READ: ‘Busy’ parents, convenience fuel child malnutrition (First of three parts)
READ: Investing in 2 kitchens a win for 5,000 children (Second of three parts)
MARIA Lourvie Abesia, 33, feeds her four-year-old and one-year-old daughters “tuslob-buwa,” dipping the puso (hanging rice) into a frying pan containing a sauce made of pig brains, pork stock and oil, in a street stall in Barangay Sawang Calero, Cebu City.
The children’s distended stomachs show their malnutrition. Their five-year-old sibling is the same height as the four-year-old.
Abesia had seven children. But only five remain. A little past one year old, her second child died of bronchopneumonia; her fourth child died of cord coil in the womb.
Of the children under five years old in Cebu Province, 14,914 or 3.8 percent were underweight or severely underweight, 11,269 or 2.9 percent were wasted or severely wasted, while 44,534 or 11.5 percent were stunted or severely stunted in 2017, according to the Operation Timbang (OPT) Plus conducted in Cebu’s 44 towns.
Underweight refers to low weight for age; wasting, to low weight for height; and stunting, to low height for age. Stunting is a sign of chronic undernutrition.
Malnutrition exacts an economic price on the country.
According to Save the Children Philippines, malnutrition costs the Philippines P328 billion, or 2.84 percent of the Gross Domestic Product, yearly in the form of educational costs from grade-level repetition by basic education students, and potential income losses as a result of low educational achievement and premature child deaths.
“Children who are stunted in the first two years of life are more likely to repeat grade levels, drop out of school, and delay school entry. They are also more likely not to finish secondary education,” said Save the Children.
This is why government officials have been racing to ensure the proper nutrition of children under two years old.
Intervention
From mid-2016, the National Nutrition Council (NNC) 7 has been implementing the Early Childhood Care and Development Intervention Package for the First 1,000 Days (ECCD IP/1000) in three Cebu towns to secure children’s health in the first 1,000 days—counted from conception to the first two years of life.
The program involves having barangay health workers and barangay nutrition workers better monitor all children below two years old and all pregnant and lactating women, to ensure that the children get immunization and other health services due in their age group, and the women get pre-natal and post-natal care.
It also involves the distribution of home food production materials to the target beneficiaries.
“These include seeds, fertilizers, garden tools and some livestock. All these will be utilized to create home and community gardens that will ensure the food security of the target beneficiaries,” said Retz Pol Pacalioga, ECCD-F1K provincial nutrition coordinator of the NNC 7.
Barangay-level activities also include nutrition education classes and participatory cooking demonstrations for mothers to learn how to prepare complementary food to give to their children.
The World Health Organization recommends exclusively breastfeeding babies for the first six months; and after this, continued breastfeeding and provision of complementary solid food up to two years old or beyond.
The National Nutrition Survey showed that in 2015, only 48.8 percent of mothers practiced exclusive breastfeeding in the first six months of their babies’ life.
Spike
Pacalioga underscored the importance of intervening early.
“Most cases of stunting happen when the mothers start complementary feeding. In the 0-5 age group in the OPT, from six months old to two years old is where you get the biggest spike in the cases of stunting,” he said.
This is because mothers usually give their children just porridge or soup even until the child reaches one year old, he said, which won’t give the child enough nutrients.
The 2017 OPT Plus results in Cebu Province show that 1,881 babies 0-5 months old were stunted. This figure jumped to 2,361 in the 6-11 months age group, then more than tripled to 8,777 in the 12-23 months group.
By 48-59 months, the number had risen to 10,569, showing the cumulative effects of undernutrition on children’s development.
Target towns
In Cebu, the ECCD IP/1000 program, set to run from 2016-2018, targeted 5,451 pregnant women, 4,668 lactating women and 8,401 infants 0-23 months old in Santa Fe, Dalaguete and Tuburan towns.
The result is that in 2017, wasting prevalence in the children fell to 3.6 percent from 5.41 percent in Tuburan, and to 2.92 percent from 4.47 percent in Dalaguete from 2016, but increased to 3.21 percent from 2.69 percent in Santa Fe.
Stunting prevalence worsened to 25.06 percent in Dalaguete from 21.68 percent; to 20.44 percent in Santa Fe from 9.58 percent; while it dipped to 19.61 percent in Tuburan from 19.75 percent.
Pacalioga said wasting prevalence fell as a result of the introduction of the ready-to-use therapeutic food (RUTF).
The Department of Health 7 started distributing in Cebu last year the RUTF for the outpatient treatment of children 6-59 months old suffering from acute malnutrition.
As for the high stunting incidence, Pacalioga put it down to the use of inappropriate tools in getting the weight of the child, and the lack of training of health personnel at the time.
“The weighing scale used for adults (beam balance) is not very accurate for weighing children. The Salter Scale for children is more sensitive for getting the weight of the child. The three towns now have this,” he said.
Trainings for the program were rolled out only in mid-2017, and the training of barangay implementers concluded just last quarter, he said.
Helping mothers
There were more positive results in the iron folic supplementation of the pregnant women. Coverage improved to 72.21 percent from 17.85 percent in Tuburan, to 69.18 percent from 18.99 percent in Santa Fe, and to 37.3 percent from 21.14 percent in Dalaguete, auguring well for the health of their unborn children.
But it was still difficult to convince pregnant women to make at least four prenatal visits, Dalaguete and Sante Fe showing drops in visits to 38 percent from 47 percent, and to 63 percent from 71 percent, respectively.
Pacalioga said some mothers may have found the health center too far from their homes since the health center in every village was usually located in the town proper.
“They don’t want to spend on the fare. They’d rather spend the time farming,” he said. “Some are also hard-headed. They don’t see the need for pre-natal care since they did without it in the past. Pre-natal care is where you can discover any complications. We’re trying to change their mindset, so we include that in the nutrition education classes.”
Visiting 62 of the towns’ 97 barangays from April 2017 to April 2018, the provincial nutrition committee found some barangay nutrition committees non-functional, so they still had to lobby with the barangay captains to support the barangay’s nutrition programs.
Today, however, Pacalioga said, Dalaguete and Santa Fe now have 30 mothers per barangay who graduated from the nutrition education classes. The graduates in Dalaguete have even formed Infant and Young Child Feeding support groups that help the community by teaching the younger mothers proper breastfeeding and care of their children.
This will lead to a greater reduction in the stunting and wasting prevalence this year, he said.
Bottleneck
“But one of our bottlenecks is the election,” Pacalioga said. “That is always a problem because after the elections, barangay captains remove health workers who are not their allies. So continuity of the program becomes a problem.”
“The government has invested so much in training these barangay-based workers. These barangay nutrition workers are our frontline workers. So now we’re meeting with the barangay captains and mayors in the three towns, so we can be assured that the money we (NNC 7) spent on training the health workers won’t be wasted. We tell them it’s better if they don’t remove those trained health workers,” he said.
Aside from the cost, the time spent training new workers delays the implementation of nutrition programs.
“The barangay-based workers are the ones handling the program. So if they are changed, we have to start from scratch,” he said. “Training in the ECCD is three phases. We finished two phases of the training already. Module 1 took two days. Module 2 was five days. Module 3 is another two days.”
The three modules are connected, so it would be difficult for new workers to understand Module 3, without having taken Modules 1 and 2.
To discourage the practice of changing barangay workers, Pacalioga said they plan to talk to the Association of Barangay Councils presidents and members to tell them that if they change the trained workers, then they would have to shoulder the cost of training the new workers.
Widespread
The practice of replacing trained barangay nutrition scholars (BNS), barangay health workers and day care workers after elections occurs in other towns and cities of Cebu as well.
The Department of Social Welfare and Development (DSWD) 7’s Melinda Cañares, focal person of the Supplemental Feeding Program for children in day care and Supervised Neighborhood Play, said: “If you change the day care worker, it will take time to train a new one. The feeding will be delayed again. When it’s the season of changes, I always worry that the DSWD funds will not be utilized again.”
The day care worker is trained not only in conducting the day care sessions with the children but also in accurately taking their weight and height. The day care worker and the day care center also have to be accredited by the DSWD 7.
“The day care worker also handles other programs in partnership with the LGU (local government unit),” Cañares said.
“It’s even worse when it’s the BNS who is replaced because the BNS is the one who identified the malnourished children and coordinated on the intervention for these children. That’s what local officials don’t see,” said DSWD 7 regional information officer Leah Quintana.
The BNS is principally responsible for the nutrition program of the barangay.
In a northern Cebu town, Quintana said, since a barangay captain and the mayor are from different political parties, the honorarium of the BNS has been shifted from the City to the barangay. Just to retain the worker, the barangay has been paying the honorarium, which is lower than what the City can offer.
“That is the struggle of the national agencies,” Cañares said.
No end
Although she admits that it affects the implementation of government-sponsored feeding of malnourished children and other nutrition programs, Cebu City’s Department of Social Welfare Services head Lea Japson said the practice of replacing local workers with allies of winning candidates after elections has yet to end.
Japson, who oversees the city’s malnutrition concerns, said the replacement of workers is not only because of politics.
“Politics aside, the replacement is done to ensure that those in the barangay health centers and day care centers are those that they can trust to deliver the best service to the constituents. But that’s not the only basis. The replacements are most of the time, chosen based on their performance,” she said.
To ensure that manpower changes won’t have drastic effects on the implementation of programs, Japson said she had assigned DSWS personnel in each of Cebu City’s 80 barangays to see what the barangays need and how the DSWS can help implement their nutrition programs.
In Lapu-Lapu City, Mayor Paz Radaza said the provision of health care services to barangay constituents had never been disrupted. She said barangay health workers, day care workers and nutrition scholars paid by the City could not just be changed.
“The barangay will not dictate, especially if they (workers) are performing (in their jobs),” she said.
Changes are made only when workers don’t perform their duties well, the mayor said.
Beyond the pilot
The ECCD IP/1000 is supposed to end this year. But with social preparation of the implementers and beneficiaries in the target areas taking time, the actual implementation happened only in the last quarter of 2017.
So there are plans to extend its implementation to 2022 “to get a clearer picture of its effects on the beneficiaries and at the same time expand to other areas in the region,” said Pacalioga.
“But since this is just a pilot program, the funding for the program is only until this year,” he said.
The 2018 budget may still last until the second quarter of 2019. But beyond that, while the program will be continued, it will do so without any more funding from the NNC.
“We hope for the sustainability of the program even without our funding,” Pacalioga said.
The local government units themselves would then have to foot the bill for the following: 1) garden tools and materials at P40,000/barangay, 2) special events at P10,000/barangay, 3) snacks for the mothers during nutrition education classes at P20 to P30/mother, 4) the ingredients for the participatory cooking demos, and 5) the travel allowance of municipal level officials going to the barangays to conduct the Technical Assistance and Monitoring and Evaluation visits.
Pacalioga said the LGUs could afford this. In fact, some of them implemented these activities even before NNC came into the picture in 2016, since they are really the ones tasked to do this. The NNC just came in for added support. With RTF, FVQ
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