EVERY week, Miranda (not her real name) receives just P140 from her husband working as a construction worker in Mandaue City.
With this meager amount, she must feed herself, her two children by him, and his two other children by another woman.
To survive, Miranda begs for food from the neighbors and takes odd jobs like watching other people’s children or property, cleaning houses and doing farm work, said Flor Villarazo, rural health midwife at Poblacion South, San Fernando town, where Miranda resides.
But this is not enough. Miranda’s children are malnourished.
“The mother is also malnourished,” Villarazo said. “She weighs less than 30 kilos (66 pounds).”
Cebu is the richest province in the Philippines, but close to a million of its people live below the poverty line, a third of whom don’t make enough to meet their food needs.
Some 986,557, or 21.5 percent, of people in Cebu live below the poverty threshold of P1,812/month (P60 or US$1.20/day) needed for a person to meet both his basic food and non-food needs, while 369,384 have less than the P1,262/month (or P42 or $0.84/day) needed to meet just their food needs, Philippine Statistics Authority figures show.
Their malnutrition has exacted a heavy toll on the nation.
Everybody loses
Save the Children Philippines put the economic losses associated with child undernutrition in 2013 alone at P328 billion, equivalent to 2.84 percent of the 2013 Philippine Gross Domestic Product.
In “Cost of Hunger: Philippines,” it broke down these losses into educational costs of P1.23 billion due to grade-level repetition by hungry primary and secondary students, P166.5 billion in potential income loss due to lower educational achievement of the undernourished, and another P160 billion in potential income loss due to premature child mortality.
In the school year 2013-2014, some 48,597 Filipino students, or 15 percent of students who had repeated a grade level did so as a result of being stunted before the age of five years old, it said.
“Stunting is a chronic form of malnutrition,” said Julieta Tutor, nutritionist-dietician IV at the Department of Health (DOH) 7.
“Studies show that children who are stunted (have low height-for-age) at 12-36 months of age have poorer cognitive performance and lower grade level attainment. By the age of 60 months, the cognitive impact of stunting is irreversible,” according to Save the Children.
In 2015, some 33.4 percent of Filipino children under the age of five were stunted, the group said.
This means the stunting prevalence stayed about the same for 15 years, despite the Philippines’ commitment under the Millennium Development Goals to reduce this from 36 percent in 2000 to 22 percent in 2015.
The effect of this failure to arrest undernutrition was that in 2013, a staggering 32.6 million, or 53 percent, of the country’s working age (15-64 years old) population were found to have been stunted before they reached the age of five.
Save the Children said working-age Filipinos stunted as children completed just 5.74 years of education on average, versus 7.16 years for those not stunted.
In Central Visayas, the 37.7 percent prevalence of stunting in children under five was higher than the Philippine average of 33.4 percent, according to the 2015 updating of the National Nutrition Survey.
Acute
Acute malnutrition, indicated by wasting (being too thin for one’s height), plagues too many.
With wasting prevalence of 7.9 percent in children under five, the Philippines ranked 37th among 130 countries in wasting prevalence in the 2016 Global Nutrition Report.
The global nutrition target for 2025 adopted by the World Health Assembly is to reduce child wasting to less than five percent.
Six towns in Cebu are among the top 100 cities and municipalities in the country with the highest prevalence of wasting based on 2016 Operation Timbang Results of preschool children 0-71 months old.
San Fernando ranked 21st with a wasting prevalence of 9.46 percent; Oslob, (#38, wasting prevalence 8.12 percent); Tabogon (#63, wasting prevalence 6.81 percent); Barili (#67, wasting prevalence 6.68 percent); Pinamungajan (#73, wasting prevalence 6.44 percent), and Aloguinsan (#88, wasting prevalence 5.98 percent.)
Two other towns in Central Visayas, both in Negros Oriental, made the list. Jimalalud and Basay ranked 10th and 25th, respectively, with their wasting prevalence of 12.07 percent and 9.13 percent.
Since there are 1,634 cities and towns, this means some 90 percent of the country’s towns and cities fared better.
The top five cities and towns in wasting prevalence nationwide are Minalabac, Camarines Sur (58.41 percent wasting prevalence); Sirawai, Zamboanga del Norte (20.22 percent); Bulalacao, Oriental Mindoro (18.98 percent); Lingig, Surigao del Sur (14.89 percent); and Banisilan, Cotabato (13.67 percent).
Intervention
To prevent more children from becoming wasted and stunted, the Department of Health last year rolled out the Philippine Integrated Management of Acute Malnutrition (Pimam) program that aims to help children aged six months to five years suffering from acute malnutrition, which may be either severe acute malnutrition (SAM) or moderate acute malnutrition (MAM).
Dr. Anthony Calibo, chairman of the Community-based Management of Acute Malnutrition Working Group and of the National Infant and Young Child Feeding Technical Working Group, said the program began with 17 provinces last year, including Bohol and Cebu.
This year, 20 more provinces, including Siquijor, and five cities were added to the program.
Negros Oriental will be included in the fifth year of the implementation, said the DOH 7’s Tutor.
The wasting prevalence was the basis for the inclusion of the priority provinces in the Pimam.
The 2015 updating of the National Nutrition Survey put the prevalence of under-five wasting in Cebu at 7.1 percent; Bohol, 8.5 percent; Siquijor, nine percent; and Negros Oriental, 5.6 percent.
“Of the wasting in Cebu, only 20 percent was SAM, while 80 percent was MAM,” Tutor said.
Identification
Malnourished children are located through the Operation Timbang (OPT) Plus, the annual weighing and height measurement of all pre-schoolers 0-59 months old every first quarter of the year by health center officials in the communities.
The barangay nutrition scholars and barangay health workers (BHW) have a master list of children zero to five years old. If the children don’t show up at the health center or other appointed place for the weighing, the BHWs go to their houses to weigh them.
Outside the OPT Plus, children below two years old are weighed monthly for growth monitoring, Tutor said.
For beneficiaries of the Department of Social Welfare and Development’s anti-poverty program, Pantawid Pamilyang Pilipino Program, the weighing is done during their required monthly visits to the health center.
“We are managing SAM below two years old because if the child is already stunted at age two, he will forever be stunted. The stunting is already irreversible. He will never be able to catch up to the right height for his age,” Tutor said.
Aside from those under two years old, those to be monitored monthly are children, regardless of age, found during the Operation Timbang to have a nutritional or growth problem.
“There is also weighing in the public schools twice a year,” Tutor said.
OPT Plus used to cover children 0-71 months. But starting this year, it was adjusted to focus on children 0-59 months old “because we found double entries of children due to early schooling,” said Dr. Parolita Mission, National Nutrition Council 7 nutrition program coordinator.
Lucky ones
Dr. Hayce Famor-Ramos, medical officer III and Pimam manager for Central Visayas, said Pimam will help an initial 5,000 children in Cebu.
“The 5,000 is just an estimate of the SAM in Cebu who are 6-59 months old,” said Ramos. “Once the program is implemented, we will know the actual number. We just needed the 5,000 as a basis to procure the commodities,” which are the ready-to-use therapeutic food (RUTF), and F-75 and F-100 therapeutic milk for the dietary treatment of malnourished children.
Ramos said the F-100 and F-75 are for the inpatient treatment of SAM, while RUTF is for the outpatient or community treatment of SAM.
Although Pimam is for both SAM and MAM, only the SAM will be treated for now because “for now, the commodities and guidelines we have are for SAM only,” she said.
Training
The first year of Pimam was spent on training.
“First is letting the community know about severe acute malnutrition,” Ramos said. “Usually, parents bring kids to the clinic or health center due to cough, fever, diarrhea or pneumonia, not knowing that the child developed diarrhea or pneumonia because it was severely malnourished.”
“We have misdiagnosing of patients. We treat patients based on the disease, like diarrhea or pneumonia,” she said. “In the past, the cases of severe malnutrition were discovered only at the Vicente Sotto Memorial Medical Center (VSMMC). So we teach all doctors and nurses how to identify SAM in children because once SAM is diagnosed, then the treatment will be different.”
The indicators for malnutrition are underweight (low weight for age), wasting (low weight for height), and stunting (low height for age).
Confined
In the past, children with severe malnutrition were directly admitted in the hospital. In Cebu, the only hospitals capable of admitting such cases were the VSMMC and the Cebu City Medical Center.
But the DOH 7 is now moving toward the outpatient treatment of acute malnutrition because it is seen as a better way to sustain the treatment of the ailing child.
“Before, those with SAM were sent to the malward (malnutrition ward) for two months,” Tutor said. “So the mother also has to spend two months in the hospital. So they don’t complete the treatment because the mother has other children to attend to as well. But this time, if the child identified to have SAM has no health complications (or the presence of another disease), he can just be treated in the community. The hospital will just stabilize him, but no rehabilitation is done there. The community is now capable of treating the SAM patient.”
“Malwards have been scrapped in all hospitals nationwide,” said Ramos.
Today, patients admitted for diseases are placed in the wards for that disease.
Procurement
Dr. Calibo said the Philippines acquires the RUTFs through the UN Procurement System.
“RUTF is manufactured outside of the Philippines. There are RUTFs coming from France, India and Africa,” he said.
As the DOH scales up the program to include more provinces and patients, Calibo doesn’t anticipate any problems procuring the commodities.
“Cost is not a problem,” he said. “As long as this is planned ahead and a budget is allocated, then DOH will procure. (But) Bureau of Customs clearance can sometimes affect the timely release of these commodities from the international port.”
Asked to estimate the cost to treat a child with RUTF for the duration of his treatment, Calibo said: “The number of RUTF sachets will depend on the weight of the child. There is no fixed number. The RUTF (150 sachets/box/child) costs P2,900. F-75 costs P3,960, while F-100 costs P4,920.”
On procuring the commodities locally to ensure their availability, Tutor said: “The World Health Organization has given the formula for the F-75 and F-100. But the micronutrients are expensive and have to be imported for mixing with the basic formula, so no local food firm has offered to do this,” Tutor said.
As for the RUTF, she said: “The Department of Science and Technology is working on formulating a local version of the RUTF with the same components because there are ingredients available locally. The base of the RUTF is peanut butter. The only problem is the (sourcing of the) nutrients and the medicines.”
After receiving the commodities in April, the DOH 7 started delivering them to the local government units in May. Each child is allocated one carton, which contains 150 sachets, Tutor said.
Of the 5,000 boxes that arrived, 2,500 boxes have been delivered to the warehouses of the Cebu Provincial Health Office, which will distribute these to the municipalities and cities under it.
“Of the remaining 2,500 boxes, we have delivered 1,000 to Cebu City, 500 to Mandaue City and 500 to Lapu-Lapu City. The remaining 500 boxes are with DOH 7 as a buffer if there will be areas in need,” Tutor said.
Insurance
In 2016, the DOH, Unicef and the Nutrition Cluster, working toward countrywide scale-up of the National Guidelines for the Management of SAM, proposed linking SAM management services with the Philippine Health Insurance Corp.’s (Philhealth) outpatient and inpatient insurance packages.
Philhealth 7 regional vice president William Chavez said his office had not yet received guidelines on this linkage, but that Philhealth has covered the treatment of malnutrition since 2014.
For cases of life-threatening and debilitating malnutrition, nutritional marasmus (severe undernourishment causing emaciation), severe malnutrition with marasmus, and protein-energy malnutrition, the case rates are P11,700 for confinement in hospitals and P8,190 for confinement in primary care facilities and infirmaries.
From 2014 to 2016, Philhealth 7 paid out a total of P3.81 million in claims for these cases, of which 85 percent went to indigent members, Chavez said.
“The management of severely acute malnourished infants and young children through the administration of RUTF is free of charge,” Dr. Calibo said. “The services come from DOH hospitals, local government unit rural health units, barangay health centers and health stations. The commodities used in the hospitalization of severely acute malnourished infants and young children, RUTF, and F-75/F-100, are also for free as these are procured by the national government.”
The national guidelines recognize, however, that children treated for acute malnutrition usually suffer both a nutritional deficit and an infection, so they task local health officials to ensure the enrollment of families, especially the indigent, in Philhealth, so their health expenses may be covered.
Treatment
For outpatient therapeutic care of SAM, Ramos said the child should not eat any other food except for the RUTF. The RUTF is ready to eat. One just sucks the contents out of the sachet.
“RUTF is the medicine of the child in the form of food,” Ramos said. “He cannot eat anything else. Breastfeeding is okay, plus water.”
“If there is no improvement in four months, the treatment is considered a failure,” Tutor said. “Then we refer the child to inpatient care. We don’t wait for four months. If along the way, there is no improvement, we admit the child to investigate if there might be congenital anomalies or other chronic diseases like tuberculosis or cancer. Because normally you can be cured (reach target weight) in four to eight weeks if you religiously take the RUTF,” she said.
The SAM outpatient treatment is done at home. The mother gives the RUTF to the child.
“The mother picks up the weekly allocation of commodities when she visits the health center weekly to have her child weighed,” Tutor said. “She should bring the empty sachet. If the sachet is always empty, but there is no improvement in the weight of the child, then we investigate if someone else might have eaten the RUTF.”