counselors who make several visits to pregnant women and
mothers with infants and young children, using “negotiation skills” and locally developed motivators to
encourage the women to try improved feeding practices, while keeping good records of progress made.
This programme has now undergoing citywide expansion and has been replicated in a number of
additional nearby barangays. The programme implementers and WHO have prepared reports on how and
programme has been implemented and the results from monitoring and evaluation efforts, in the hopes
that the experience and guidelines provided will encourage other municipalities and LGUs to replicate the
programme. (See Annex 4 for further details.)
The Nutrition Center of the Philippines, in partnership with Cebu City Nutrition Committee, launched a
comprehensive barangay nutrition programme for the four nutritionally depressed barangay of Cebu City.
It trains the barangay workers to target families with newborns to <3 yr olds, pregnant women, lactating
women and underweight preschoolers, providing innovative support. An important feature of the Cebu
initiative is that it has a comprehensive IYCF approach, focusing both on breastfeeding and
complementary feeding interventions, and also is both preventative (for all children under 3) and curative
(providing additional support for underweight children.) The programme has begun to be replicated in
nearby areas. (See Annex 4 on “Innovations” for
details on both the Pembo and Cebu City initiatives.
Mother baby friendly workplaces and public
places. Useful work has been underway for some time
to establish mother baby friendly workplaces. Arugaan
has been working on this strategy for years. As early
as 1994 the NGO received a seed grant from WABA
to set up crèches in the workplace and later the NGO
developed training modules and detailed guides for
child care in the workplace. The DOH, WHO and
UNICEF worked with the TUCP and the ECOP and
other union leaders to develop pilot mother baby



                                                                                                        17
friendly workplaces. This started with two factories in 2006 and then an additional four workplaces in
2007 that have facilities for expressing and storing expressed breast milk, time for milk expression, and
regular seminars for pregnant women on IYCF. The DOH is in the process of drafting a guide on “Setting
up mother and baby friendly workplaces in the Philippines”.
Awareness of the importance of supporting breastfeeding in public places has grown as well.
Breastfeeding stations were installed in all SM Malls in 2006 and other malls put up breastfeeding
stations in 2007, with assistance from Children for Breastfeeding, UNICEF and other NGOs.
Breastfeeding stations/rooms were also set up within the city government of Manila, the provincial
government of Davao del Norte, Tadeco Plantation, Davao international airport, and the UNICEF Office
in Manila. At the same time, advocacy work is underway to increase the publics’ and businesses’
acceptance of breastfeeding in public.
Maternity protection
Paid maternity leave in the Philippines is limited to 60 days (about 8.5 weeks) for normal births and 78
days for c-sections. At least 4 weeks of the leave must be taken after birth and leave is allowed only for
the first four births, including miscarriages. 30 minutes of paid breastfeeding breaks per day is also
mandated.
Employed women are eligible for the leave if they have made 3 or more monthly contributions to Social
Security, including domestic workers whose salaries exceed 1,000 pesos per month. The allotted leave is
considerably less than the 14 weeks provided for in the 2000 ILO Maternity Protection Convention
(#183), which the Philippines has not ratified. 18
3.5 Integration strategies and cross-cutting issues
In addition to the major foci of the IYCF programme described above, there has been work to integrate
IYCF into key programmes focused on “children in difficult circumstances” such as those affected by
emergencies and HIV/AIDS19.
Emergencies are a regular occurrence in the Philippines, with yearly typhoons, floods and landslides and
the on-going armed conflict in the South. In the past the issue of IYCF in these difficult circumstances has
been poorly understood, with humanitarian relief planners and teams often ignorant of the detrimental
effects of infant formula donations and use. Recently national partners have attended a course on Infant
Feeding in Emergencies with UNICEF support and the first regional meeting on this topic was held in
Bali in March 2008. A national policy on the donation of infant formula during emergencies was
developed and endorsed by DOH-HEMS later that year. Work needs to continue to provide adequate
safeguards for children in these challenging situations.
The prevalence of HIV/AIDS, reported in the SOWC 2009 as less than .1% for adults 15-49 years, has
been described as “low and slow” in the Philippines. However, there are underlying factors, such as the
large number of overseas Filipino workers, the tourism and the entertainment industry, and the increasing
rates of pre-marital sex among teens, that could lead to a spread of the epidemic. The DOH claims that
HIV prevalence is under-reported and that prevalence should now be classified as “hidden and growing”.
Peri-natal mother to child transmission (MTCT) was estimated as only at 1.5% in 2007, but it may be
somewhat higher, as many people may hide their positive status, fearing social stigma. UNICEF/Manila
has included HIV/AIDS as one of its programme areas since 2004 and the IYCF Action Plan has targeted
PMTCT as one focus area. Guidelines and modules have been developed on voluntary confidential
counseling and testing (VCCT), core trainers are available to cover this topic and 13,000 health workers
were trained on HIV in the context of IYCF in 2006 as part of the “IYCF Counseling Course”, but rapid

18
   From “Maternity Protection in International Law and Practice in South-East Asia”,
http://www.asianfoodworker.net/maternity/mp-law-seasia.htm, 2004.
19
     Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome


                                                                                                             18
turn-over of trained staff is a continual challenge. A prevention of mother-to-child transmission (PMTCT)
initiative has been launched at Davao Medical Center with training provided to 35 hospital staff. None of
the women tested thus far have been positive. Later this year Davao’s experience will be shared and
decisions made regarding “next steps”.
Human milk banking is still practiced in the Philippines and, at the time of the evaluation, there was no
Government policy on HIV testing of donors. In some of the crèches communal breastfeeding is
practiced, again with no policy on HIV testing.
Breastfeeding or IYCF content, to some degree, has been integrated into several other key programmes,
including the IMCI, the Female Functional Literacy programme, and the Maternal and Newborn Care
interventions. However, coverage of key IYCF messages and practical guidelines definitely needs to be
strengthened in each of these initiatives. The training module produced by UNICEF for Enhanced Child
Growth (community IMCI) has sessions on “Rights of the Child” and “Breastfeeding”. Work to integrate
practical guidance on how to support mothers delivering at home to “latch on” their babies immediately
after birth has been inserted into the Helen Keller International SHIELD20 programme in Mindanao,
providing an example of how key steps in the continuum of care should be integrated into initiatives.
HRBAP and gender mainstreaming has been an important “cross-cutting issue” in UNICEF programming
in the Philippines. The “human rights-based approach to programming” (HRBAP) underpins UNICEF’s
approach to the Child Friendly Movement and its various Country Programmes for Children, but there
has been some resistance in the government in a country where “rights” are not much a part of the general
thinking and where the U.S., which didn’t sign the Convention on the Rights of the Child, has a strong
influence. The focus, to a large extent, is still on “needs”. “Duty bearers” such as government officials,
health workers, NGOs and the community receive some sensitization to their responsibilities through
various training activities. The involvement of “claim holders” such as women and their children was
quite intense during the successful activism by women’s groups in achieving the adoption of the Milk
Code and protecting it from industry challenges. Large numbers of women, often with their babies,
participated in demonstrations, held simultaneous “breastfeedings” that achieved world records and drew
media attention to their cause, and participated in public hearings concerning the changes needed. In
addition, women have participated in planning through focus group discussions in some of the
disadvantaged barangays within the CPC areas.
UNICEF chairs the “UN Gender Mainstreaming Committee” which has worked to ensure that gender
equality and women’s empowerment are prioritized in all UN supported programmes and projects. A
National Plan of Action for the Filipino Girl Child has spurred debate and greater understanding of gender
issues. Gender equality has generally been a positive aspect of the Philippines’ social development
situation.

3.6 Resources invested
Detailed information on resources invested for health care both nationally and by UNICEF through its
health and nutrition budget within the CPC is available. Unfortunately, neither the DOH nor UNICEF
Philippines was able to disaggregate what had been spent on breastfeeding or IYCF through the years. It
is useful to look briefly, however, at the overall resource and expenditure picture, to get a sense of what
resources have been available for health and nutrition, how they have been allocated, and what is planned
for the future.
The Philippine National Health Accounts 2005 report (published in 2008) states that in 2004 the
Philippines total expenditure on health was 3.4%, well below the 5% recommended by WHO for
developing countries. A large percentage of the government’s budget for health goes to tertiary care,


20
     Sustained Health Improvements through Empowerment and Local Development


                                                                                                            19
draining potential resources from primary health care. It can be assumed that there are few resources for
IYCF.
Government spending on the health sector declined from 2000 to 2006, down from Philippine Peso (PhP)
14.66 billion to PhP 13.66 billion in 2006. Debt servicing, unfortunately, increased during this period,
from 25% of the government’s budget in 2002 to 32% in 2006, exceeding social services (28%) and
economic services (19%) (CPC 6 Mid term Review (MTR) #46.) About 29% of total health care
expenditure was by the government (14.5% by the national government and 15.4% by local
governments), while a full 47.4% was direct, out-of-pocket expenditure by households. Social insurance
(PhilHealth) contributed 9.2% and health management organizations, employer-based plans and private
insurance accounted for 13.5% (Sit Analysis 2007, p. 16).
In 2007 the Government’s budget for the health sector went up to almost PhP 20 billion and, as a result,
there was a large increase in IYCF GOP funds.
UNICEF provides its funding for health and nutrition through its Country Programmes for Children, with
both regular resources (RR) allocated by UNICEF/NY and other resources (OR) received from donor
governments and private resources raised specifically for the country. The 5 year funding for CPC 6 was
US$ 43.57 million, 6% higher than CPC 5’s funding. Through fundraising, actual available funds have
risen to US$53.17 million and the actual budget for the first 3 years exceeded by almost 65% the planned
amount. UNICEF Philippines programme utilization figures for CPC 6 for 2007 report a total expenditure
of US$15.58 million, with $3.22 million of that allotted to Health and Nutrition, with about half of that
for “Child Health and Sanitation”.
Recently, the potential for support for health and nutrition, and thus IYCF, has increased with good news
both from the DOH and the National Nutrition Council (NNC). Recent decisions have been made within
the GOP to approve a massive increase in the budget of the DOH, with an increase of about 9 billion PhP
for various programmes. The case for this increase was made based on the unfolding preparation of
provincial health investment plans within the context of the national health report, F1, which convinced
the Department of Budget to invest more. One billion PhP has been allotted for maternal mortality rate
reduction. (Other allocations were not available to UNICEF Philippines at the time of this case study.) In
addition, the NNC has had 400 million PhP available in 2008 alone to promote IYCF through the
Accelerated Hunger-Mitigation Program. The AHMP is hoping that these funds will make it possible to
go to scale with health reforms, including those related to IYCF. There is concern, however, about the
quick nature of this expenditure and the effectiveness of the investment, under the circumstances, with a
review planned for 2009.
Meanwhile, UNICEF is taking the lead in getting together a joint programme on “Children, Food Security
and Malnutrition”, which is an opportunity for a Spanish-funded MDG window. In addition, UNICEF
itself will be receiving an extra grant of US$10 million from AUSAid during CPC6, with continued
support in CPC7, to scale up its programme in selected disadvantaged regions, with a focus on health and
nutrition. This should allow needed work to determine how the challenges of working in a devolved
system can be addressed.

3.7 Sustainability, replication and scale-up
MBFHI. Sustainability has been one of the most difficult challenges faced by the breastfeeding and IYCF
programmes in the Philippines, as can be seen in the programme descriptions above. While the MBFHI
made impressive achievements in the 1990s, organizers and reviewers alike admitted that the Initiative’s
key weakness was lack of an effective scheme for sustainability. In the early years of BFHI, UNICEF, at
global level, pressed for adoption of the Initiative at country level and UNICEF country offices provided
support, while neglecting to press sufficiently for national ownership and financing. In the Philippines,
the DOH, through its Fabella National Training Center and the MBFHI management team within HOMS,
was very active in conducting training, assessments, and initial designations of MBF facilities, but


                                                                                                        20
neglected to set up viable systems for refresher training or for on-going monitoring or reassessment, or to
develop a system for management and financial support that could withstand the challenges posed by staff
turnover and administration changes at the top level.
As the DOH and its partners works to revitalize the MBFHI, it is being guided by the 2007
Administrative Order, which provides guidelines for introducing the new “mother-friendly” criteria,
provides useful indicators for each of the ten steps, clearly states responsibilities of the hospital staff for
compliance with the Milk Code, and describes training requirements, administrative roles of the National
Management Committee, Technical Working Group and coordinators at various levels, and a new
assessment and accreditation process. It requires that an annual MBFHI implementation report be
submitted by the health facilities to the CHD and reassessments undertaken every three years. Much more
work is needed, as well as additional financing, to fully implement these new guidelines. The agreement
reached with PhilHealth that requires facilities to achieve MBF status in order to be accredited by
PhilHealth is an innovative approach, which should encourage many facilities to seek MBF designation.
Additional work is needed to explore ways to provide more integrated MBFHI, IYCF and maternal and
child health (MCH) monitoring and support.
The Milk Code. The achievements of the breastfeeding community on the Milk Code, most recently with
final approval of the RIRR, have been impressive. However, all concerned admit that this is just the
beginning of the real struggle to successfully monitor and enforce E.O. 51 and the RIRR’s provisions.
There was a somewhat of a lull in the formula companies’ aggressive marketing tactics after the RIRR
was approved, but now they are beginning to pick up again. The inter-agency committee tasked under the
RIRR with monitoring and enforcement of the Code needs to be established and functional, with adequate
resources to ensure long term viability. Immediate work is needed to clearly interpret and disseminate the
current rules and to finalize and implement monitoring mechanisms and strategies for enforcement at all
levels. At the same time, an on-going creative media campaign is needed as an essential tool in helping to
“bring back the breastfeeding culture”.
IYCF in the community and workplace. Probably the biggest challenge of all for IYCF is achieving
scale-up and sustainability of viable mother support systems for breastfeeding in the community and
workplace. This is very important, since more than half of the Philippine’s mothers deliver at home, and
the MBFHI only helps to provide a “good start” for those babies delivered in maternity services. As
described earlier, the task of providing community-level IYCF support is extremely difficult given the
“devolved” nature of the health delivery system. Support is needed at the local level, through well trained
and motivated local health professionals and BHWs or BNSs, with effective systems in place for
supporting those mothers most in need, and on-going mentoring, monitoring and supervision. The most
disadvantaged barangays include indigenous communities, those affected by conflict and those in
extremely remote terrain – the most difficult to reach. While a few innovative and encouraging projects
such as the peer counseling initiatives in Makati and Cebu City (see Annex 4: “Innovations”) have
demonstrated what can be achieved, strategies for sustaining and replicating successful support at scale
need to be developed, with accountability on the ground. Experience has shown that political leaders at
various levels need to be engaged and convinced to provide financial, technical and logistical support.
Advocacy work through the Leagues of Cities, Municipalities, and Barangays is proving to be a useful
tool for accelerating expansion. Demonstrating cost-effectiveness is important, but, none-the-less,
substantial funding will be needed to reach even the more disadvantaged households. At the same time,
further work is needed to scale-up and replicate successful “pilot” projects to offer breastfeeding support
in the workplace and “breastfeeding friendly” public places.
In addition, Infant and Young Child Nutrition needs to be supported in an integrated way, and a focus on
both optimal breastfeeding and complementary feeding is necessary. The relatively high stunting (30%)
and underweight (28%) rates in the country point to the fact that the window of opportunity for
prevention of undernutrition (the first two years of life) needs to be fully utilized in the Philippines.



                                                                                                            21
Education. While capacity-building of health workers and volunteers will continue to be needed, the
largest gains are likely to come when needed IYCF-related knowledge and skills are successfully
integrated into the educational systems, including the primary and secondary schools and universities as
well as basic “pre-service” education for medical and nursing students who will later care for mothers and
children. Again, there are substantial challenges, as mentioned earlier, to scale-up and sustainability,
given the resources needed and the lack of a mechanism, in the case of “pre-service” education, for
dictating curricular improvements from central level.

4. Discussion
4.1 Accomplishments and areas for improvement
Accomplishments
The sections above on IYCF policies and programmes describe in detail the accomplishments in the
breastfeeding and IYCF initiatives in the Philippines over the past 15 years. The level of programme
intensity has varied greatly, with two key periods of high activity and accomplishment. As early as the
1970s the Philippines began to play a leading role in demonstrating the benefits of “rooming-in” and, in
the 1990s achieved impressive results under the MBFHI, with over 83% of the 1,713 targeted hospitals
certified. In that time period, as well, strong efforts were made to monitor and enforce the Milk Code,
although violations continued. Unfortunately, as described earlier, support for BFHI waned
internationally in the late 1990s and for MBFHI in the Philippines as well, as “re-engineering” took hold
within the DOH and UNICEF Philippines began to focus on other priorities. Adherence to the “Ten
Steps” began to slip and the UP Retrospective Study revealed very poor compliance.
During the early 2000s accomplishments in the area of breastfeeding were few. The 2002 Global Strategy
for IYCF helped to re-energize and refocus programmes around the world, including in the Philippines,
with a more integrated focus. In 2005 the Philippines made great strides, with the IYCF Policies and
Action Plan completed. Both the DOH and UNICEF, in collaboration with many partners, began to re-
focus on IYCF, as an important aspect of their broader health and nutrition programmes. Efforts began on
revitalizing MBFHI, with guidance from a new Administrative Order, large scale IYCF training started to
get underway in selected areas and, very importantly, the eventually successful struggle for the passage of
the RIRR for the Milk Code, served both to energize the breastfeeding community (NGOs, the
government and international organizations) and alert the general public to the importance of protecting
this practice. At the same time, demonstrations of successful breastfeeding promotion and support both in
the workplace and at community level, such as those in Makati and Cebu City, provided insights into
useful mother support strategies.
Areas for improvement
The work needed to provide the sustained protection, promotion and support needed to further improve
key IYCF practices has just begun, with many of the challenges outlined in the earlier review of problems
remaining:
   While the MBFHI is in the process of being revitalized, the encouragement of improved practices for
    home deliveries has not yet been sufficiently emphasized – an important focus in a country with more
    than half the births still taking place at home. In addition, within MBFHI itself, much further work is
    necessary for the Initiative to be fully integrated within the national health system, with the support
    for on-going training, reassessment and/or monitoring needed to sustain adherence to the Ten Steps.
   While much has been done to strengthen support at the community level and within workplaces, great
    challenges still remain in going to scale with community-level support for optimal IYCF practices,
    with progress particularly difficult due to the devolved nature of the health system. (See below.)
    Further efforts are needed to increase community-based counseling and support for IYCF, with




                                                                                                        22
    harmonized communication messages, focusing on improving key practices such as exclusive
    breastfeeding and decrease in provision of water, formula and other liquids in the first six months.

4.2 Factors contributing to programme results
Direct programmatic factors
Exclusive breastfeeding increased somewhat in the late 1990s (according to the 1998 NDHS), after a
period of intense MBFHI and Code monitoring activity, and then decreased (according to the 2003
NDHS) after a lull for several years in any breastfeeding promotion, protection and support. The data
reflects what would be expected, given the declining emphasis on breastfeeding programming in three to
four years before the 2003 survey. It is likely that exclusive breastfeeding rates did not increase further
because there was limited activity in the health services, other than in the maternities, or in the
community.
The relationship between some of the other IYCF indicators and programme activities is less clear. As
seen in the description of NDHS results, early initiation rates have continued to rise, even from 1998 to
2003. It may be that this behaviour has been easier to change in a sustainable way than longer term
exclusive breastfeeding, where factors such as formula promotion and challenges such as combining
breastfeeding and work continue to have an impact. In addition, until recently the programme has focused
mainly on the BFHI and achieved high coverage, which has directly contributed to the increased rates of
early breastfeeding initiation, but would not be expected to result in increased rates of exclusive
breastfeeding for the first six months without additional health system, community and communication
actions to support, promote and protect the practice. ( Note: If newer definitions of “early initiation”, with
greater emphasis on “baby-led” initiation and extended skin-to-skin contact are applied in the Philippines,
rates of “proper” initiation will probably be lower, indicating additional work needed to optimize this
practice.)
The trends related to formula feeding are somewhat surprising, with formula and bottle use decreasing for
all three sets of ages (0-3, 4-6, 7-9 months) between 1998 and 2003. It would seem that rates should have
increased, with the lowered Milk Code monitoring and enforcement during these years, but economic
factors such as poverty levels and the cost of formula may have made this mode of infant feeding less
affordable. Mothers may be switching to cheaper milk products and even condensed milk, although the
2003 data don’t give figures for “other milk” alone. Provision of plain water with breastfeeding has gone
up substantially between 1998 and 2003 for children < 6 months, on the other hand, indicating that further
concentrated work is needed to alert mothers and other caregivers to the dangers of this practice and that
no water is needed, even in extremely hot weather.
Factors external to the programme
External factors also continue to have a strong effect on results. As mentioned earlier, these include,
among others, cultural beliefs favoring early introduction of water, other liquids and foods, and
continuing pressure from the milk companies. The challenging political and economic situation is
important as well, where changes in administrations greatly disrupt or even halt successful programmes,
endemic corruption and the increasingly unequal distribution of wealth penalizes the poor, and the
periodic natural and man made emergencies most affect the disadvantaged. Women are increasingly
joining the labor force, while workplaces supportive of breastfeeding are still not the norm. Female
literacy also influences programme results. The massive transformation in access to information in the
early 2000s, with TV saturation now up to 98%, has given the formula companies even more access to
their potential markets. Challenges within the health system itself also continue, with a relatively low
level of spending, high turnover and emigration of well trained and experienced personnel and a devolved
set up making it difficult to affect wide-scale sustainable change at the local level.




                                                                                                           23
4.3. Lessons learned and innovations
The experiences in the Philippines in the struggle to devise and implement effective interventions to
improve IYCF practices at the policy, health system and community levels are rich with useful examples
and lessons learned that can be shared, both in-country, where “learning from the past” can assist
breastfeeding advocates as they plan for the next phase of the struggle and internationally, where some
innovative strategies could be useful to consider. These “lessons learned” and “innovations” are featured
in Annex 4 of this case study: They include lessons learned from “The Milk Code struggles” and “The
Mother Baby Friendly Hospital Initiative and a description of two innovations at the community level:
“The Community-based Breastfeeding Program of Barangay Pembo in Makati City” and “The
Comprehensive Nutrition Programme for Nutritionally Depressed Barangays in Cebu City’

5. Recommendations
The recommendations below were developed after consideration of all the data gathered, including
information from document reviews and the perspectives and suggestions provided during key informant
interviews and the stakeholder meeting.
Policies, plans and programme management
o   The national IYCF programme is on the way to revitalization but management, supervision and
    coordination will need to be greatly strengthened if it is to have the desired impact. A senior manager
    needs to be assigned full time to the IYCF programme within the DOH, housed in the National Center
    for Disease Prevention and Control (NCDPC), to focus on community, communication and Code
    activities, as well as the IYCF programme as a whole. A second staff member is needed to focus
    specifically on the MBFHI and other health system ICYF training and support, most likely housed in
    the National Center for Health Facility Development (NCHFD). Full time programme managers
    should also be assigned at regional level. At both levels, “under-studies” should be identified, so the
    programme will not suffer in case of turnover. Responsibilities at provincial and local levels should
    be further specified as well.
o   Work needs to begin on drafting the national IYCF strategy for 2010-2015, after review of
    achievements and challenges during the current programme, with UNICEF working closely with the
    DOH and other partners as the planning proceeds.
o   IYCF activities undertaken by the NNC/AMHP, MBFHI, NGOs, the professional associations, the
    CPC, the NCP and other organizations or programmes in which IYCF content is integrated need
    systematic coordination. The National IYCF Inter-agency Committee should be fully activated and
    consideration given to preparation of an “umbrella plan” to insure the most efficient use of resources.
    NGOs should continue to be encouraged and “energized” to contribute.
o   Following the Programme Implementation Review of the National Plan of Action for IYCF last year,
    an implementation plan with deliverables was drafted. This more detailed planning process should be
    continued, on an annual basis, with plans clearly specifying who will do what, when, and how
    progress will be measured. The source of budget needs to be clearly specified as well. If possible,
    more comprehensive implementation plans should be prepared in the future, with attention given to
    all aspects of IYCF, including a greater emphasis on complementary feeding. The Technical Working
    Group (TWG) needs to meet on a regular basis to determine whether the programme is on track in
    completing the activities planned and meeting objectives. The functioning of the “Implementing
    Mechanisms” of the IYCF Policies should undergo review as well, with the national IYCF
    Coordinator in charge of this process.




                                                                                                         24
The Milk Code
o   Now that the Revised IRR has been approved, it is critical not to lose the momentum gained, as
    continued diligence is needed to insure that the Code is adequately monitored and enforced. A first
    step could be work to provide a simplified “lay” version of the wording of the Supreme Court ruling,
    with clear guidelines for what is permissible and not and how Code violations will be monitored and
    penalized.
o   The composition, scope of work, and resources available to the Inter-Agency Committee (IAC) on the
    Code should be reviewed within the context of the Revised IRR, with the objective of insuring that
    the Inter-Agency Committee is strong and active. The Code monitoring tool drafted by the Bureau of
    Food and Drugs (BFAD) should be finalized and circulated as soon as possible. In addition, multi-
    sectoral monitoring teams should be capacitated and supported at all levels. The Leagues at various
    levels should continue to be sensitized to the Code’s importance, and, at community level, help
    should be requested from the LGUs and local NGOs.
o   Further work should be undertaken to sensitize professional groups such as the Philippine Medical
    Society, PPS, POGs, IMPA to the importance of breastfeeding and the Code, what the regulations are
    concerning health worker support for the Code, and why they are necessary.
Maternity Protection and Mother-Baby Friendly workplaces and public areas
o   The DOH, UNICEF and other partners should work together to advocate for longer paid maternity
    leave and other entitlements in line with the ILO Maternity Protection Convention No. 183.
o   The efforts to sensitize employers to the need for mother friendly workplaces, with rooms for
    breastfeeding and expression, breastfeeding breaks, and other support such as provision for childcare
    for breastfeeding mothers, when feasible and useful, should continue, with certification for those
    places of employment that have made the needed adjustments.
o   Municipalities that have fostered needed breastfeeding support in workplaces and public areas should
    continue to be recognized and encouraged to share their successes with others. NGOs such as
    Arugaan and Children for Breastfeeding should continue to be encouraged to help with this effort.
    Hopefully the “Expanded Breastfeeding Act” mandating the establishment of lactation stations in the
    workplace and public places will be passed, adding government support for these efforts.
Communication
o   An assessment of the various approaches to communication that have been implemented in the past is
    needed to determine their effectiveness and make recommendations on the future design and
    approach to communication to contribute to ensuring that the decline in exclusive breastfeeding is
    reversed.
o   A comprehensive communication strategy using multiple channels is required, based on formative
    research on cultural beliefs, practices and barriers to good breastfeeding practices, as well as on which
    channels of communication and influence have the greatest impact on behaviours. Messages should
    be harmonized across the health system, community, schools, the media, etc. Hopefully the
    development of a multi-year communication strategy using the COMBI methodology, being
    undertaken by the DOH, UNICEF, WHO and other stakeholders will be a good initial step in putting
    a strong strategy in place.
o   Media efforts and other communication channels proven to be effective should be used to alert the
    public of the importance of the Code, how it protects families and their babies, and how to identify
    and report infractions. A media campaign with periods of intense advocacy in support of
    breastfeeding is essential, due to advertising pressure from the formula companies. The dangers of
    mixed feeding and giving water should be stressed. Adequate funds will be needed for this purpose.



                                                                                                          25
The Mother Baby Friendly Hospital Initiative
o   As mentioned above, a strong full-time manager for the MBFHI and other IYCF activities within the
    health system should be identified within the DOH, in addition to a full-time manager for the IYCF
    programme as a whole. This would free up the Fabella National Training Center to concentrate on
    TOT for trainers and assessors, as well as other IYCF training activities with which it is tasked.
    Further work is needed to decentralize the training and assessment activities, with training teams
    identified at regional, provincial and lower levels, and a well-functioning system developed for
    training and supervising them. The strategies for training hospital staff should include follow-up to
    ensure that the new knowledge and skills are converted into relevant actions in the maternity services.
o   Consideration should be given to re-instituting a systematic programme to orientate policy-makers,
    hospital administrators and officials at various levels to the importance of MBF facilities and the roles
    they can play. Advocacy could be undertaken through the leagues of municipalities and provinces.
    The revised “BFHI Course for Decision-makers”, Section 2 of the updated BFHI materials, could be
    reviewed as a possible tool to use in this process.
o   Further work should be undertaken to strengthen the system for MBFH monitoring and reassessment
    and consider other strategies to ensure full institutionalization of the MBFH within the standard
    operating procedures of hospitals and long term sustainability. The new internal “Monitoring Tool”
    available in the final version of the updated BFHI materials could be reviewed to determine if it
    would be useful for periodic checks of compliance. As suggested, annual reports by the designated
    facilities should be required. The useful collaboration with PhilHealth, requiring MBFHI designation
    for PhilHealth accreditation, should continue, to insure the process is efficient and effective.
o   The MBFHI, with leadership from the DOH and technical assistance from UNICEF and WHO,
    should further examine effective strategies for ensuring that MBF facilities provide follow-up support
    for mothers on return home. This could include setting up adequate referral systems so mothers are
    connected with community support and coordinating with LGUs, NGOs, midwives, barangay health
    workers and volunteers, to help organize and supervise peer counselors and support group leaders.
    Work to develop mechanisms to support MBF home deliveries should continue as well.
Training and education
o   While training of health personnel on IYCF has expanded in recent years, a more systematic approach
    is needed, with a sustained system for follow-up support, mentoring and monitoring in place. The
    harmonizing of training tools for lactation management, IYCF and community support groups has
    been a good start. The quality of trainings given by various groups, including NGOs, needs to be
    monitored, to ensure that needed topics are covered and all content in accurate and acceptable. “One
    shot trainings” of massive numbers of workers should be avoided. Rather, an on-going system of
    training, mentoring and supervision should be put in place at national, regional, provincial and local
    levels, with strategies for dealing with staff “turnover” and with plans for periodic refresher training
    in place. Important “non-technical” training topics such as supervisory, advocacy and negotiation
    skills should be considered for inclusion. A plan for achieving scale across the country with this
    training and supervision strategy needs to be developed and commitment and resources for its
    implementation assured.
o   The IYCF Plan of Action proposes that medical, nursing and midwifery schools should both
    strengthen their IYCF/MBF curricula and provide short postgraduate lactation courses. Development
    of a systematic initiative to undertake this challenge should continue because, although difficult, it is
    the best way to ensure a sustained improvement in health professionals’ IYCF-related knowledge and
    skills. Past efforts, such as that by the NCP in collaboration with the Association of Philippines
    Medical Colleges in the mid 1980s, should be reviewed, as well as lessons from instructors currently
    working to integrate IYCF into their own curricula and the new IYCF Model Chapter for textbooks



                                                                                                          26
       for medical students and allied health professionals published by WHO in 2009. A strategy for
       strengthening IYCF curricular content should be developed with the involvement of high level
       educational leaders from key schools, so as to increase the likelihood that the guidelines will be
       adopted.
o      Strong consideration should be given to ensuring that basic, proven healthy family practices,
       including those related to IYCF, are integrated into the curricula for primary, elementary and
       secondary schools. This should be led by the Department of Education, but technical support should
       be given by the DOH, with possible involvement of NGOs, if interested. The Nutrition Guides
       developed by the NCP for elementary school grades, focused on malnutrition, could be studied, as an
       example of one approach.
The community
o      Increased efforts are needed to promote, protect and support optimal IYCF practices at scale at
       community level, including strengthening of BHW capabilities in this area, expansion of lay/peer
       counseling on IYCF in barangays, and further fostering of mother support groups. A plan for
       achieving scale across the country in all 42,000 barangays, including on-going training and
       supervision of BHWs, needs to be developed and commitment and resources for its implementation
       assured, with greater coordination among the partners involved.
o      Innovative “pilot projects” such as the peer counseling system being implemented in Makati and
       neighboring municipalities and the system for nutrition surveillance and support being field-tested in
       disadvantaged areas of Cebu (see “Innovations” section) should be reviewed and taken to scale.
o      Strategies for working successfully in a “devolved” system, such as engaging the League of
       Barangays and LGUs, should be continued. Consideration should be given to instituting island group
       meetings with mayors and governors, once a year, where they could be given technical updates,
       advisory notes, and guidance. Now there is a very detrimental “disconnect”, with no regular technical
       programme support at the local level.
o      Care should be taken, as work continues to achieve wider coverage, to keep in place simple
       monitoring and evaluation systems, which can provide data showing impact and convince other
       localities to replicate successful approaches. UNICEF’s work, with additional AUSAid support, to
       strengthen health services in four disadvantaged provinces will hopefully include a strong IYCF
       community component, which can then be replicated. UNICEF should not just focus on
       implementing small pilots with limited reach, but should play a catalytic role in leveraging other
       partners to replicate them and ensure that all districts are covered in a stepwise approach.
o      Strong consideration should be given by the DOH, UNICEF and other partners to making the
       commitment to advocating strongly with LGUs and the Barangay Captains to identify adequate
       numbers of BHWs and BNSs per population and assist in their training. Consideration should be
       given to the recommendation by the former UNICEF Representative21 of a strategy for strengthening
       the current BHW system, in which BNSs and BHWs are selected/appointed by the Barangay Captains
       to serve as volunteers at the Captains’ discretion. Local authorities could be encouraged to pay these
       volunteers, who would focus on health promotion, while the DOH, with support from various
       partners, could supply one additional paid BHW in each barangay, who would focus treatment, if a
       way can be found to do this, even under the “devolved” system. This second BHW could remain in
       place, even with changes in political regimes. Many countries have made substantial progress in child
       survival initiatives at community level, when community health workers are given proper training,
       guidance, support and remuneration. A move towards restoring a strong BHW network across the



21
     Dr. Nicholas Alipui


                                                                                                            27
    country is the most important thing the government could do, with the support of UNICEF and other
    partners. It is essential if MDG targets are to be met.
Integration
o   Systematic work should be undertaken by the DOH, UNICEF and other partners to determine what
    need there is to further integrate IYCF content into related programmes, such as those for IMCI,
    Female Functional Literacy, schools, the enhanced child growth programme, maternal and newborn
    care guidelines and initiatives, household food security programmes, social protection schemes,
    emergency and humanitarian relief guidelines, and HIV/AIDS initiatives to prevent mother to child
    transmission of the virus. The Pabasa sa Nutriyson package should include a separate breastfeeding
    module. Whenever appropriate, a more integrated life cycle approach insuring a continuum of care
    for the mother and child should be adopted.
o   Although complementary feeding and maternal nutrition were not assessed in this evaluation, given
    the high rates of low birth weight and stunting, it is noted that much greater emphasis is needed on
    delivering an evidence-based, effective package of services to improve maternal nutrition and ensure
    optimal complementary feeding.
UNICEF’s role
o   UNICEF has played a very active and effective role in the last few years in helping to revive critically
    needed programmes and focus new approaches on IYCF promotion, protection and support. It should
    continue use its convening power to ensure that IYCF is scaled up, playing a catalytic role in:
    o finding and mobilizing new partners,
    o leading and participating in sustained high level advocacy for policy development, stressing the
        need to prioritize IYCF in the development agenda,
    o fostering development of needed programmes and tools,
    o leveraging resources to achieve scale with sustainable health system and community IYCF
        actions, fully integrated within national and local health programmes
    o supporting formative research on barriers to optimal infant feeding and using the results to
        develop harmonized messages for communication and counseling,
    o continuing to work with partners on the development and implementation of an evidence-based,
        comprehensive communication strategy using multiple channels,
    o supporting efforts to institutionalize the MBFHI in a sustainable manner,
    o helping to build the capacity of regional and local training and resource centers, and assisting the
        DOH in developing a strong system for mentoring and supervision of cadres trained,
    o contributing, with other partners, to a continued effort to strengthen national Code monitoring
        capacity and support the establishment of a sustainable and effective national system to monitor
        and enforce the Code, and
    o providing technical assistance with planning for IYCF support in difficult circumstances, such as
        emergencies and HIV
o   The HRBAP and gender equity should be considered in all its efforts, with added focus on developing
    the capacity of “rights holders”, in addition to “duty bearers”. The successful efforts to involve
    breastfeeding women in very active advocacy for implementation of the RIRR, was a good example
    of this. Greater efforts could be made to involve women at the community level in work with partners
    to organize support for optimal IYCF practices that best meets their needs.
o   A key focus of its work with the DOH and other partners should be to identify, test, and foster
    adoption of sustainable approaches, as well suited as possible to withstand the challenges of working
    in a devolved system with a high rate of staff turnover. Strong advocacy for strengthening the BHW
    network (see above) should be an essential initiative.




                                                                                                         28
Annexes:
   1. Materials reviewed
   2. Key informants and interview schedule
   3. Milestones in the Philippines IYCF Programme
   4. Innovations and lessons learned




                                                     29
Annex 1. Materials reviewed
Documents, presentations and websites
BASICS, Newborn health in the Philippines: a situation analysis. Published by the Basic Support for
Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International
Development. Arlington, Virginia, June 2004.
Basilio, Juanita, Reversing the bottle-feeding culture in the Philippines (PPT presentation), presented
during the IYCF Program Implementation Review, 26-28 Sept 2007, Dacha Hotel, Tagaytay City by J
Basilio, DOH-NCDPC.
City Health Department (CHD) Nutrition Health Accomplishment 2008, PPT presentation shared by the
Nutrition Center of the Philippines.
Clavano, NR, Mode of feeding and its effect on infant mortality and morbidity. J Trop Pediatr. 1982 Dec.
28(6): 287-293.
Council for the Welfare of Children, Government of the Philippines, What Bargangay officials can do to
set up a Child-Friendly Locality, printed with the assistance of UNICEF and AusAID, date?
Countdown to 2015, Maternal, Newborn & Child Survival, Philippines, 2008 Report. (Philippines
countdown 2015.pdf)
Department of Health, Creation of the National Infant and Young Child Feeding (IYCF) Management
Committee and Technical Working Group for Implementation of the IYCF Program> (Dept. Personnel
Order No. 2006-3285, November 27, 2006.
Department of Health, Draft: Guidelines for the National Regional Milk Code Monitoring Team, no date.
Department of Health, Ensuring Better Health and Nutrition for mothers and Children: The Community-
based Breastfeeding Program of Barangay Pembo, Makati City, Metro Manila, Center for Health
Development National Capital Region, Bureau of Local Health Development, gtz and World Health
Organization, no date.
Department of Health, Infant feeding during emergencies, PPT presentation during the IYCF Program
Implementation Review, 26 Sept 2007, Dacha Hotel, Tagaytay City (Infant Feeding During
Emergencies.ppt).
Department of Health, National Policies on Infant and Young Child Feeding (Administrative Order No.
2005 – 0014 (May 23, 2005), Department of Health, Office of the Secretary, Republic of the Philippines
Department of Health, Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities
with Maternity and Newborn Care Services, A.O. 2007-0026, Office of the Secretary, July 10, 2007.
Department of Health, The Rooming-In and Breastfeeding Act of 1992. (Republic Act No. 7600),
Republic of the Philippines, 1992.
Department of Health, Setting up a Mother and Baby Friendly Community, Parts 1 and 2, DOH,
Philippines (BF CommunityPHLAdvocacy.ppt and BF CommunityPHLTOFINAL.ppt)
Department of Health, Setting up mother and baby friendly workplaces in the Philippines, draft
document, Manila, Philippines.
Department of Health, Setting up mother and baby friendly workplaces in the Philippines, draft
document, Manila, Philippines.
Department of Health, Suggested key steps on establishing breastfeeding support groups in the
community, “Peer to peer approach”, draft document, Manila, Philippines.



                                                                                                          30
Department of Health, World Breastfeeding Week, 1-7 August 2007, The Philippine Celebration,
BFWeek2007.ppt.
Fernandez, Ines, Mother Support in Crisis, Calamities and Conflicts, Mother Support Model: Experience
in the Philippines, Presented at 2nd National Breastfeeding Conference, August 06, 2006, Grand Miracle
Hotel, Bangkok, Thailand. (PPT slides)
Flor, “The Philippine Nutrition Cluster’s Battle for the Best: The Breast: Enforcing EO RIRR through
Safeguarding Donations” www.ennonline.net/pool/files/ife/flor-avoiding-donations-in-the-philippines-
ppt.ppt -
ICDC, Pharmaceutical and Health Care Association of the Philippines vs. Health Secretary Francisco T.
Duque III et al. from ICDC Legal Update, January 2008.
Inquirer.net, Makati City expands breastfeeding program, by DJ Yap, first posted 7/14/08,
file:///C:/Documents%20and%20Settings/Anns/My%20Documents/A%20UNICEF%20-
%20laptop/A%20Philippines%20case%20study%20-%20laptop/Makati-City-expands-breastfeeding-
program.htm
“Maternity Protection in International Law and Practice in South-East Asia”,
http://www.asianfoodworker.net/maternity/mp-law-seasia.htm , 2004.
National Nutrition Council, Accelerated Hunger-Mitigation Program, summary sheet, Manila,
Philippines.
National Nutrition Council, Medium-Term Philippine Plan of Action for Nutrition 2005-2010 Mid-Term
Assessment Report, Manila, Philippines, no date.
National Nutrition Council, The Updated Medium-term Philippine Plan of Action for Nutrition, 2008-
2010, Manila, Philippines, draft 24 June, 2008.
NSO and UNICEF/Philippines, Monitoring the situation of children and women, Sub-Regional Multiple
Indicator Cluster Survey, 2007, National Statistics Office and UNICEF, Manila, Philippines, 2007.
Ordenes-Cascolan, Lala, The Philippine Milk Code: A timeline. The Daily PCIJ, June 20, 2007.
(http://www.pcij.org/blog/?p=1789 )
Paje, Rosalie, Mother-Baby Friendly Hospital Initiative Program, PPT presentation during the IYCF
Program Implementation Review, 26-28 Sept 2007, Dacha Hotel, Tagaytay City by R.P. Paje, National
Center for Health Facility Development, DOH.
Partnership for Maternal, Newborn and Child Health Countdown to 2015, Maternal, Newborn & Child
Survival, Philippines, (Data Chart) 2008
Philippine Pediatric Society, Breastfeeding, Policy Statements, Series 2004 Vol. 1 No. 1
http://www.pps.org.ph/policy_statements/breastfeeding.pdf
Republic Act 7600, or the Rooming-In and Breast Feeding Act of 1992 (requires both private and public
health institutions to create an environment where physical and psychological needs of mothers and
infants are satisfied?)
Republic of the Philippines, Philippine National Health Accounts, 2005, National Statistical Coordination
Board, February 2008.
Ramos, Joshua G., Implementation of E.O. 51 (Milk Code), PPT presentation during the IYCF Program
Implementation Review, 26-28 Sept 2007, Dacha Hotel, Tagaytay City by J.G. Ramos, Director III,
BFAD-DOH.




                                                                                                       31
Solon, Florentino, Comprehensive Barangay nutrition program for the four nutritionally depressed
barangay of Cebu City 2007-2008, PPT presentation prepared by the Nutrition Center of the Philippines
in partnership with Cebu City Nutrition Committee, 2008.
UNDP, Human Development Report, United Nations Development Programme, Geneva, Switzerland,
2005 and 2007/2008.
UNICEF Annual Reports, Philippines:
       Annual Report 1981, Philippines, Papua New Guinea, The Pacific, UNICEF Manila
       UNICEF 1982 Annual Report, Philippines, Papua New Guinea and The Pacific
       UNICEF 1987 Annual Report on the Programme of Cooperation in the Philippines
       UNICEF 1993 Annual Report on Country Situation, Philippines
       UNICEF Philippines, 1994 Annual Report
       Philippines 1996 Annual Report UNICEF
       Philippines 1997 Annual Report UNICEF
       1998 Annual Report UNICEF Manila, Philippines
       1999 Annual Report Philippines, UNICEF
       2000 Annual Report, Philippines, UNICEF, Manila, 2000.
       Philippines 2001 Annual Report UNICEF
       Philippines 2002 Annual Report, UNICEF, Manila, 2002.
       UNICEF Philippines Country Office Annual Report 2005
       UNICEF Philippines 2006 Country Office Annual Report
       UNICEF Philippines, Country Annual Report, 2007.
UNICEF Headquarters, Study on NGOs and CSOs (Philippines), 2006.
UNICEF Philippines, Country Programme Action Plan between the Government of the Republic of the
Philippines and the United National Children’s Fund, Sixth Country Programme for Children 2005-2009,
Manila, Philippines.
UNICEF Philippines, Fifth Country Programme for Children Mid-Term Review, Philippines, 2001.
UNICEF Philippines and DOH. Infant and Young Child Feeding. Counseling manual. (Equip health
workers with counseling techniques), 2006 5,080 copies
UNICEF Philippines, Sixth Country Programme for Children (2005 – 2009) Mid-Term Review,
UNICEF/Philippines (draft 2007).
UNICEF Philippines, Programme Utilization: 2000 – 2008, Data for all country programmes and details
for health and nutrition, PROMS printout.
UNICEF Philippines, Philippine Situation Analysis 2007, draft.
UNICEF Philippines, The Philippines’ Battle for the Breast, Advocating for Stricter Enforcement of the
Milk Code, PPT.
University of the Philippines, Retrospective study of MBFHI experiences in the Philippines, 2006.
Wellstart International, Philippines: A Creative Breastfeeding Program Serves as a “Baby Friendly”
Model World Wide, Case Study Series, Country Case Study No. 6, Developed by A. Brownlee in
coordination with Dr. M. Galon, Undersecretary of Health, DOH and Dr. A. Fernandez, Dean, Medical
College, University of the Philippines, Wellstart International, San Diego, CA, 1998.



                                                                                                     32
Williamson, Nancy, “Breast-feeding trends and the Breast-feeding Promotion Programme in the
Philippines, Asia-Pacific Population Journal, Vol 5, No. 1: 113-124.
WHO/Philippines, “Ruling in a victory for Philippines children, says WHO”, Statement by WHO
Philippines Country Representative, Dr. Nyuntu Soe on the Supreme Court’s decision on the revised
Implementing Rules and Regulations of the E.O. 51 or the Milk Code, Manila, 12 October, 2007.
WHO/Philippines, What are the costs of inappropriate infant feeding practices including infant formula
in the Philippines? Paper presented to the National Anti Poverty Commission, May 25, 2006.
IEC Materials
Department of Health, Salamat Inay, KahiAnnext busy ka sa trabaho, GATAS NG INA pa rin ang
pasalubong mo, and Gatas Ng Ina, DOH, National Center for Health Promotion, 2007.
Department of Health, Breastfeeding is beautiful, Cover and Feature on Breastfeeding in HEALTHBeat,
July-August 2007, organized by DOH-National Center for Health Promotion (NCHP).
UNICEF, Breastfeeding Advocacy co-production with DZMM Radio. Radio programmes, AM/FM Radio
– 60 second radio spots, 4x1hr radio programmes (To educate public about breastfeeding and benefits
derived from breastfeeding), UNICEF Manila, 2006
UNICEF, Breastfeeding in the first hour. Video, UNICEF Manila, 2007. (demonstrates a child’s natural
breast crawl maneuver right after birth) 70 copies
UNICEF, Breastfeeding. Poster. UNICEF Manila, 2006 (Urge mothers to breastfeed) 5,000 copies
UNICEF, Breastfeeding. Resource kit. UNICEF Manila, 2006 (Promote the benefits of breastfeeding)
2,000 copies
UNICEF, Formula for Disaster. Video, UNICEF Manila, 2007. (Part of Milk Code campaign.- provides
evidence on violations of milk companies against the Mild Code) 1000 copies
UNICEF, Magic of Breastfeeding. Poster. UNICEF Manila, 2007. (Provides info on colostrum and
breastfeeding in the first hour), 5,000 copies
UNICEF, Milk Code violations. Documentary – 15 minute film. (To document flagrant violations of the
Executive Order 51 or the Milk Code and generate support for breastfeeding. UNICEF Manila, 2006.
UNICEF, Milk Code. Poster. UNICEF Manila, 2006. (Promote provisions of Milk Code), 5,000 copies.
UNICEF, Miracle of Breastfeeding, dates?.
UNICEF, Mothers Milk Magic. Radio programmes - 3-6 minute segments(To educate public about
breastfeeding and dispel myths/misinformation about breastfeeding), UNICEF, 2006
Training Materials
Arugaan, Child Friendly Creche, Let’s eat, learn, play. Manila, Philippines, no date.
Department of Health, Integrated Management of Pregnancy and Child Birth, Pregnancy, Childbirth,
Postpartum and Newborn Care: A guide for essential practice in Philippine setting. Adapted from the
WHO by the DOH with support from JICA, UNFPA and UNICEF. C. WHO, 2003
Department of Health, IYCF Training Course: Updates, PPT presentation during the IYCF Program
Implementation Review, 26 Sept 2007, Dacha Hotel, Tagaytay City, (IYCF trg module.ppt)
ICDC, 18 course on Code Monitoring, International Code Documentation Center, Penang, Malaysia.
Integrated Management of Childhood Illness (IMCI), session on “”Counsel the Mother”, including
training on counseling on feeding recommendations for sick and healthy children from birth to two years
of age and older.


                                                                                                      33
National Lactation Management Training Center, national lactation management training materials, Jose
Fabella Memorial Hospital, Manila, Philippines.
National Lactation Management Training Center, MBFHI assessor training course, Jose Fabella
Memorial Hospital, Manila, Philippines.
National Lactation Management Training Center, MBFHI training course for maternity staff, Jose Fabella
Memorial Hospital, Manila, Philippines.
National Lactation Management Training Center, MBFHI orientation session for hospital administrators,
Jose Fabella Memorial Hospital, Manila, Philippines.
Nutrition Center of the Philippines, Manual on Infant Nutrition with emphasis on breastfeeding, NCP and
Association of Philippine Medical Colleges (APMC), Manila, 1985.
Nutrition Center of the Philippines, Pabasa Sa Nutrisyon, including Nutri-Guide, Community Guide,
Flipchart, Family Profile, and Game Tools, Manila, Philippines (available for purchase).
UNICEF-Philippines, “Session 2: Rights of the Child” and “Session 9: Breastfeeding”, training materials
for Enhanced Child Growth.
WHO, Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993.
http://www.who.int/child_adolescent_health/documents/who_cdr_93_3/en/index.html
WHO, Infant and young child feeding counselling: An integrated course. (Revised for use in the
Philippines), World Health Organization, 2006.
http://www.who.int/nutrition/publications/infantfeeding/9789241594745/en/index.html
WHO, Infant and young child feeding: Model Chapter for textbooks for medical students and allied health
professionals, Geneva, World Health Organization, 2009.
http://www.who.int/nutrition/publications/infantfeeding/9789241597494/en/index.html




                                                                                                     34
Annex 2. Key informants and interview schedule
Key informants


                Name                           Address                       Contact Details


Dr. Ma. Margarita Galon          c/o FIMO, Department of Health         743 7236 (Tita)
Consultant                       2nd flr., Bldg. 4, San Lazaro         c/o
                                 Compound                              tstingzon2000@yahoo.com
                                 Sta. Cruz, Manila

Ms. Edna Nito                    ational Center for Health Promotions 711 6130; 7438301 loc 2827
                                 Department of Health, San Lazaro     evnito@yahoo.com
                                 Compound, Sta. Cruz, Manila          09193675364
Mr. Tony Roda                                                         troda63@yahoo.com


Ms. Jovita Raval                 National Nutrition Council            843 5818
                                 Nutrition Bldg., 2332 Chino Roces     jovie_raval@yahoo.com
                                 Ave.Extn. TaguigCity

Dr. Evelyn del Castillo          Dr Jose Fabella Memorial Hospital     evedelcast@yahoo.com
                                 Lope de Vega Street, Sta. Cruz,       evedelcast@hotmail.com
                                 Manila                                09213005877

Dr. Rosalie Paje                 National Center for Health Facility    7438301 loc 1454/1401
                                 Development, Bldg. 4                  09179969341; 742 8091/87
                                 Department of Health                  docpaje@yahoo.com
                                 San Lazaro Compound Sta. Cruz,
                                 Manila

Dr. Juanita (Nitz) Basilio       National Center for Disease           7117846
                                 Prevention and Control Department     09176256454;
Ms. Vicenta (Bessie) Borja       of Health                             nitzbasilio@hotmail.com
                                 San Lazaro Compound, Sta. Cruz,       nitz_basilio@yahoo.com
                                 Manila
                                                                       7329956; 09178005681
                                                                       bessieborja@hotmail.com

Ms. Evelyn (Gagay) Policarpio    Bureau of Food and Drugs, FCC         8425606; 09159086933
                                 Compound, Civic Drive                 evelynpcarpio@yahoo.com
                                 Alabang, Muntinlupa

Dr. Mary Asuncion A. Silvestre   Rm., 315, MAC 2 Bldg.                 09175352438
FPSNbm, FAAP, Neonatologist      Manila Doctors Hospital               c/o 723 0101 (St. Lukes)
                                 UN Ave., Ermita, Manila               miannesilvestre@gmail.com



                                                                                                 35
Ms. Inez Fernandez                ARUGAAN, Starlight cor. Vista sts. 09192330200; 9225189
Executive Director                SSS Village, Marikina City 1811    innes.sea@gmail.com




Dr. Elvira L. Henares-Esguerra    Children for Breastfeeding,           09189212970; 8103372
Director                          Philippine Lactation Resource and     children_for_breastfeeding@
                                  Training Center                       yahoo.com
                                  TESDA Women’s Center, TESDA
                                  Complex, Km. 13 SLEX, Taguig
                                  City

Ms. Nona Castillo-Andaya          Nurturers of the Earth                09198395555
                                                                        nurturers2005@yahoo.com.p
                                                                        h


Ma. Lourdes V. Salud              Makati City Health Department         8998927
MD, MPA, City Health Officer      c/o Makati City Hall, J.P.Rizal St.   899 8916 (Myrna)
                                  Makati City                           malousalud@yahoo.com

Dr. Cora Salinas/Ms. Alma Gamad                                         8701607
                                                                        c/o killa_mike@yahoo.com


Dr. Howard Sobel                  WHO-WPRO                              sobelh@wpro.who.int
Project Officer                   UN Ave., Manila                       09274936078
                                                                        7183098 (Cathy-Dr. Anden’s
Ms. Beth Dumaran                  CHD-NCR                               off.)
                                  Welfareville Subd., Mandaluyong
                                  City                                  09228315110; 5354521


Ms. Carmen Solinap                Trade Union Congress of the Phils.    8944721
                                  (TUCP)                                carmenmsolinap@yahoo.com


Dr. Gloria Ramirez                Philippines Children’s Medical        9240838
Head, Human Milk Bank & BF        Center                                draglorram@yahoo.com
Adviser                           2nd flr., Research Office
                                  Quezon Avenue, Quezon City




                                                                                                36
Interview schedule, Manila, Philippines
for Dr. Ann Brownlee, AED Consultant on IYCF
14-18 July 2008, Manila, Philippines

    Day             Time       Venue                        Activity                     Resource Persons/Remarks
 12 July     1800          NAIA               ETA: 1715 via Hawaiian Airlines         Tin/Chut for airport p/up and hotel
 Saturday                                     0455 Proceed to Sommerset Salcedo
 13 July     1300                             Briefing with Dr Rien and Elham         Elham/Rien
 Sunday
 14 July     0830 -        UNICEF                  Courtesy call: OIC-Deputy Rep     CD
 Monday      1100 -1200                            Discussions w/ Health/Nutrition   HN POs
                                                    Staff
             1200-1300                            Lunch and travel time to Manila…    Transport…(Tin/Chut)
             1330 – 1530   Fabella Hospital        Mtg/interview/visit to hosp…      Dr. Evelyn del Castillo
             1530 - 1600                          Lunch and travel time to Ortigas…   Transport…(Tin/Chut)
             1600 - 1730   RTI, Pasig City         Mtg/interview….                   Dr. Consuelo Aranas
             PM                                            Back to Hotel
 15 July     0700                                  Pick-up hotel and travel time to   Transport…(Tin/Chut)
 Tuesday                                                      venue…
             0800-0900     WHO-DOH Mla         Mtg/interview…                        Dr. Howard Soebel
             0900 - 1200   DOH Library        Mtg/interview/discussion/s in group     DOH-NCDPC/NCHP/NNC/BFAD:
                                                                                      Dr. Nitz Basilio – DOH NCDPC
                                                                                      Ms. Bessie Borja – DOH NCDPC
                                                                                      Ms. Jovie Raval, NNC
                                                                                      Dr. Marge Galon – DOH Consultant
                                                                                      Dr. Sally Paje – DOH NCHFD
                                                                                      Mr. Tony Roda/Ms. Rowena Bonoan,
                                                                                      NCHP
                                                                                      Ms. Gagay Carpio, BFAD
             1200-1300                            Lunch and travel time to Manila…    Transport…(Tin/Chut)
             1300 – 1430   Mla Doctors Hosp         Mtg/interview                    Dr. Mary Ann Silvestre
             1430 -1530                               Travel time to San Juan…        Transport…(Tin/Chut)
             1530 – 1700   IMAP, San Juan           Mtg/interview…                   Dr. Patricia Mines Gomez
             PM                                             Back to Hotel
 16 July     0700 – 0815   Sommerset Hotel     Telecon with Dr. Martha               Dr. Ann
 Wednesday                                    No. to call: 0062217778040 room
                                              201
             0815 – 0900                      Pick-up hotel/travel time to Manila…    Transport…(Tin/Chut)
             0900 – 1030   UP Mla Coll of           Mtg/interview                    Dr. Grace Agrasada
                           Med
             1030 - 1200                           Lunch and travel time to Quezon    Transport…(Tin/Chut)
                                                               City…
             1230 – 1330   PPS, QC                  Mtg/interview-CANCELLED,         Dr. Genesis Rivera - tbc
                                                     16Jul
             1400 - 1500   PCMC                     Mtg/interview…                   Dr. Gloria Ramirez
             1530 – 1630   POGS                                                       Dr. Ma.CorazonZaydaGamilla
                                                                                      (Dr. Bismark substituted)



                                                                                                        37
           PM                                            Back to hotel
17 July    0800 -                                 Pick-up hotel to UNICEF…        Transport…(Tin/Chut)
Thursday   0900 - 1030   UNICEF conf rm         Mtg/interview                    Ms. Inez Fernandez (Arugaan)
           1045 – 1215   UNICEF conf rm         Mtg/interview                    Mr. Alex Llelamo (X-WHO)
           1230 - 1300                          Lunch and travel time to Taguig   Transport…(Tin/Chut)
           1300 – 1430   NCP                    Mtg/interview….                  Dr. Florentino Solon
           1500 – 1630   UNICEF conf rm         Mtg/interview….                  CBF:
                                                                                  Dr. Elvira H. Esguerra
                                                                                  Ms. Nona Castillo
           PM                                            Back to hotel
18 July    0800 - 0930   MC’s office            Debriefing/discussion w/ HN      MC
           0930 – 1530   UNICEF 31st flr.       Workshop with                    Chut/Tin (venue: UNICEF conf
                         conf room               stakeholders/IYCF - TWG…         rm)
                                                Makati Health Dept…to join       Makati CHO:
                                                 workshop                         Dr. Ma. Lourdes V. Salud, CHO
                                                                                  Dr. Cora Salinas
                                                                                  Ms. Alma Gamad
           PM                                           Back to hotel
19 July                  ETD                    To airport, travel back to BKK    Chut/Annie




                                                                                                   38
Annex 3: Milestones in the Philippines IYCF Programme
 IYCF policies, plans and programmes                     BF/IYCF training and education
 The Milk Code                                           Mass media and promotion
 The Mother Baby Friendly Hospital Initiative            Community-based promotion and
                                                             support
                      Milestones: IYCF policies, plans and programmes
       1983: National Movement for the Promotion of Breastfeeding established by DOH and UNICEF
        began support for breastfeeding.
       1986: E.O. 51 (the Milk Code) signed by President Cory Aquino.
       DOH prepared draft Five Year Plan (1988-1992) for Breast-feeding Promotion in the
        Philippines.
       1992: Rooming-in and Breastfeeding Act approved by Senate.
       1999: Child-Friendly Movement launched by GOP, UNICEF and partners.
       1999-2003: UNICEF Fifth Country Programme for Children – CPC 5 - (including IYCF)
        implemented.
       1999: Start of “Re-engineering” within the GOP which led to transfer of many DOH employees
        involved in BF/IYCF programme work to other positions.
       2001: National Strategic Framework for Plan Development for Children 2001-2025 (Child 21)
        produced.
       2004: Breastfeeding policy statement published by the Philippine Pediatric Society.
       2004: IYCF task force created.
       Dates?: Orientation of local chief executive and barangay chairpersons on IYCF, which resulted
        in forging of memorandum of agreement among Liga ng mga Barangay, DOH and WHO
        Philippines on promotion of optimum IYCF and Milk Code compliance.
       2005 – 2009: UNICEF Sixth Country Programme for Children - CPC 6 - (including IYCF)
        underway.
       2005-2010: Medium-Term Philippine Plan of Action for Nutrition 2005-2010 (jncluding IYCF)
        underway.
       2005: National Policies on Infant & Young Child Feeding (A.O.2005-0014) & Philippine
        National Plan of Action on Infant & Young Child Feeding – 2005 -2010 completed.
       2006: UNICEF advocated at policy level for stronger mother and child friendly nutrition
        programmes with emphasis on BF/IYCF. This included advocacy at the first National
        Conference of Nutrition Stakeholders in the Philippines, Manila, April 2006.
       2007: Guidelines on the acceptance and processing of foreign and local donations during
        emergency and disaster situations (A.O 2007 – 0017) prepared.
       2007 – 2010: Accelerated Hunger-Mitigation Program (including IYCF components)
        established by the President and implemented by National Nutrition Council.
       2007 – 2008: Expanded Breastfeeding Act” mandating the establishment of lactation stations in
        the workplace and public places and the integration of breastfeeding education into the school
        curricula passed by Senate but stalled in the House.




                                                                                                   39
                                Milestones: The Milk Code
   1981: Adoption of the International Code of Marketing of Breast-milk Substitutes by the World
    Health Assembly. Philippines National Code to regulate the marketing of breast-milk substitutes
    and supplies drafted.
   1981-1985: NGOs led by the National Coalition for the Promotion of Breastfeeding (NCPB),
    later named BUNSO, lobbied for the passage of the Philippine Code.
   1986: BUNSO staged a street march of breastfeeding mothers and babies together with
    community leaders, doctors, lawyers and church pres in front of offices of four milk companies.
    Breastfeeding mothers and babies joined the final drafting the Code.
   1986: Philippine Code of Marketing of Breastmilk Substitutes (E.O. 51) signed into law.
   1994: Milk Code Task Force formed and in 1995 proposed stringent implementation of the Milk
    Code.
   2000: Controversial Administrative Order issued by Sec. of Health Romualdez allowed milk
    manufacturers to engage in breastfeeding activities such as education, production and
    development of breastfeeding materials – IRR revised in favor of milk companies.
   2005: 30 partners from govt. and NGOs trained on monitoring the Milk Code, with resource
    persons from IBFAN Malaysia, and then major seminar on advocacy for the new IRR held for
    NGOs.
   2004 to 2006: 12 drafts of Revised Implementing Rules and Regulations for Milk Code prepared
    by Task Force.
   2006: Revised Implementing Rules and Regulations (RIRR) of the National Milk Code signed
    by Health Secretary.
   2006: Supreme Court denied and then granted Temporary Restraining Order (TRO) on RIRR
    requested by Pharmaceutical Healthcare Assoc. of the Philippines
   2005-2007: Intense advocacy for breastfeeding and the RIRR by UNICEF, WHO, DOH, and
    NGOs led by the Save the Babies Coalition. Drafts of IRR discussed in public hearings. The
    Senate, House and Malacanang held public hearing inquires on Milk Code.
   2007: UNICEF produced and disseminated “Formula for Disaster” video on unethical baby-food
    marketing.
   Oct 2007 Supreme Court lifted TRO and affirmed the RIRR except for 3 provisions including
    the total ban on advertisements.




                                                                                                40
           Milestones: Mother Baby Friendly Hospital Initiative (MBFHI)
   1975: Dr. Clavano started rooming-in at Baguio General Hospital, with impressive effects on
    incidence of diarrhea and infant deaths at the Hospital.
   1979: Breastfeeding and rooming-in started at Fabella Hospital for normal vaginal deliveries and
    by 1986 milk formula was totally phased out with breastfeeding achieved in the NICU.
   1980: DOH directed public health facilities to promote breastfeeding and reinforce the
    “rooming-in” policy and in 1985 directed private hospitals to also adopt “rooming-in”.
   1985 – 1992: Filipino teams from Fabella, other key hospitals, DOH, and medical/nursing
    schools received training in lactation management by Wellstart Intl.
   1989: Fabella, with Dr. Ricardo Gonzales as Medical Director, was officially recognized by
    DOH as a “Rooming-in Facility”.
   1991: Fabella was designated as the “National Lactation Management Training Center” and later
    helped set up a regional LM training center in Cebu.
   1992: The international BFHI was launched and Philippines participated in “Master Trainers and
    Assessors Workshop” for BFHI and served as one of 12 “starter” countries. The Philippines
    MBFHI was launched a few months later.
   By 1996 over 78 BFHI courses given at Fabella and other training sites for over 4,000 trainees
    and by 1998 the National Center had trained teams from Myanmar, China, Malaysia, Thailand,
    Jamaica, Mexico, Vietnam & Mongolia.
   1993 – 1999: Strong progress on designation under leadership of Dr. Marge Galon at
    HOMS/DOH, with 139 MBF hospitals in 1993, 667 in 1995, and 909 in 1997. reaching a peak
    in the late nineties, with 1,427 or 83% of the 1,713 targeted facilities certified.
   2000: With compliance slipping, a one day MBFHI Programme Review and Evaluation was
    held to discuss strategies for sustainability and preventing back-sliding.
   2000-2003: Very little MBF training by the National Center at Fabella and no assessments or
    awards. “Re-engineering” within DOH resulted in loss of experienced staff and change in
    priorities.
   2004-7: National Center conducted several lactation management training of trainer courses and
    MBFHI assessor courses.
   2005-7: MBFHI was integrated into Philippine Health Insurance (PhilHealth) accreditation
    programme and tool.
   2006: UNICEF worked with DOH to develop technical guidelines on the MBFHI and a
    framework for MBF settings in the workplace, schools, industry and community.
   2006 or 7: Retrospective study of the MBFHI conducted by U of Philippines, covering 98 govt.
    and private hospitals in 15 regions.
   2007: Administrative Order issued on “Revitalization of MBFHI” (AO# 2007-0026).
   2007 – present: Reassessment and training of hospital teams begins, with “Certificates of
    Commitment” awarded and then Certification if compliant after two years. Training Center also
    conducted 3 TOTs and is being asked to conduct a number of regional TOTs to cover all
    hospitals in priority areas, with support from the Accelerated Hunger-Mitigation Program.




                                                                                                 41
                     Milestones: BF/IYCF training and education
   1985: Manual on Infant Nutrition with emphasis on breastfeeding was prepared by the Nutrition
    Center of the Philippines for the Association of Philippine Medical Colleges and used for 5
    years.
   Dates? School Guide for Teaching Proper Nutrition, including breastfeeding (for grades 1 – 6)
    produced by Nutrition Center of the Philippines and available for purchase.
   2000 – 2002: A number of health professions attended courses on breastfeeding counseling and
    lactation management in various regions and provinces, with support from UNICEF.
   2003: Handbook: Integrated Management of Pregnancy…Childbirth, Postpartum and Newborn
    Care produced for Philippine setting (includes breastfeeding management)
   Dates?: National technical conference with medical practitioners under the umbrella of
    Philippine Medical Association was held, with updates and workshops for pediatric and
    obstetric departments of large hospitals and medical societies developed plans of action for
    breastfeeding promotion.
   2005-2006: 8 core trainers were trained on IYCF counseling and promotion of the revival of
    breastfeeding support groups and then provided three “training of trainer” courses for 11
    provinces in 2005. Then in 2006 62 trainers trained on IYCF counseling, 60 health workers
    provided lactation management training, and 13,000 health staff trained on IYCF.
   2005-2007: 5 TOTs on IYCF were held, with 3 part of the AHMP, to create a critical mass of
    advocates and counselors in IYCF. The 86 graduates of the AMHP-TOT include staff from each
    DOH-CHD and each regional office of the NNC and staff from 39 provinces and the central
    office of the NNC.
   2006: National Technical Conference on Breastfeeding” organized by DOH, in collaboration
    with UNICEF and WHO, and attended by 400 medical professionals from the medical societies.
   By 2007: 481 municipal and city health and related personnel in 164 municipalities in Priority
    One provinces of the AHMP were trained on IYCF with help from Fabella and then 3,206
    workers and volunteers or 31% of total barangays in Priority One provinces of AHMP were
    trained on IYCF. Over 75% of the focus barangays are to be covered by IYCF training, with
    over 24,000 participants targeted.




                                                                                               42
                        Milestones: Mass media and promotion


   1992: World Breastfeeding Week first celebrated world-wide, with coordination by WABA and
    endorsement of UNICEF, WHO and FAO. Groups in the Philippines started observing it soon
    after.
   2005: President issued proclamation for week long World Breastfeeding Week every first week
    of August.
   ?? – 2008: DOH National Center for Health Promotion producing IEC materials promoting
    breastfeeding and IYCF. The “Idol ng Breastfeeding” citation was launched, which recognizes
    women breastfeeding successfully in face of challenges.
   2005 – 2007: Breastfeeding covered extensively in media in support of Milk Code, with DOH,
    NGOs, UNICEF, WHO encouraging coverage. (249 print articles, 81 TV spots)
   2005 - 2006: UNICEF developed IEC materials on breastfeeding, reviving the breastfeeding
    culture in workplaces and community and distributed behavioral change communication
    materials on IYCF in focal areas
   2006: Philippines achieved Guinness World Record in Simultaneous Breastfeeding in Single
    Site (3,541 breastfeeding mothers in Manila)
   2006-7: UNICEF helped develop and implement national communication campaign on
    breastfeeding, “The Miracle of Breastfeeding”, and developed and disseminated 20,000
    (English) and 30,000 (Tagalog) breastfeeding posters.
   2007: The Philippines and WABA led Synchronized Breastfeeding Worldwide to achieve
    Guinness World Record in Simultaneous Breastfeeding in Multiple Sites (16 countries – 10,000
    mothers)
   2007: “Baby crawl” video produced at Fabella and viewed during WBW.




                                                                                              43
                        Milestones: Community-based promotion and support

        1999 – 2003: 2,220 health & nutrition posts established under the CPC 5 Programme, with
         barangay health and nutrition workers tasked with breastfeeding promotion and support.
         ?? - 2008: Cities of Caloocan, Makati and Taguig passed City Resolutions or Ordinances in line
         with recommended feeding practices of DOH and WHO and worked to create breastfeeding rooms,
         monitor and report Milk Code violations, train workers, promote breastfeeding and establish
         community support groups to aid pregnant and new mothers with IYCF problems.
        2005 – 2008: A model for a community-based breastfeeding programme and community support
         groups was tested in Barangay Pembo by Makati City, in collaboration with CHD-Metro Manila,
         WHO, UNICEF and other agencies and then replicated in other barangays.
        2005 on: Pabasa sa Nutrisyon strategy developed by the Nutrition Center of the Philippines (NCP),
         involving interactive nutrition learning sessions (including IYCF) for mothers, was implemented
         by NCP, with 50 trainings for 1,681 participants in 26 municipalities, 9 cities and 23 provinces.
         Also included in ECCD and AMHP.
        2005-7: 150 peer counselors trained in 17 barangays, 7 cities and 4 municipalities under the CPC 6.
        2006-7: Breastfeeding support groups established in 103 barangays in 24 focus areas under CPC 6
         with support from “Children for Breastfeeding”.
        2006-7: Breastfeeding stations installed in all SM Malls in 2006 and other malls put up
         breastfeeding stations in 2007. Breastfeeding stations/rooms also set up within city govt. of Manila,
         provincial govt. of Davao del Norte, Tadeco Plantation, and Davao Intl. airport, and UNICEF/Phil.
        2006-2008: Modeling of mother baby friendly workplaces by the Trade Union Congress of the
         Philippines (TUCP) and other union leaders in collaboration with DOH and WHO, including
         provision of facilities for expressing and storing expressed breast milk and time for milk
         expression and regular seminars for pregnant women on IYCF.
       2007 – 2008: Nutrition Center of the Philippines, in partnership with Cebu City Nutrition Committee
        launched a comprehensive barangay nutrition programme for the four nutritionally depressed
        barangay of Cebu City. It trains the barangay workers to target families with newborns to <3 yr olds,
        pregnant women, lactating women and underweight preschoolers, providing innovative support.




                                                                                                           44
4. Lessons learned and innovations
Lessons Learned: The Milk Code struggles
History and overview of the “Milk Code struggles”:
(Please see the Milk Code description in Section 4 of this case study (pages 8 to 9) for an overview of the
Initiative.)
Lessons learned:
As seen by the chronicle in this case study, the “Milk Code struggle” has been a long one, with many ups
and downs, which will continue. With the ruling of the Supreme Court that all but 3 of the 57 provisions
of the Revised Implementing Rules and Regulations for the Milk Code could stand, the breastfeeding
community scored an enormous victory against great odds. When UNICEF, WHO, the DOH and their
partners began to advocate for the finalization and passage of a strong RIRR to put “teeth” in the Milk
Code, it was faced with three main issues: 1) limited government resources for breastfeeding promotion,
2) strong marketing by milk companies allowed by loop holes in the IRR and penetration of the health
system, and 3) little concern, support and outrage from the public, civil society and the media. (UNICEF
Milk Code presentation)
The DOH had only 60,000 peso a year for breastfeeding promotion while the formula companies
marketing budget was over 100 million. Formula was widely advertised and promoted, with gifts for both
health workers and mothers pervasive and “med reps” even reaching pregnant women with their advice
before health care workers made contact. There was little awareness of the dangers of formula on the part
of mothers, health professionals or political leaders, from the President on down. Mothers would even
apologize to BHWs that they couldn’t afford formula, even through they knew it was the best. And yet,
the breastfeeding advocates prevailed in this “round” of the battle. Lessons learned from this struggle are
presented below.
The importance of using the power of the UNICEF brand and those of other international
organizations. A key asset that was well used in the Milk Code struggles was the reputation of
international organizations such as UNICEF, WHO and others. Dr. Alipui, UNICEF Representative
during most of the recent battles, when reflecting on “lessons learned” said “The first is the power of the
UNICEF brand. It has opened doors for us with opinion leaders, policy makers, and influential
journalists. We have a global brand with credibility and an impeccable reputation. Let’s use it.” UNICEF
had access to the parliament and Senate, as they already had a track record, having recently finished a
juvenile justice campaign that led to shifting juveniles from jail into rehabilitation programs. As a result
they had access to high places and were respected. In addition, both UNICEF and WHO knew the
importance of leveraging international opinion. They felt that “the Supreme Court justices and other
policy makers listened better because of all the reports coming out in the international press as well as
support coming from breastfeeding experts and other personalities from all over the world…” (UNICEF
presentation on the Milk Code, ppt.)
The importance of using “evidence-based” arguments, backed by well-respected sources, and going
on the offensive. One critical aspect of the struggle was UNICEF’s and WHO’s ability to marshal the
facts concerning the dangers of formula and use the evidence effectively in the very high-powered debate
that took place in the media, the courts and the halls of congress. Pulling together the key studies
internationally and extrapolating the figures to illustrate the impact of formula use in the Philippines was
not an easy task, taking long hours on the part of UNICEF and WHO experts, with assistance from the
Centers for Disease Control (CDC). A WHO spokesperson reported that, as the “battle” progressed, the
sophistication of the industry increased. Fifteen statisticians from the formula companies were lined up
against a university statistician, with 220 pages of evidence prepared for the “formula side”. At first the
breastfeeding spokespersons tried to refute every study their adversaries quoted. Eventually they realized
that it was most powerful to work with CDC colleagues and marshal evidence from respected journals


                                                                                                         45
such as the Lancet, and then just forcefully state the evidence of the importance of breastfeeding for
young child survival. Both WHO and UNICEF were quoted hundreds of times, and having evidence-
based arguments was very persuasive. In addition, they made sure that the breastfeeding advocates used
the same statistics and used them in the same context, so all partners were consistent with each other.
The importance of “knowing the law” and using well informed lawyers, both from inside and
outside the country. In addition to fighting the battle on the basis of scientific evidence, the struggle had
to be waged on legal grounds. At one point in the “Milk Code hearings” a hearing room was declared
“full” when breastfeeding advocates from Children for Breastfeeding asked to attend. They insisted on
being admitted and found that almost 75% of the attendees were milk company lawyers. UNICEF
obtained advice from an expert legal advisor on a pro bono basis and maximized the use of its Child
Protection Specialist, who provided invaluable technical skills in conducting legal research and
developing the legal arguments in defending the RIRR in the Supreme Court and mobilized other expert
resources. 30 partners from government and the NGOs were trained on Milk Code monitoring, and both
the International Code Documentation Centre (ICDC) in Penang and UNICEF/NY’s legal advisor on the
Code gave well appreciated advice. This aspect of the fight was critical because, in the end, the Supreme
Court had to make its ruling after considering all the technical and legal evidence.
When the Supreme Court made its decision concerning what aspects of the RIRR were acceptable, it
ruled that it could not sustain the absolute prohibition on advertisements of breast-milk substitutes
because there was no convincing evidence that World Health Assembly (WHA) Resolutions, although
signed by most Member States, were considered obligatory or enforced or practiced by at least a majority
of the Member States. It would be helpful for UNICEF and WHO to document the implementation of the
International Code and the WHA resolutions in Member States for use in future efforts to ban marketing
of breast-milk substitutes in the Philippines and elsewhere. If this is not possible, national legislation
banning advertising will be necessary before an executive agency such as the DOH can enforce it.
The value of “banning together” in the
struggle, even though some tensions
surfaced. One early incident before the most
recent push for the Milk Code came about as
the result of an AC Nielsen report that the
three highest earning consumer products were
infant formula, cell cards, and San Miguel
beer, and a high level Secretary’s comment
that this showed the Philippines was finally
“modern”. This caused the UNICEF
Representative to issue a high profile rebuttal,
describing why high sales of formula were not
something to be proud of. As UNICEF, along
with WHO colleagues began to serve as energetic and forceful spokespersons for the Code, they called
upon DOH and the breastfeeding advocacy groups to join them.
As advocates became energized, the coalition grew in size, including Children for Breastfeeding, a
breastfeeding coalition of over 100 breastfeeding groups organized by Arugaan, supporters from faith
based organizations, professional societies, and many international supporters, among others. The
collaborative, high-energy efforts of these highly committed and vocal advocates, from mothers and NGO
leaders to representatives of key international organizations paid off. Some organizations, such as
Children for Breastfeeding, had political connections, reaching as high as the President, which greatly
helped in convincing her to support the cause. At times there were tensions between NGO groups and
some need to repair damage when politicians were alienated but, on the other hand, the willingness of
these organizations to fight hard for their beliefs, and UNICEF’s and WHO’s ability to listen to and
effectively utilize these valuable resources paid off.


                                                                                                           46
The importance of using creative and “dramatic” strategies to get the attention of the media, the
public and political leaders. While proving that the argument of the “breastfeeding coalition” was the
strongest based both on scientific evidence and legal grounds, it was critical to win the fight in the “court
of public opinion”. This was especially challenging, due both to the lack of knowledge of the effects of
formula and wide spread apathy both among the public and politicians on the issue. The media is
privately owned and it was difficult to get front page coverage and even, at times, any coverage at all, due
to the media’s reluctance to offend the milk companies, who were some of their most profitable
advertisers. Thus the breastfeeding coalition had to use creative, dramatic and sometimes shocking tactics
to get attention. UNICEF, WHO and the DOH waged an intense media campaign on its websites, through
posters, radio and TV spots, and spokespersons were willing to be interviewed whenever required. A well
crafted video produced by UNICEF, “Formula for Disaster, was widely aired inside and outside the
country. The breastfeeding NGOs advocates staged a number of “eye catching” events, including, for
example:
o    Demonstrating and lobbying outside key
     hearings and other events, more than 1000
     women sporting brightly painted umbrellas
     with breastfeeding slogans next to Quezon
     City Hall, holding vigils for children lost due
     to formula and, in one case at least 20
     women baring their breasts painted with
     graphics and slogans outside the Supreme
     Court.
o    Marshalling “record setting” numbers of
     breastfeeding women to attend the hearings
     themselves, persuading “protocol” to allow
     poor women without “proper” attire to attend
     for the first time in the history of a Palace
     event; circulating petitions with well-known
     senators, bishops, socialites and others
     persuaded to sign them, with the petitions then featured in the press with the help of UNICEF;
     asking celebrities to serve as role models; persuading businesses to support the cause; and engaging
     mothers to develop innovative exhibits.
o    Holding mass “breastfeedings” spearheaded by Children for Breastfeeding during World
     Breastfeeding Week, achieving the Guinness World Record for Simultaneous Breastfeeding in a
     Single Site (3,541 breastfeeding mothers in Manila) in 2006 and then, in partnership with WABA, a
     similar Record for Simultaneous Breastfeeding in Multiple Sites (with 16 countries and 10,000
     mothers) in 2007 – capturing both the media’s attention and the public’s imagination and thus
     making “front page” news.
Significance of the lessons and relevance for future programming:
As mentioned in the case study, the joint experiences in the Milk Code struggles thus far, eventually
resulting in a good solid “win” at the Supreme Court, have greatly energized the breastfeeding
community, helped them to form valuable new bonds, gather and use valuable technical and legal
expertise and test powerful advocacy skills. As the UNICEF annual report for 2007 observed, “organized
civil society developed a new found sense of its own identify and ability to campaign for the realization of
children’s rights, and more importantly, to achieve success without large amounts of financial
resources.”
The struggle is far from over, as many challenges lay ahead, such as developing and circulating a good
“lay” version of the RIRR’s key provisions, finalizing and putting in place a sustainable Code monitoring


                                                                                                          47
process at all levels, and devising a legally acceptable strategy for prosecuting violations. UNICEF and its
partners should capitalize on this major success and the lessons learned to actively work on the next steps
needed, while enthusiasm and public support is high.
Sources of information:
ICDC, Pharmaceutical and Health Care Association of the Philippines vs. Health Secretary Francisco T.
Duque III et al. from ICDC Legal Update, January 2008.
Inquirer.net, “Mothers bare breasts, buck “milk and murder”, June 20, 2007.
(http://archive.inquirer.net/view.php?db=1&story_id=72225:
Interviews with respondents from UNICEF Manila, WHO Manila, DOH, Arugaan, Children for
Breastfeeding, IMAP and with the former UNICEF Representative, now at UNICEF/NY.
Ordenes-Cascolan, Lala, The Philippine Milk Code: A timeline. The Daily PCIJ, June 20, 2007.
(http://www.pcij.org/blog/?p=1789 )
UNICEF Manila Annual Reports for 1997. 2002, 2005, 2006 and 2007
UNICEF Manila Press releases, including “Mothers fight for breastfeeding”, 1 Sept 2006; “Breastfeeding
advocates form consolidated action against formula companies” 13 Nov. 2006; “NEWS: UNICEF lauds
Supreme Court for lifting ban on Philippine Milk Code implementation rules”, Oct 10, 2007. (From
UNICEF website: http://www.unicef.org/philippines )
UNICEF Manila, The Philippines’ Battle for the Breast: Advocating for stricter enforcement of the Milk
Code. PowerPoint presentation by Representative Nik Alipui.




                                                                                                         48
Lessons Learned: The Philippines’ Mother Baby Friendly Hospital Initiative (MBFHI)
History and overview of the Initiative:
(Please see the Mother Baby Friendly Hospital description in Section 4 of this case study (pages 9 to 11)
for an overview of the Initiative.)
Lessons learned:
The Mother Baby Friendly Hospital Initiative experience in the Philippines is a rich one, offering many
“lessons learned”. The 1990s was a period a energetic implementation of the Initiative, with many
creative strategies employed and the impressive achievement of 1,427 hospitals certified, or a full 83% of
the targeted hospitals. In the late nineties, as chronicled above, UNICEF and government support for the
Initiative began to fade and compliance slipped. Little was done to sustain or revitalize the Initiative until
2006, when a retrospective study was undertaken of almost 100 mother baby friendly hospitals by the
University of the Philippines, and then, after the issuing of the Administrative Organ on “Revitalization of
MBFHI” the following year, the DOH, along with other partners, began the process of gearing up the
Initiative again. The key lessons learned during this 15 year period, both positive and negative, are
summarized below.
The availability of a successful “pilot” programme and solid data showing its effectiveness in the
country itself can be very useful in convincing decision-makers to undertake an Initiative such as
the MBFHI. The work of Dr. Natividad Clavano at Baguio General Hospital, in the 1970’s, provided a
clear example of the strong impact implementation of such measures as closing the hospital nursery,
rooming in, and limiting formula use could have on morbidity and mortality. Her example and availability
to provide training for the staff at Fabella encouraged that “flag ship” maternity hospital to initiate similar
changes even before BFHI was launched at a global level.
International leadership and top level advocacy is important, as well. While encouraging changes had
begun in the 1970s and 80s, the launching of the BFHI at global level helped spur the Philippines to
institute the “Ten Steps” at a faster pace. The high profile visit of Dr. James Grant and his visit with
newly elected President Ramos and high level DOH officials provided the encouragement necessary for
the Initiative to really take off, with the President declaring that 100 hospitals should become “baby-
friendly” in the first 100 days of his administration. In the late nineties, on the other hand, when
UNICEF/NY and thus to greater or lesser extent its country offices, went on to other initiatives, top level
support at country level died down as well. The adoption of the WHO/UNICEF Global Strategy for IYCF
in 2002 and renewed advocacy at international level for BFHI helped greatly to convince UNICEF
country offices and governments to consider “revitalization” of the initiative.
Innovative and “cost-cutting” measures in a demonstration hospital that help solve
“implementation challenges” can energize an Initiative such as MBFHI, catching the imagination of
other facilities. Some of the innovative approaches Fabella used, under the leadership of its Medical
Director, Dr. Ricardo Gonzales, included
o    Instituting creative “cost-cutting” measures to make the “mother baby friendly” changes less
     expensive. For example:
       -   The legs of the high beds were cut shorter and plywood put under the mattresses, to make the
           beds more suitable for “rooming-in”.
       -   Beds were moved together in “pairs”, when mothers wished, so one mother could watch two
           babies, when the other needed to be away for the few minutes, thus freeing up the staff from
           this task.




                                                                                                            49
       -   Staff from the normal newborn nursery and formula room were reassigned to provide mother-
           baby care and education on the rooming-in wards, once the nursery and formula room was
           closed.
       -   A simple refrigerator was used for breast milk storage and free or low cost containers for cup-
           feeding.
       -   Fabella organized a “Lactation Brigade” of retired midwives and other volunteer breastfeeding
           counselors with lactation management expertise who assisted mothers who had newly
           delivered with breastfeeding problems.
o    The Medical Director, Dr. Gonzales, made a simple calculation of the savings his hospital had
     realized by implementing the “10 Steps”, by estimating the costs of maintaining a newborn nursery,
     if it were to be re-instituted. As mentioned earlier, the hospital was saving 6,410,720 PhP per year
     ($310,037US), an impressive 8% savings for the hospital’s budget, which served to convince both
     other hospital administrators and DOH officials, that the MBFHI was cost-effective.
Systematic orientation of hospital administrators to the MBFHI and advocacy to gain their
commitment can greatly increase the adoption of a change such as “Baby-friendly”. When Fabella
became the official “National Lactation Management Training Center” for the MBFHI, one strategy that
it used throughout the country was to orient hospital administrators to the “Ten Steps”, how to make the
changes, and what difference it could make to their facilities. The example of Fabella, with it’s ability to
implement the Initiative in a large, rather poorly equipped hospital, using creative cost-saving measures,
and with it’ Medical Director available to “make the case”, was convincing. One of the MCH Directors at
DOH, who had visited both the diarrheal disease control (DDC) units and the “baby-friendly” venues
around the country, observed that the MBFHI was expanding much faster that the DDC programme, and
attributed this to systematic advocacy with the hospital administrators.
Development of a well-managed system for scaling-up and supporting the Initiative, embedded
within the health system, is essential for successful functioning of the programme. Although some
support was available from UNICEF/NY and the Country Office, the Government of the Philippines was
committed to the Initiative, and the Secretary of Health (Dr. Juan Flavier) tasked the DOH’s Hospital
Operations and Management Service (HOMS) with developing a full system for implementing and
supporting the Initiative, a decision that was essential in a country with almost 1,500 facilities spread over
a number of islands. A team of 5 professionals at HOMS, overseen by a very capable manager, Dr.
Margarita Galon, was charged with management of the MBFHI. A Regional Training Center was set up
in Cebu City to complement the work of Fabella at national level, coordinators were designated
throughout the country, and a system of “training of trainers and assessors” was instituted. A “Speakers
Bureau” was organized, with experts available to assist with the trainings and assessments. “Sister
Hospitals”, identified among the “baby friendly government hospitals, were asked to mentor private
hospitals seeking certification.
If the Initiative is to have full impact, “Step 10”, fostering mother support at the community level,
must be fully implemented. (This was a challenge in the Philippines because of the cost and
organizational complexities of this component of the programme.) While the MBFHI was successful
in achieving changes within the hospital, the efforts to fully implement “Step 10” were less successful.
While hospitals did foster the development of some mother support groups and thus achieved designation,
the challenges of setting up viable systems for mother support in surrounding communities proved
difficult, given the work the hospitals were tasked with “within their walls” and the costs of setting up and
supporting mother support at community level. Many of the mothers came to deliver from communities
outside the hospitals’ catchment areas, and thus were difficult to support for this reason. Viable
“community support systems” are essential if a national breastfeeding promotion programme is to have
sufficient impact, but it is likely that other measures, in addition to those possible within BFHI, are
necessary to put it in place. (See innovations presented earlier.)


                                                                                                           50
The development of an Initiative that is “immune” to regime change and includes a strategy for on-
going monitoring and reassessment is essential for sustainability. (This was not achieved in the case
of the Philippines.) The Initiative, during the early to mid nineties, was successful in training, assessment
of hospitals and awarding “baby-friendly” achievement, but neglected to put into place a viable system
for on-going monitoring and reassessment. In addition, mechanisms for training new staff, in light of
rapid turnover of hospital personnel, were not fully developed. Thus, over time, compliance with the “Ten
Steps” slipped. In addition, the programme was not organized in such a way that when major changes
were made within the DOH, during the effort to “re-engineer” the system, the Initiative could continue to
thrive. Both top level support and the expertise to manage the program were lost, as management
personnel were shifted to other posts. In recent efforts to “revitalize” the MBFHI, particular attention is
being paid to this weakness within past programming. An on-going monitoring system is being
developed, reassessment will be required every three years, and designated hospitals must submit annual
reports on their adherence to the “Ten Steps”. Other measures that are more difficult to achieve may be
necessary as well, such as a “regime proof” budget line for the Initiative and strategies for maintaining the
needed expertise at the management level, when key managers are transferred or retire.
Creative measures for embedding the “baby-friendly” criteria into systems for quality assurance
and accreditation are essential as part of a plan for insuring sustainability. The recent agreement
with PhilHealth that MBF certification will be a requirement for hospitals seeking PhilHealth
certification may help to revitalize and sustain the Initiative. Early in the Initiative some consideration
was given to instituting MBF certification as a requirement for licensing of hospitals, but HOMS
preferred that hospitals voluntarily commit to becoming baby-friendly. The recent requirement that
hospitals must achieve MBF certification (along with a number of other requirements) before they are
eligible for accreditation by Philippine Health Insurance, and thus become eligible for reimbursement for
services they give, seems a promising one. With persistent encouragement from UNICEF,and
commitment of DOH-National Center for Health Facilities (NCHF) and Phil Health the “PhilHealth
Circular” was signed, making this requirement official. There are 1500 hospitals in the Philippines that all
aim to achieve accreditation by PhilHealth, and so the requirement of MBF certification as part of the
process is a useful “carrot” to convince them to apply for MBF training and assessment.
Significance of the lessons and relevance for future programming:
These lessons may be useful both for the Philippines and for other countries, as they seek to revitalize an
important Initiative that has been shown to effectively assist hospitals in providing the support both
pregnant and newly delivering women need to feed their infants in an optimal way. However, it is
essential that strategies be further explored for increasing the “cost-effectiveness” of the programme and
instituting systems for refresher training, monitoring and reassessment necessary to sustain compliance
with the “Ten Steps”. Strategies such as putting in place the budget and personnel needed for long-term
management of the Initiative, and integrating the requirement for baby-friendly certification into
licensing, hospital accreditation or health insurance schemes need consideration. And, most important of
all, the BFHI needs to be complemented by a well developed and effective system of community-based
breastfeeding support, well coordinated with the Initiative.
Sources of information: Information sources include:
o   Wellstart International, Country Case Study No. 6, Philippines: A Creative Breastfeeding Program
    Services as a “Baby Friendly” Model World Wide”, 1998.
o   Interviews with DOH and UNICEF officials and the MBFHI coordinator at Fabella and review of
    documents during the field visit to Manila for development of this case study, July 2008.




                                                                                                          51
       Innovation: Community-based breastfeeding program of Barangay Pembo, Makati City,
       Metro Manila
Problem or issue addressed:
Barangay Pembo is the most populated barangay (district) in Makati City, with over 25,000 people. Data
gathered by health center staff during client visits indicated that only 4 out of 10 of the women with
babies under 6 months of age exclusively breastfed their infants. Nationally only 16 out of 100 mothers
are exclusively breastfeeding at 4-5 months. Health workers felt that this low level of breastfeeding,
coupled with inappropriate complementary feeding practices, was a cause for alarm because of the
consequent under-nutrition and risks for morbidity and mortality. Data from the NDHS (2003) indicate
that malnutrition is the cause of 50% of under-five deaths and contributes to 61% of deaths from diarrhea,
52% from pneumonia and 45% from measles. Many of these deaths could have been prevented if mothers
followed the recommended IYCF practices. Health workers realized there was an urgent need to address
and correct misinformation on breastfeeding and to increase community awareness and provide support
for pregnant and lactating women. 22
Strategy pursued to address the problem:
In 2005, the Philippines adopted the National Framework for IYCF. That same year, the Liga ng Mga
Barangays (the League of Local Chief Executives at the Barangay level\s) held a national assembly,
attended by 150 regional league chapter presidents and 2500 municipal delegates, where the goals of the
IYCF Framework, issues around child nutrition and the possible role of barangays in addressing these
were presented. The Liga President of Makati City volunteered Barangay Pembo to be an intervention
demonstration site for a community-based breastfeeding program.
The City of Makati, in collaboration with the Center for Health Development for Metro Manila (CHD-
MM), the WHO, UNICEF and other agencies, then embarked on a pilot project. The city believed that
breastfeeding could be successful in a highly urbanized community by mobilizing and building the
capacity of a community-based breastfeeding support group. The end goals of the project were to improve
the health status of infants in Makati’s largest barangay and to serve as a reference guide for other
barangays in establishing and sustaining community-based breastfeeding programs.
The key implementation steps involved in establishing the program are summarized below:23
1. Organizing implementation mechanisms, harnessing champions and appropriating funds. A
Breastfeeding Technical Working Group (TWG), with 10 members (including the health center physician
and nutrition coordinator, various physician and midwife supervisors, the MCH and IYCF coordinators
and health education and promotion officer of the Makati Health Department, the Pembo Councilor for
Health and DOH Rep. of Makati) was formed to design, implement, supervise, monitor and evaluate the
program. It worked with the DOH and WHO to modify existing but somewhat cumbersome
methodologies into strategies that would work effectively in the community. In addition, the Kagawad
(Councilor) for health advocated for the issuance of a barangay resolution/ordinance in support of the
program and facilitated funding, the TWG organized the breastfeeding support group (peer counselors),
and the Barangay Health, Sanitation and Nutrition Council developed the necessary policies to support
the program.
2. Building awareness and getting stakeholders’ commitment. The program was launched during the
celebration of World Breastfeeding Week in August 2005 in Barangay Pembo, with key City health
officials, DOH and WHO personnel, community officials and NGO representatives and concerned
mothers invited. The large turnout and enthusiasm compelled Barangay Pembo and its partners at DOH


22
     Pembo report, p. 1
23
     Pembo report, pp. 5 – 10


                                                                                                       52
and WHO to rapidly develop the necessary tools for the program. Stakeholders also signed pledges of
commitment, which helped facilitate coordination later on.
3. Selecting community members as peer support breastfeeding counselors. Initially, existing peer
counselors and health center staff were tapped to pre-test the tools and methodologies. Since the peer
counselors already had many other tasks, the TWG advocated recruiting additional community members
to serve as peer-support breastfeeding counselors (the Breastfeeding Support Group) for the program
itself. Zone leaders helped identify counselors from the 400 mothers present at the program launch using
criteria such as successful experience, good reputation and involvement in the community, local
residency, literacy and a spirit of volunteerism and dedication. A total of 23 counselors were recruited.
4. Capacity building for the Health Center Staff and the Breastfeeding Support Group. Makati
asked the CHD of the National Capital Region to train both health center staff/zone leaders and the peer
counselors to implement the program activities. An IYCF course was given, including a 2 day course on
breastfeeding and a 3-day course on HIV counseling and complementary feeding. The breastfeeding
course was practical, including lecture/discussions, in-house role playing, and practicums in the health
centers and community where mothers were counseled. The counselors “learned by doing”, following the
process they would later use on the job. The second course, on HIV and complementary feeding, was also
attended by Councilors for Health. The participants appreciated the information and found the counseling
cards helpful.
5. Providing breastfeeding counseling services to those in need. The peer counselors then recruited
mothers in need of counseling through women’s groups, churches, schools, door-to-door visits and
encouraging people to recommend mothers with infants for counseling, with a total of 675 women
identified. Mothers who practiced non-exclusive breastfeeding or had breastfeeding problems were
selected for three home visits. The first visit included a 24-hour food recall, questions, and discussion of
reasons the mothers do or do not breastfeed. The counselors then meet with the Breastfeeding TWG and
health center staff to discuss their experiences, identify feeding practices needing improvement and
identify ways to encourage behavior change. During the second visit, done within the week, they
counseled the mothers about improving feeding practices, using appropriate motivators. The counselors
then “negotiated” with the mothers, asking them what improved practices they would agree to try. Two
weeks later the counselors interviewed the mothers a third time, observing changes in feeding practices
and receiving feedback from the families on their experiences. Sometimes further follow-up visits were
scheduled.
6. Monitoring and documentation. After the third visit, the counselors reconvene with the health center
staff, the Breastfeeding TWG and DOH and WHO representatives to discuss and learn from each others
experiences. The counselors organize the data using a standard report form which summarizes the
status/outcome of the 3 home visits and captures the recommendations made after each visit. In addition,
each counselor received a logbook to record relevant information from her exchange with the mothers.
This information and inputs from health center staff, were used to develop a master list of feeding
practices with suggestions on possible “motivators” for improvements. The TWG and health center staff
both provide needed technical support for the counselors and draw upon the counselors’ first hand
knowledge to gain insights on program implementation.
Results achieved so far:
Data collected systematically by the breastfeeding counselors showed that after just three visits the
majority of mothers who had been giving mixed feeds to their babies shifted to exclusive breastfeeding.
In addition, counselors were able to convince more than half of the mothers who were giving only
artificial feeds to start breastfeeding again.




                                                                                                           53
     Percentage of infants 0-6 months on mixed-feeding                   Percentage of bottle fed infants
             shifted to exclusive breastfeeding                             shifted to mixed feeding

 Reasons for mixed feeding           Shifted to exclusive      Reasons for bottle feeding        Shifted to mixed
                                     breastfeeding                                               feeding

 1. Not enough milk                  46     (71.9%)            1. No milk                        57    (86.4%)
 2. Mother not with baby             15     (68.2%)            2. working                        37    (68.5%)
 3. Working                          12     (50%)              3. Refusal of breast milk         16    (66.7%)
 4. Mother is sick                   7      (100%)             4. Mother is sick                 14    (93.3%)
 5. Bottle started in hospital       1      (50%)              5. Nipple infection               4     (80%)
 6. Cleft lip                        2      100%)              6. Inverted nipple                5     (100%)
 7. When tired                       2      (100%)             7. Mother Hepatitis B (+)         2     (50%)
 8. Only one breast                  1      (100%)
24


In addition, in 2006 41 infants/children out of 4066 aged 0-71 months were found to be Below Normal
Low (BNL) in weight and 9 were Below Normal Very Low (BNVL). They were included in the nutrition
rehabilitation program, where mothers of infants 0-6 months old were lectured on the importance of
breastfeeding25. After 3 months, 70% of the infants under 6 months with BNL recovered, while 88% of
the infants with BNVL became BNL.
Another results of the program is that counselors from the health center and community have improved
knowledge and skills in IYCF and are able to address breastfeeding problems and concerns, conduct
interviews, prepare proper documentation and monitor mothers through regular follow up.
Finally, through the efforts of the local health unit, in coordination with the DOH and WHO, the barangay
council was encouraged to undertake breastfeeding advocacy. A local ordinance was formulated and
approved to provide financing for the program. A basic training on breastfeeding was conducted,
involving key health and nutrition staff, and breastfeeding advocacy has been integrated into the class
held for couples every quarter. (Pembo report, p. 5)
Sustainability and scale-up:
The City of Makati and its partners in the pilot programme were very careful to build the pilot
community-based breastfeeding programme in a way that would help sustain it at barangay level and
offer the example and tools needed to replicate it in other local government units. As described above, the
organizers began with advocacy through the Liga ng Barangays, and developed this first demonstration
project with a city government and community that saw the need for improvement and was committed to
the process. An ordinance was passed, providing on-going financial support at the local level, necessary
in a devolved health care system. Leaders, managers and health workers at all the key levels were
sensitized and trained when appropriate. Peer counselors were selected among committed mothers who
had attended the launching event, based on clear and appropriate criteria. TWG and health center staff
were involved in the trainings and then continued to provide support for the peer counselors, forging a
strong partnership between the local health system and the counselors. Data were systematically collected
and analyzed to provide evidence of effectiveness and to use to advocate for on-going support.
In addition, the program organizers and their partners developed, field tested, and fine-tuned materials
that were both needed for an efficient programme and valuable for programme replication. These

24
  Pembo report, p. 4
25
  Other rehabilitation strategies included micronutrient supplementation, supplementary feeding and health and
nutrition education, among others.


                                                                                                                 54
included a document entitled “Establishing Breastfeeding Support Groups in the Community – Peer to
Peer Approach” used to guide programme implementation, a conceptual framework for the programme, a
sample ordinance and pledge of commitment, training schedules and materials, guidelines for home visits
including questionnaires and a handbook with typical breastfeeding practices and motivators for change, a
follow-up record/report and data summary sheet, and the full report of the process with guidelines for
whom to involve at the City, Barangay and Support Group level, and their roles.
This hard work has paid off. By mid 2008 Makati City had successfully replicated the Pembo program in
seven other barangays, owing largely to the support of village officials and residents, and was training
health workers and volunteers in 10 additional barangays with a 400,000 PhP ($8,500 US) grant from
WHO).(Article in inquirer.net) Other cities are interested in replicating the program as well.
Lessons learned and implications for UNICEF’s work:
As stated in the Pembo report:
     Barangay Pembo’s Community-Based Breastfeeding Program shows how trusted community
     members can be effective in changing the perspectives/mindsets of their fellow constituents. It is an
     initiative that combines technical know-how with practical methodologies and approaches so that
     counseling for something as personal as breastfeeding becomes an exercise that mothers become
     comfortable and willing to participate in.
The program strengthened the management skills of the various stakeholders, particularly of the health
center staff and counselors, and provided a systematic way of gathering the relevant data, analyzing it,
and planning interventions that respond to what the results say the clients need. The process provided
counselors and their mentors first hand experience of the value of recording information in a way that it
can be used as a practical guide for subsequent visits and follow-ups and also as a source of information
on what further training is needed for the counselors themselves.
The demonstration program provides a solid example of a practical community-based program that can be
“scaled-up” through replication throughout the country, with continued support from the DOH, WHO and
UNICEF. Especially useful is the “modeling” of how to engage the key stakeholders necessary for
implementation of a program such as this in the Philippines “devolved” health care system, although it
could be equally useful, with some adjustments, in other countries as well.
Remaining challenges and future activities:
The organizers reported several challenges. In some cases mothers who gave birth at one of the hospitals
were advised to give artificial feeds before their infants were roomed-in. It was also discovered that many
of the patients in that hospital were non-Pembo residents using fake addresses, which has implications for
the accuracy of the data and its use for planning purposes.
While Makati City continues to work on expansion and consolidation of its program, efforts should
continue to replicate the initiative in surrounding cities, while advocating for its adoption in other parts of
the country. Makati is a relatively prosperous city, and thus could easily find the funds to support the
program. Other LGUs may have fewer resources available. It is fortunate that the program is relatively
inexpensive and cost-effective, using volunteer counselors. Support is needed only for meetings,
transportation, trainings, and other similar expenses, as well as for the time devoted by city officials and
health system personnel. It will be helpful to clearly specify what funding may be needed in varying
circumstances, as well as the “payoff” to be expected in improved practices and resulting health and
nutritional benefits. It will also be important to determine, over time, how successful the programme is in
retaining the volunteer peer counselors, and whether payment or other additional incentives will need to
be considered.




                                                                                                            55
Sources of information:
The information for this “innovation” came from the report, Ensuring Better Health and Nutrition for Mothers and
Children: The Community-Based Breastfeeding Program of Barangay Pembo, Makati City, Metro Manila.
Department of Health, Center for Health Development National Capital Region, Bureau of Local Health
Development, undated, as well as interviews. Information on “scale-up” or replication came from newspaper
reports.




                                                                                                               56
Innovation: Comprehensive nutrition programme for nutritionally depressed barangays in
Cebu City.
Problem or issue addressed:
                                                                        PREVALENCE OF UNDERWEIGHT CHILDREN
The health statistics for Cebu City for 2006                                  CEBU CITY – CY 2003 TO 2007
indicated that the situation for children, in                      35
general, was better than for the country as a                              32
whole. For example, while the neonatal death                       30

rate per 1000 nationally was 15, in Cebu City                                          24
                                                                   25
it was 9 and similarly, while the infant                                                         21




                                                      Prevalence
mortality rate per 1000 nationally was 25, in                      20                                       17           16
                                                                           16
Cebu City it was 16 (NDHS). However, an
                                                                   15
analysis of nutritional differences in the                                            11
                                                                                                 9          8
barangays of Cebu City indicated that there                        10                                                    7
were major discrepancies in the nutritional
                                                                    5
status of children in high risk barangays, when
compared with all the barangays in the City.                        0
For example, the graphic to the right, shows                            2003       2004      2005       2006       2007
twice the prevalence of underweight children                                                  Year
in the high risk barangays.                                                    Cebu City    Top 10 High Risk Barangays


Strategy pursued to address the problem:
The Nutrition Center of the Philippines and the Cebu City Nutrition Committee developed a
Comprehensive Barangay Nutrition Program (CBNP) in four high risk barangays, with a total population
of 40,000. The Program started in September of 2007. 100 families were targeted per barangay, for a total
of 400 families with pregnant women and/or lactating women, newborn to 3 year olds, and/or
underweight preschoolers. . The programme
objectives for 2008 included promoting
breastfeeding and appropriate complementary                       Executive Action
feeding among parents of underweight and under 3
old children, and pregnant and lactating women.
Other objectives related to provision of                                              “I want to focus on
appropriate foods and nutrients for both the                                             malnutrition”

women and children.                                                               Mayor Tomas R. Osmeña


The process began with a nutritional analysis that
demonstrated the disparities described above,
which then were presented to Cebu City officials
                                                                   Mayor Approved the CBNP in 4 Barangays
to gain their political and financial commitment to                  with High Underweight Preschoolers:
the programme. The Mayor approved the
Comprehensive Barangay Nutrition Program,                                          1.4 Million Budget
providing a 1.4 million PhP budget. ($30,000 US)
Existing barangay nutrition and health workers (BHWs and City Nutrition Scholars - CHSs) were then
trained in program strategies and all aspects of Cebu Health Department services. Priority target
households (100) in each of the 4 barangays were then identified by the workers responsible.
The BHWs and CNSs were then designated to work with the target households, with each worker having
responsibility for about 20 households. (See “Spot Map” below). The first task of the workers was to
survey and “profile” the families in each of the target households and second, to provide the support
needed.




                                                                                                                              57
The interventions for each type of “target” beneficiary were clearly specified, and the BHWs and CNSs
given clear instructions for what to do, with the tools they needed. For example:
o    Pregnant women were enrolled in
     Pabasa, counseled on exclusive              To Designate the Barangay Nutrition
     breastfeeding and IYCF, counseled on         Workers to 100 Target Households
     family planning and enrolled in a
     special pre-natal program
     (KUMARE).
o    Lactating women were given similar
     support and counseling, as well as a
     postnatal check-up, iron-folate,
     vitamin A, and food prescriptions.          - BNW 1
                                                - BNW 2                           NDA
o    Children under 3 years of age were
                                                - BNW 3
     weighed quarterly, immunized,
                                                - BNW 4
     provided vitamin A or all                  - BNW 5  CLUSTER HOUSEHOLD SPOT MAP
     multinutrient supplementation and
     their parents counseled on IYCF, prevention and treatment of childhood illness, and hygienic
     practices, and given food prescriptions.
o    Underweight children and their parents received similar support but the children were also
     weighed monthly, de-wormed, given an iron supplement and fed with fortified food.
Partners and personnel involved:
Cebu City contracted the Nutrition Center of the Philippines (NCP) to assist the Cebu City
Nutrition Committee (CCNC) in the city nutrition program. Dr. Florentino Solon, Executive
Director of the NCP serves as the Nutrition Consultant for the City of Cebu. The NCP designed and
developed the CBNP with the 4 nutritionally at risk barangays as a model. The City Health
Department, the City Agriculture Department, and the Department of Social Welfare Services were in
charge of implementing the CBNP program component.
Personnel include trainers, supervisors and the BHWs and CNSs who undertake the home visits. The
BHWs are paid by the Barangay fund while the City Nutrition Scholars (CNS) are paid by the
Mayor’s office. Both BHWs and CNSs are required by law.
Results achieved so far:
The programme implementation review is currently underway, but some promising results related to
IYCF are already available. For example:
o    400 trainers were targeted for Pabasa training, and 442 were enrolled and graduated.
o    All 400 households targeted were surveyed as planned, with the “family profiling” completed.
o    All lactating women received postnatal check-ups, which included monitoring of breastfeeding and
     complementary feeding compliance.
o    All lactating women visited started to breastfeed, and 58% of these women were able to exclusively
     breastfeed up to 6 months. Cebu City’s exclusive breastfeeding rates in 2007 were 35% (CHD IYCF
     report).
A full evaluation will be completed in January of 2009.




                                                                                                        58
Possibilities for sustainability and scale-up:
The Comprehensive Barangay Nutrition Program has useful potential for sustainability and scale up. This
process has already started in Cebu City, with 6 more barangays being involved. The same procedures
will be followed as for the 4 initial barangays unless the program implementation review suggests
improvements.
The first step in scale-up is to engage the commitment of local government units so that they become the
prime movers in nutrition. The next step, according to Dr. Solon, is to train a Provincial and City Training
Management Team or “PTMT” who would then train the Municipal Training and Management Team or
“MTMT” of the province. The MTMT would model or demonstrate the CBNP in one village of the
municipality. The model village would be monitored and evaluated and then could become the training
center for the municipality, after its targets and objectives have been achieved.
Lessons learned and implications for UNICEF’s work:
Several lessons are important to consider, as this “innovation” is reviewed:
o    If community-based nutrition programmes are to be successful in a “devolved” health system, it is
     critical to involve the local officials, including those at provincial, city and municipal levels. Solid
     data concerning health and nutritional needs, particularly in disadvantaged barangays, is critical to
     convincing local leaders that action is needed. A successful and cost-effective “demonstration” can
     be useful as well.
o    It is important to have well-tested strategies for the intervention, such as those used in the CBNP,
     that provides the supervisors and barangay-level workers with the tools they need to address the
     most important nutritional problems faced by women and children. The approach of identifying and
     focusing on the most disadvantaged barangays and, within them, the households with individuals
     most needing support, is critical, especially given limited resources.
o    The strategy of first implementing the program in one or several typical “demonstration” barangays
     is one that UNICEF could encourage, in collaboration with the DOH, the AMHP, and provincial and
     local officials, and with technical assistance from the Nutrition Center of the Philippines.
Remaining challenges and future activities:
It will be important to review the final results from this demonstration programme early next year. If a
decision is made to replicate the programme, care must be taken to ensure that the level of human and
financial resources involved are within the means of local government units and that the programme is
“cost-effective”. Initial calculations indicate that the cost per household for a comprehensive, integrated
nutrition programme is approximately 250 PhP ($ 5.40 US) per household per month, which is affordable,
given the funds available at local level. Calculations of costs and resulting savings, in terms of estimated
lives saved and illnesses averted, will be very useful in future advocacy sessions with national and local
officials.
Sources of information:
The information for this “innovation” has been provided by Dr. Florentino Solon, Executive Director of
the Nutrition Center of the Philippines. The graphics and data for the presentation are from his
presentation on the “Comprehensive Barangay Nutrition Program for the Four Nutritionally Depressed
Barangay of Cebu City 2007 – 2008” (Presented at the Philippine Association of Nutrition (PAN) annual
convention in Cagayan de Oro, Philippines on July 31, 2008) Session III – Putting words Into action:
LGU Models that Work.)
Additional information was provided by Dr. Solon, during the interview with him in Manila and via e-
mail correspondence.




                                                                                                            59

				
DOCUMENT INFO
Description: Network Marketing Philippines Study document sample