Baseline Final Report, SHE project by Jose Chacon

SHE

SEXUAL HEALTH AND EMPOWERMENT [SHE]

Mary Ann Papong and her daughter Lem Papong Credit: Tessa Bunney

The Sexual Health and Empowerment (SHE) Philippines Project

BASELINE STUDY

SHE is undertaken with the financial support of the Government of Canada provided through Global Affairs Canada

M AY 2 0 , 2 0 1 8

May 2019

Sexual Health & Empowerment

Jose Chacon, SHE Project Officer for Monitoring, Evaluation and Learning (MEL), Oxfam Canada, designed this study; and Krizelle Umali, SHE project MEL officer, Oxfam in the Philippines, supported design and implementation of the study.

For more information and questions about this study, please contact: Oxfam in the Philippines Krizelle Anne Umali KUmali@oxfam.org.uk

Oxfam Canada Jose Chacon, MEL Officer jose.chacon@oxfam.org

Disclaimer This study was commissioned by Oxfam for the Sexual Health and Empowerment (SHE) project, funded by Global Affairs Canada. The findings, interpretations, and conclusions expressed in this work do not reflect those of Oxfam or Global Affairs Canada. Please also note that the statistics in this report are not comparable to national level statistics; the study was carried out in sample groups in targeted project areas and the statistics are therefore not reflective of standardized national data. Oxfam or Global Affairs Canada does not guarantee the accuracy of the data included in this work. The boundaries, colours, denominations, and other information shown on any map in this work do not imply any judgment on the part of Oxfam or Global Affairs Canada concerning the legal status of any territory or the endorsement or acceptance of any such boundaries.

ACKNOWLEDGMENTS The authors would like to extend our gratitude to the study’s participants for providing their inputs through the household surveys, focus group discussions, in-depth interviews and testimonies. Our appreciation also extends to the SHE project’s local partners for their commitment and hard work. This research would not have been possible without their participation. Special thanks to the Macro Health Research Organization Team who supported the data collection and initial analysis for the baseline study. Marilyn E. Crisostomo, MPH, MSPH, PhD (Candidate) acted as main researcher and Geraldine C. Maminta, RN; Laufred I. Hernandez, MMPM, MA, PhD (Candidate), Reynaldo Imperial, PhD, and Calvin S. de los Reyes, PhD, acted as co-researchers. Feminist Data and Research team, Ana Androsik, PhD in Feminist Economics (Candidate) and Evgeny Vorotnikov, PhD in Economics/Econometrics, supported the statistical and Community Attitudes Index calculations and analysis. Substantive editorial support from FDR was provided by Ana Androsik, Jeannine d’Entremont and Edmund Doku. Other researchers and facilitators involved in the collection of I stories, stakeholder analysis, law and policy analysis and baseline validation are Laniza Lacsamana, Ma. Himaya Tamayo Gutierrez and Pocholo Andrew Velasquez of the Center for Women’s and Gender Studies (UP CWGS), and Allan de los Ryes, Romeo Dongeto and Aurora Quilala of the Philippine Legislators’ Committee on Population and Development (PLCPD). Finally, our thanks to all those who read the first drafts and provided their feedback and comments.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

Table of Contents ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

7. RESULTS OF THE STUDY. . . . . . . . . . . . . . . . . . . . . . . . . 28

ABBREVIATIONS AND ACRONYMS. . . . . . . . . . . . . . . . . . . . . . 4

7.1 ULTIMATE OUTCOME: IMPROVING SRHR IN THE PHILIPPINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

DEFINITIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

7.2 PILLAR ONE: ENGAGING COMMUNITY MEMBERS TO SUPPORT GENDER-RESPONSIVE SERVICES AND PROMOTE NORMS THAT IMPROVE HEALTH-SEEKING BEHAVIOR. . . . . . . . . . . 31

EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2. COUNTRY CONTEXT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3. THEORY OF CHANGE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4. OBJECTIVES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 5. METHODOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

5.1 DESK REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

5.2 PRIMARY DATA COLLECTION . . . . . . . . . . . . . . . . . 19

5.3 STUDY SITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5.4 QUANTITATIVE DATA COLLECTION. . . . . . . . . . . . 20

5.5 QUALITATIVE DATA COLLECTION . . . . . . . . . . . . . 22

5.6 DATA COLLECTION AND ANALYSIS . . . . . . . . . . . 23

5.7 ETHICAL CONSIDERATIONS . . . . . . . . . . . . . . . . . . 23

5.8 LIMITATIONS OF THE STUDY . . . . . . . . . . . . . . . . . 24

6. LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

7.2.1 KNOWLEDGE, SKILLS AND CAPACITY OF WOMEN, GIRLS AND BOYS REGARDING THEIR SRHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 7.2.2 ATTITUDES AND BEHAVIOURS MODELLED BY VARIOUS GENDER AND AGE GROUPS AND INFLUENCERS IN SUPPORT OF SRHR . . . . . . . . . . . . . . . . . . . . . . . 33 7.2.3 COMMUNITY ATTITUDES RELATED TO SRHR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7.2.4 CAPACITY OF THE PUBLIC AND PRIVATE HEALTH SYSTEMS TO PROVIDE COMPREHENSIVE AND GENDER-RESPONSIVE SRHR INFORMATION AND SERVICES . . . . . . . . . 38 7.3 PILLAR TWO: BUILDING KNOWLEDGE AND CAPACITY OF INSTITUTIONS AND ALLIANCES TO INFLUENCE CHANGE. . . . . . . . . 39 7.3.1 CURRENT CONTEXT OF HEALTH SERVICES PROVISION IN THE PHILIPPINES. . . 39 7.3.2 REVIEW OF KEY LEGISLATION AND POLICIES RELATED TO SRHR IN THE PHILIPPINES. . . . . . . . . . . . . . . . . . . . . . . . . 41 7.3.3 ONGOING DEBATE IN RELATION TO ABORTION IN THE PHILIPPINES. . . . . . . . . . . 42 7.3.4 BARRIERS TO IMPLEMENTATION OF RELEVANT POLICIES . . . . . . . . . . . . . . . . . . . . . 44 7.3.5 CIVIL SOCIETY INVOLVEMENT IN SRHR-RELATED ADVOCACY AND INFLUENCING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 8. RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT â&#x20AC;&#x201C; BASELINE STUDY 2019

List of Tables and Figures Table 1: Summary of SHE Project’s Indicators Baseline Values by Outcome . . . . . . . . . . 9 Table 2: Breakdown of Stakeholder Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table 3: Geographic Locations for Primary Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Table 4: Sample Size per Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table 5: Distribution of Respondents by Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table 6: Distribution of Respondents by Age and Gender Groups . . . . . . . . . . . . . . . . . . . . 21 Table 7: KII Respondents by Level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table 8: FGD Target Participant per Social Group of Interest . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table 9: HHS Distribution of Respondents “Who Used FPM Before” by whether “They Are Currently Using a FPM Now” to Avoid or Delay Getting Pregnant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 10: SHE HHS - Distribution by their Actions After Experiencing Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Table 11: Attitudes toward Women’s Reproductive Autonomy. . . . . . . . . . . . . . . . . . . . . . . . . 36 Table 12: Attitudes on Women’s Sexual Autonomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

Abbreviations and Acronyms ASRH Adolescent Sexual and Reproductive Health ACFEM Arranged Child Forced and Early Marriages BARMM Bangsamoro Autonomous Region in Muslim Mindanao CEDAW Convention on the Elimination of all Forms of Discrimination Against Women CEFM Child, Early and Forced Marriage CSO Civil Society Organization CPR Contraceptive Prevalence Rate DepEd Department of Education DOH Department of Health DSWD Department of Social Welfare and Development EO Executive Orders in the Philippines FDA Food and Drug Administration of the Philippines FGD Focus Group Discussions FHSIS Field Health Service Information System FPM Family Planning Method GBV Gender-Based Violence GIDA Geographically Isolated and Disadvantaged or Depressed Areas HP Health Policy HH Household HHS Household Survey HIV Human Immunodeficiency Virus KII Key Informant Interview LGU Local Government Units LGBTQI Lesbian, Gay, Bisexual, Transgender, Questining and Intersex MCH Maternal and Child Health MCW Magna Carta of Women NDHS National Demographic and Health Survey NEDA National Economic and Development Agency PAC Post-Abortion Care PHA Philippine Health Agenda PHO Provincial Head Office

PMF Performance Measurement Framework PNTA Prefer Not To Answer POGS Philippine Obstetrical and Gynecological Society POPCOM Commission on Population RHU Rural Health Units SDNs Service Delivery Networks SHE Sexual and Health Empowerment in the Philippines Project SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health and Rights STI Sexually Transmitted Infection ToC Theory of Change UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund VAWG Violence Against Women and Girls WHO World Health Organization WRA Women of Reproductive Age WROs Women’s Rights Organizations

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

DEFINITIONS The following provides a consistent terminology to help the reader navigate through this baseline study:1 • Behaviour is what a person does or how a person acts. “Typical” means what people actually or commonly do, and “appropriate” means what people should do. Social norms provide the often-unspoken rules or expectations of behaviour. In this framework, the specific behaviour discussed is sexual and reproductive health (SRH) seeking behaviour, acts of violence against women and girls, and gender-based violence. • Attitude is how a person feels about or judges a certain thing or behaviour. Attitudes can be shaped by social norms, morals, religious or family teachings, or past experiences, among other influences. Attitudes are held by individuals, whereas social norms are held at the group or collective level. Individual attitudes can either follow or deviate from what social norms dictate. For example, a woman might feel that it is important for her to tolerate violence to keep her family together, even though the social norm in her community is that domestic violence is not acceptable. • Family Planning, as defined by WHO,2 allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy.3 In the Philippines, the NDHS 2017 does not provide a definition of family planning (FP). From the statistics results, FP is equivalent to contraceptive use. While we recognize this language is sometimes contested/ problematic, we use it in this study in order to ensure consistency/clarity in line with the language used by the Philippines demographic bodies and resources (like the NDHS 2013 & 2017). • Norms are shared beliefs about what is typical and appropriate behaviour in a group. They represent individuals’ “basic knowledge of what others do and think they should do”4 Social norms provide the often-unspoken rules or expectations of behaviour. • Social norms influence behaviour through social approval or disapproval.5 Social sanctions – such as stigma, criticism, shaming or teasing, social exclusion, and even violence – may result from not complying with expectations. On the other hand, if a person acts in accordance with social norms, the person feels as though they are acting correctly, and are likely to be more accepted, better regarded, or included by those around them. • Power is the ability to influence or control the behaviour of people, and one’s own behaviour and life. The use of power need not involve physical force or the threat of force (coercion), although it can. Power exists in relationships, within families and households. The amount of relative power a person has in comparison to one’s partner and others in the household is a critical issue in violence against women and girls (VAWG). Greater power inequality in family relationships can be a risk factor for the occurrence of VAWG. For this reason, one of Oxfam’s strategies to end VAWG is the social and economic empowerment of women and girls, so that power relationships are more equitable.

1 Haylock, Laura (2016), A Conceptual Framework for Evaluating Oxfam’s Work Towards Attitude, Norm and Behaviour Change to end Violence against Women and Girls/Gender-based Violence. Oxfam P. 7-9 2 WHO, https://www.who.int/pmnch/media/news/2010/20100322_d_shaw_oped/en/ 3 ibid 4 Alexander-Scott, M., Bell, E. and Holden, J. (2016), DFID Guidance Note: Shifting Social Norms to Tackle VAWG. London: VAWG Helpdesk, Department for International Development (DFID), p. 11-12 5 Mackie, G., Moneti, F., Shakya, H. and Denny E. (2015), What are Social Norms? How are They Measured? UNICEF and the University of California, San Diego. p. 21

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

• Unmet Need for Family Planning is defined by The Philippines Statistics Authority as the number of fecund women who are married or in consensual unions, and who either do not want any more children or want to delay the next child, but are not using any method of family planning, expressed as a percentage of all women who are married or in a consensual union.6 • Violence is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation.”7 Generally, anything that is executed in an injurious or damaging way may be described as violent even if not meant to be violence (by a person and against a person).

Interpersonal violence is divided into two subcategories:

Family and intimate partner violence – violence largely between family members and intimate partners, usually, though not exclusively, taking place in the home. This includes forms of violence such as child abuse, intimate partner violence and abuse of the elderly. Community violence – violence between individuals who are unrelated, and who may or may not know each other, generally taking place outside the home. This includes youth violence, random acts of violence, rape or sexual assault by strangers, and violence in institutional settings such as schools, workplaces, prisons and nursing homes. • VAWG/Gender-Based Violence (GBV) is the use of physical or other types of violence to enforce gender norms, or because of gender identities.8 It includes physical, sexual and psychological violence within the family, community, and violence perpetrated or condoned by the State.9 We understand GBV as “any form of violence against an individual based on that person’s biological sex, gender identity or expression, or perceived adherence to socially-defined expectations of what it means to be a man or woman, boy or girl”10 while VAWG, the largest subset of GBV, specifically refers to violence against women and girls. • Women’s Sexual Autonomy refers to women’s ability to resist unwanted sex and ability to make healthy decisions about sexuality.11 • Women’s Economic Autonomy refers to women’s capacity to generate income and personal financial resources, based on access to paid work and under conditions of equality with men.12 • Women’s Reproductive Autonomy refers to women’s power to decide about and control matters associated with contraceptive use, pregnancy and childbearing.13

6 Philippines Statistics Authority. https://psa.gov.ph/content/unmet-need-family-planning-0 7 WHO, http://www.who.int/topics/violence/en/ downloaded April 26, 2016. 8 WHO, http://www.who.int/topics/gender_based_violence/en/ downloaded April 26, 2016 9 Oxfam. Ending Violence Against Women: An Oxfam Guide, 2012, p.5 10 JHPIEGO (2018), Gender Service Delivery Standards: Facilitation Guide, p. 15 11 WHO (2010), Measuring sexual health: conceptual and practical considerations and related indicators, WHO, Geneva, p. 15 12 Gender Equity Observatory for Latin America and the Caribbean (2018) 13 Upadhyay, U.D., Dworkin, S.L., Weitz, T.A. & Greenfoster, D. (2014). Development and Validation of a Reproductive Autonomy Scale, Studies in Family Planning, 45(1), 19-41.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

EXECUTIVE SUMMARY INTRODUCTION At the start up of the Sexual Health and Empowerment (SHE) project in the Philippines this Baseline Study contextualizes the current state of sexual and reproductive health and rights (SRHR) in project target municipalities, and assesses the enabling environment at the national level and in its six focus regions to implement effective SRHR programming. The five-year (2018-2023) SHE Project is implemented by Oxfam with the support of Global Affairs Canada. The project will work with seven local partner organizations (AMDF, FPOP, MIDAS, PKKK, SiKAP, Tarbilang Foundation, and UnYPhil Women) and one international partner organization (Jhpiego) responsible for delivering activities in the target provinces and municipalities. During the implementation, the project will select additional partners to promote and influence laws and policies on SRHR and prevention of GBV. The Baseline Study identifies the project’s indicator values, analyzes the SRHR context in the Philippines, and provides an analysis of relevant laws and policies to design future influencing strategies.

OBJECTIVES 1. Assess the level of knowledge, attitudes, autonomy, practices and status on/of sexual and reproductive health and rights (SRHR) of potential direct beneficiaries and their access to SRHR services. 2. Analyze and describe relevant laws, policies, programs and services for SRHR in selected project municipalities.

METHODOLOGY The study used both qualitative and quantitative data collection methods in line with feminist research methods. Best practices and ethical guidelines were followed for data collection. Particular effort was taken to be sensitive to the complex nature of information gathered e.g. information on violence against women and girls (VAWG). These guidelines, prepared by Oxfam Canada, drew heavily from the WHO 1991 guidelines (Putting Women First) for data collection with adults and UNICEF’s 2013 Ethical Research Involving Children (ERIC) Compendium for data collected from children (individuals below the age of 18). In all cases, consent from parents or guardians was obtained. The geographic areas for the study were selected based on the literature review, consultations with project implementing partners, availability of funds, timeline, and accessibility. The quantitative part of the study included face-to-face surveys using structured mobile-based questionnaires with 1,923 community members (equal ratio of female and male adolescents and adults) from 480 households, while the qualitative component consisted of 78 Key Informant Interviews (KIIs) and 16 Focus Group Discussions (FGDs) with 128 people, evenly distributed across the target provinces. In addition, the study collected 13 personal stories from women and girls, in order to better understand the intersectional issues related to norms and access to SRHR and SRH services.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

RESULTS The baseline study found that women and girls in the Philippines face significant inequities that limit their ability to enjoy their sexual and reproductive health and rights (SRHR), free of coercion or any form of violence. In this formative research, 2,173 persons provided their opinions and information in hopes their testimony will bring about transformative change. The ability to decide to have a child or not, the spacing of children, safer sex practices, access to abortion and post-abortion care (PAC), as well as services and information for teens, are limited in the project’s targeted areas. Social norms, attitudes and other systemic elements continue to limit education, sources of information and access to SRHR services in a society constrained by the Catholic Church and faith-based lobby groups. A set of personal histories (13 “I Stories) provided solid evidence about how rape, early sex initiation, teen pregnancies, the illegality of abortion and a lack of information and access to safe post-abortion care are affecting the lives of young girls and women in rural Philippines. Social norms and attitudes are also shaping their views of future life options. This Baseline Study introduces an innovative way to explore positive and negative attitudes toward SRHR. Women’s reproductive autonomy and women’s sexual autonomy, to the extent that women are empowered to exercise decisions on reproductive health choices, birth spacing and taking care of their bodies, are a predictor for attitudes toward SRHR. When accessing information and appropriate services, the majority of the female respondents (girls and women) agreed with the statement that it is important to raise awareness on SRHR, protect women’s security against domestic violence, and develop and maintain effective women’s rights organizations. Most respondents felt that it is important for health service providers to be trained with regard to sexual and reproductive quality service delivery. The respondents felt that it is important to train these providers to appropriately respond to sexual violence cases. Fragmented coordination, collaboration and different jurisdictional mandates among national agencies, regional and provincial offices and local government service points are the underlying issues that prevent effective SRHR implementation of laws, policies and programs. Local governments find themselves without the resources (time, personnel, and budget) to meet women’s and girls’ needs for SRHR services. The baseline study reviewed and validated the project’s outcome indicators and set baseline values for the start of the project. Table 1 summarizes the values for each indicator. The baseline results show that these indicators are interlinked, as per the project’s system design, forming an “indicator system.” All values for the outcome indicators refer to the targeted population direct beneficiaries.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

TABLE 1: SUMMARY OF SHE PROJECT’S INDICATORS BASELINE VALUES BY OUTCOME INDICATORS

DESCRIPTION

BASELINE VALUE (HHS)

REFERENCE TABLE IN APPENDIX A

Ultimate Outcome (1000): Improve sexual and reproductive health and rights for women and girls in remote conflict-affected and disadvantaged regions of the Philippines 1000.a: % and number of women with unmet need for FP including modern methods, disaggregated by age group.

WRA married or in a union who are not using contraceptive and do not want children on day of HHS.

Target WRA population: 57,878 Baseline Value: Women 32.3% Girls 13.3%

Table 14: Currently Using/not using FPM

1000.b: % of teen pregnancy rates among target population

Teens are young women between 15 and 19 years old; baseline value is the percentage of those teens who have given birth or are pregnant on day of HHS

Target population (girls only): 20,732 Baseline Value: Girls 7.4%

Table 29: Are you Pregnant now?

1000.c: Perspectives on positive attitudes that promote SRHR and GBV prevention among target population

Possitive attitudes are those who strongly agree or agree with a set of statements refering to women’s sexual, reproductive, and economic autonomy.

Target population: 86,386 Baseline Value: Women 50% Girls 48% Men 46% Boys 47%

Table 35: Community Attitudes Index

Intermediate Outcome 1100: Enhanced utilization of gender-responsive sexual and reproductive health information and services (public and private) by women of reproductive age, adolescent girls and boys

1100.a: % and number of new family planning acceptors, disaggregated by age and sex

1100.b: number of individuals disaggregated by age groups and sex, who have accessed quality and gender sensitive sexual and reproductive health services including modern contraception in the targeted health facilities

% calculated by subtracting the baseline value from the total % of those who say they are using a FPM on day of mid term and final HH survey Access is the # of people who, during the life of the project, have received services from the targeted health facilities/service providers. SRHR services would include but are not limited to FP counselling, modern contraception, counselling and STI testing (GAC Key Indicator)

Target population: 86,386 Baseline Value: Women 68.0% Girls 87.0%

Table 14: Currently Using FPM

Men 69.0% Boys 40.0% TBD Baseline Value will be set in Y2 following capacity assessment of RHU to determine how many individuals a RHU can serve in a year with present resources. On the day of the HHS, girls (30.5%), women (59.6%), boys (41.8%) and men (62.9%) had access to FP services in their locality. The assessment will focus on the rest of the services.14

14 See page 34 of this report for a discussion on knowledge and access to SRHR services and Appendix A: Table 13 for knowledge of where to obtain FP commodities.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

INDICATORS

DESCRIPTION

BASELINE VALUE (HHS)

REFERENCE TABLE IN APPENDIX A

Intermediate Outcome 1200: Improved effectiveness of women’s rights organizations (WROs) to advance rights related to sexual and reproductive health and prevention of gender-based violence

1200.a: #/total interagency collaborations between WROs, CSOs, and government agencies promoting SRHR / preventing GBV

During the life of the project, WROs, CSOs and networks improve their effectiveness through coordination and working groups as a result of org strengthening, alliances and public engagement activities funded by the project

1200.b: Level of confidence of WROs on their own ability to coordinate and advocate to protect and promote the rights related to SRH and the prevention of GBV

Qualitative data on WROs’ perceptions relating to expanding their sphere of influence (working with others in alliances or consortiums)

Baseline value = 0 Partners are yet to identify key actors to form alliances, cooperation and collaboration priorities.

N/A

TBD Baseline Value will be set in Y2 following following CAT4SRHR assessments.

N/A

Immediate Outcome 1110: Increased knowledge, skills and capacity of women, girls and boys regarding their Sexual and Reproductive Health and Rights (SRHR) 1110.a: % of target population knowing where to access SRHR services of contraceptives commodities

Knowledge about Family Planning Method (FPM) and services; quantitative data from HHS, qualitative data from “I stories”, FGD

Target population: 86,386 Baseline Value : Women 47.4% Girls 24.3% Men 51.5%

Table 13: Knowledge where to obtain a FPM

Boys 34.1% 1110.b: % of girls and women (WRA) able to make reproductive health choices alone and/or supported by their partner, disaggregated by age

Right to decide and choice of FPM and services; cross calculation of those who have ever used FPM and those who are using one now. Quantitative data from HHS, qualitative data from “I stories”, FGD (GAC Key Indicator)

Target WRA population: 57,878 Baseline Value: Women 58.7%

Table 24: ever used a FPM

Girls 35.1%

Immediate Outcome 1120 Improved positive attitudes modelled by women, men, girls, boys, and influencers in support of SRHR information and services 1120.a: Perspectives of targeted population on positive attitudes that promote women’s reproductive autonomy

Measured by a series of questions; an index (%) is calculated to quantify the value of reproductive autonomy. Qualitative information from FGD from midterm and final evaluations.

Target population: 86,386 Baseline Value: Women 61.0% Girls 55.0%

Table 36: Women’s reproductive Autonomy

Men 66.0% Boys 63.0%

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

INDICATORS

DESCRIPTION

BASELINE VALUE (HHS)

1120.b: #/total public declarations and actions by influencers to support SRHR, and in support of women’s rights and leadership

During the life of the project, quantitative indicator with evidence from changes in influencers’ discourse (radio, sermons, articles, etc)

Baseline value = 0 Partners will document statements by influencers that reflect or quote directly project’s messages.

REFERENCE TABLE IN APPENDIX A

N/A

Immediate Outcome 1130 Improved capacity of the public and private health system to provide comprehensive and gender-responsive SRHR information and services

1130.a: #/total facilities providing gender responsive SRHR information and services

Criteria for assessing gender responsive SRHR info and services: 1) Facility has space with audio-visual privacy for examination of clients and provision of counselling; 2) Facility has record of SRHR counselling provided by trained staff; 3) Facility is providing at least three modern methods of FP.

1130.b: #/total rural health units that have at least 3 modern contraceptives available on day of assessment

The 3 modern methods include at least 1 longacting, reversible method (GAC Key Indicator)

TBD (Y2 following capacity assessment of RHU)

N/A

TBD (Y2 following capacity assessment of RHU)

N/A

Immediate Outcome 1210 Increased organizational capacity of partner organizations and selected WROs/CSOs to deliver effective programs on SRHR and GBV prevention 1210.a: Level of confidence partners and/ or WROs in their own ability to deliver effective programs on SHRH and GBV prevention 1210.b: #/total partners and/or WROs on target with their Action Plan to increase capacity

This indicator measures the autonomy and awareness of the organisation’s own performance. Descriptive account of their self-assessment. The indicators measure the organization’s agency to increase its own capacity

TBD Baseline Value will be set in Y2 following following CAT4SRHR assessments.

N/A

TBD Baseline Value will be set in Y2 following following CAT4SRHR action plans to increase capacity.

N/A

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

INDICATORS

DESCRIPTION

BASELINE VALUE (HHS)

REFERENCE TABLE IN APPENDIX A

Immediate Outcome 1220 Strengthened capacity of WROs/CSOs to generate knowledge to influence policy and practice on women’s rights, particularly on SRHR and GBV prevention

1220.a: #/total partners and/or WROs drafting their own learning agenda on SRHR

1220.b: Perceptions of partners on their capacities to generate knowledge on women’s rights

Refers to the ability of partners to incorporate feminist MEL principles into their work during the life of the project.

Refers to the generation and use of knowledge products to support influencing and advocacy actions for women’s rights during the life of the project.

Baseline value = 0 Although partners have already identified and classified learning questions to address during the life of the project

N/A

Baseline value = 0 Partners are yet to define influencing strategies and the knowledge products to support them.

N/A

Immediate Outcome 1230 Improved ability of WROs and networks to promote women’s rights and influence policy makers on SRHR and GBV prevention 1230.a: #/total advocacy and public engagement activities completed by funded partners which are focused on SRHR and prevention of GBV

Refers to the ability of WROs and networks to engage the public and policy makers in advocacy and influencing campaigns (GAC Key Indicator)

1230.b: #/total WROs/ networks reporting on at least two improved influencing skills

Descriptive account of the type of skills acquired or improved. These are project partners and WRO/networks involved in influencing activities during the life of the project.

Baseline value = 0 Partners are yet to define influencing strategies and the public engagement to support those strategies

N/A

Baseline value = 0 Measured during the life of the project according to self assessments.

N/A

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

RECOMMENDATIONS The following recommendations are based on the overall research; they are organized to follow the project’s ToC.

Recommendations related to the Pillar One (Outcome 1100): 1. This baseline provides evidence that teen pregnancy is a primary concern. It is recommended that the project redefines its target age/sex groups to add the 10 to 14 age group and develop outreach and information strategies to cover their needs. A specific needs assessment should also be undertaken on information and access to SRHR services for ages 10 to 19. 2. Addressing VAWG is also a priority; particularly emotional, physical and sexual violence might be under reported in the national statistics. It is recommended that the project provides accurate information about the rights of and services available to survivors of violence. 3. G iven the lack of resources and the constraints of local government units to address both teen pregnancy and VAWG, it is recommended that the project add a “follow up” component to the referral mechanism already planned. The project might explore using the the Field Health Service Information System (FHSIS) to identify the number of cases reported. 4. B aseline data shows that most women did not wish to get pregnant in their most recent pregnancy. It is recommended that the project highlight women’s reproductive and sexual autonomy in its influencing strategies. 5. A clear empowerment framework for girls and women needs to be drafted to guide the influencing strategies to change attitudes of the target population and health service providers.

Recommendations related to Pillar Two (Outcome 1200): 6. Given the lack of information and research on SRHR issues, it is recommended that topics such as identifying the impact on women and girls of abortion and post-abortion care, rape, and VAWG should be a priority for the learning and knowledge generation the project is funding. Further research on behaviour modelling is needed, specifically identifying reference groups for girls such as peers, family members and religious leaders. 7. The national reports on the state of international agreements like the CEDAW and the Millenium Goals provide an opportunity for the project to leverage its national influencing strategies. Project partners could produce shadow reports on those indicators relevant for international reporting. 8. The baseline found a dichotomy exists among jurisdictions and mandates, policy initiatives and developments among national agencies and local governments. It is recommended that WRO/CSOs design and establish social accountability strategies and mechanisms, from the local level up to the national level, to ensure the implementation of laws and policies and that SRHR services reach those who need them. At the local level, interagency actions should be promoted to reinforce local WROs’ agendas to eliminate VAWG, and prevent GBV. 9. It is recommended that project partners actively consolidate, support and tap the existing networks in advocacy, as they are a storehouse of lessons and strategies. As evidenced by the stakeholder analysis, it may be that the existence of a strong informal network of advocates and champions on SRHR, antiGBV, and gender equality, is what sustains the advocacy in times of backlash when there appear to be elements that threaten to derail or impede the progress made on these issues.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

1. INTRODUCTION This report presents the research findings from the Baseline Study conducted for the Sexual Health and Empowerment (SHE) in the Philippines project. The report has been structured as follows: • Country Context • ToC helps readers understand the structure in which the findings are presented • Objectives • Methodology section provides details on the approach to the research and highlights any limitations and challenges • Key findings from the baseline study undertaken in the target areas are presented based on the primary and secondary data collected • The recommendations of the study team are presented for use in planning project and interventions with partners

2. COUNTRY CONTEXT In the Philippines, women and girls face numerous challenges in exercising their SRHR. Key barriers include gender inequality and limited decision-making power; deeply rooted values, beliefs and social norms regarding women, their sexuality and rights; lack of comprehensive sexuality education in and out of schools; low access to SRH services and restrictive parental consent requirements; the criminalization of abortion; sexual and gender-based violence; sex trafficking; and a range of discriminatory socio-cultural practices, including child, early and forced marriage. These challenges are evinced across a broad range of SRHR and GBV indicators in the Philipnines: • Roughly a third of women’s pregnancies are unplanned and/or unwanted, with women below age 20 being most likely to have mistimed births;15 • The country has one of the highest adolescent fertility rates in Southeast Asia, with 47 births per 1,000 females aged 15-19, and where at the national level, 9% of adolescent girls aged 15-19 have begun childbearing;16 • The country has a low contraceptive prevalence rate (where the 2017 CPR for modern contraceptive methods was 40% among married women aged 15-49, and 17% among sexually active married women of the same age range);17 • While abortion is illegal under all circumstances and highly stigmatized, the procedure remains common, though often performed in unsafe conditions. Tens of thousands of women are hospitalized annually and roughly 1,000 women die each year because of complications from unsafe abortions;18

15 NDHS (2017) Philippines https://dhsprogram.com/pubs/pdf/FR347/FR347.pdf. 16 UNFPA (2018), Mothers Too Young: Understanding the Patterns of Child Marriage, Early Union and Teen Pregnancy in Southeast Asia, https://asiapacific.unfpa.org/en/news/mothers-too-young-understanding-patterns-child-marriage-early-union-and-teen-pregnancy. 17 NDHS (2017) 18 Guttmacher Institute (2013) “Unintended Pregnancy and Unsafe Abortion in the Philippines”, https://www.guttmacher.org/report/ unintended-pregnancy-and-unsafe-abortion-philippines-context-and-consequences.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

• Though the provision of post-abortion care (PAC) is legal, reported human rights violations when accessing PAC are frequent;19 • The quality of healthcare services remains inconsistent across the country, with the devolution of health services to under-resourced local governments resulting in highly unequal access among the different regions and provinces of the country; • Twenty per cent of Filipino women have experienced physical violence from the age of 15;20 • A recent report on LGBTQI youth illustrated widespread bullying and harassment in schools based on sexual orientation, gender identity and expression (SOGIE), as well as discriminatory policies and practices.21 The disparities in SRHR and elevated levels of GBV are more prevalent in the country’s GIDAs, many of which are conflict-affected or disaster-prone. Early pregnancy rates, for example, are higher in rural versus urban areas, where the percentage of young women aged 15-19 who have begun childbearing is at 10% in rural areas, and as high as 15% in Northern Mindanao (versus 7% in urban areas).22 Within GIDA there are also other economic issues such as income insecurity, loss of livelihoods, lack of land rights and land disputes, which further exacerbate women’s and girls’ vulnerability and influence health outcomes. Early pregnancy, moreover, not only places young women’s and girls’ physical health at risk,23 but can also have other negative social and economic ripple effects. Unmarried pregnant adolescents may face stigma, rejection, and threats of violence; and girls who become pregnant before turning 18 are more likely to experience violence within a marriage or partnership.24 Early pregnancy also often forces girls in the Philippines to leave school, jeopardizing their future economic prospects and excluding them from other opportunities, while often perpetuating cycles of poverty.25 A 2016 UNFPA study found that the Philippines forfeits approximately 33 billion pesos each year in lost income due to early pregnancy.26 The Philippine government has made efforts to improve access to SRH information and related services through the Responsible Parenthood and Reproductive Health Act of 2012 (RH Law). The RH Law also reiterates that women have the right to access PAC and to be treated in a “humane, non-judgmental, and compassionate manner”27 reinforced in 2016 by the comprehensive Prevention and Management of Abortion and Its Complications (PMAC) policy. Full implementation of the RH Law, however, has been hindered by opposition from anti-choice and conservative religious groups. In 2018, the PMAC policy was replaced by one narrower in scope that rolls back key safeguards aimed at protecting women who seek PAC from discrimination and abuse.28 These challenges illustrate some of the wider legislative and socio-political hurdles obstructing SRHR in the Philippines, as well as the need for ongoing advocacy and influencing efforts to ensure full implementation and advancement of SRHR-related laws and policies. 19 Center for Reproductive Rights (2017) Criminalization of Abortion in the Philippines, https://www.reproductiverights.org/sites/crr. civicactions.net/files/documents/2018-philippines-abortion-legislative-brief.pdf 20 NDHS (2013), https://dhsprogram.com/pubs/pdf/fr294/fr294.pdf, Philippine Commission on Women, Violence Against Women, https://pcw.gov.ph/focus-areas/violence-against-women . 21 Human Rights Watch (2017),https://www.hrw.org/news/2017/06/21/philippines-lgbt-students-face-bullying-abuse. 22 ]NDHS (2017) 23 Pregnancy and childbirth complications continue to be the leading cause of death among 15 to 19 year-old girls worldwide. Adolescent mothers (aged 10-19 years old) also face higher risks of eclampsia, puerperal endometritis, and systemic infections than women between the ages of 20-24. WHO (2018), Adolescent Pregnancy, https://www.who.int/news-room/fact-sheets/detail/adolescentpregnanc . 24 WHO (2018), https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy. 25 UNFPA (2018), In the Philippines, Information Key to Halting Teenage Pregnancy, https://www.unfpa.org/news/philippines-information-key-halting-teenage-pregnancy#. 26 UNFPA (2018), In the Philippines, Information Key to Halting Teenage Pregnancy, https://www.unfpa.org/news/philippines-informationkey-halting-teenage-pregnancy#, UNFPA (2016), Education, Earnings and Health Effects of Teenage Pregnancy in the Philippines, https://philippines.unfpa.org/en/publications/education-earnings-and-health-effects-teenage-pregnancy-philippines. 27 Department of Health, Philippines. “An Act providing for a National Policy on Responsible Parenthood and Reproductive Health”, https://www.doh.gov.ph/sites/default/files/policies_and_laws/ra_10354.pdf. 28 M. Upreti and J. Jacob (2018), “The Philippines rolls back advancements in the post-abortion care policy,” Int. Journal of Gynecology & Obstetrics (142): 255–56, https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/ijgo.12530.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

3. THEORY OF CHANGE The SHE Project aims to achieve long-lasting transformative change by strengthening the capacities of women and girls to secure their SRHR. Thus, the project’s Theory of Change (ToC) is built on the following two pillars: • PILLAR 1: Engaging Community Members to Support Gender-Responsive Services and Promote Norms that Improve Health-Seeking Behaviour. SHE’s first pillar seeks transformational change through the promotion of SRH information hubs and services in target communities, by transforming discriminatory social norms through awareness-raising and mobilization activities, and improving access to high-quality, comprehensive SRH information flow and services, including GBV prevention and support. (Implemented in partnership with eight international, national and local partners: AMDF, FPOP, Jhpiego, MIDAS, PKKK, SiKAP, Tarbilang Foundation, and UnYPhil Women) • P ILLAR 2: Building knowledge and strengthening the capacity of WROs, institutions and alliances to influence and advance the full implementation of SRHR-related laws, policies and programs SHE’s second pillar is national in scope and seeks transformational change through strengthening the capacity of WROs and networks of people’s organizations to advocate for women’s rights, SRHR and ending GBV. The project will provide capacity-strengthening support and funding to 10 WROs networks working on SRHR and GBV, and will establish a responsive funding mechanism to provide timely funding to WROs/networks to carry out actions they themselves identify as priority in support of SRHR, GBV and women’s rights. These two pillars are interconnected through an integrated and multi-faceted, socio-ecological approach, which works toward change at multiple levels (individual, community, institutional and societal) with diverse actors who are crucial to realizing and sustaining change. SHE’s outcomes aim to achieve better-integrated health systems; to strengthen the capacity and leadership of women, girls and their organizations to influence social norms; and to provide an enabling environment at all levels, where existing SRHR-related policies, laws and programs are effectively implemented and advanced. Building on Oxfam Canada’s successful experience of working to shift power relations, this ToC takes a nonlinear view of change, recognizing that there are risks in working to promote, protect and fulfill SRHR, which could lead to backlashes or attempts to push back or reverse previous gains in this sector. These r isks need to be anticipated, mitigated, and managed throughout the duration of the project. ToC at large is informed by Oxfam Canada’s understanding that Southern-based, grassroots CSOs – particularly WROs are key agents in determining the direction of change in their societies. As such, strengthening project partners’ capacity to work effectively to promote SRHR is key to long-term sustainability, and therefore a central component of this project.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

4. OBJECTIVES The baseline study design integrates a rights-based approach, a global SRHR framework, and a socio-ecological approach. Please see Annex A for more details. The overall goal of this study were as follows: • Create a baseline for measuring project outcomes • Collect evidence testing the assumptions underpinning the project’s ToC • Provide evidence-based recommendations toward implementation The specific objetives of the baseline study were as follows: • Assess SRHR at individual and household levels • Measure attitudes, norms and behaviours regarding SRHR • Assess the capacity of public and non-public entities to provide SRH services • Evaluate public policy and practice regarding SRHR as it relates to the SHE project • Undertake local and national stakeholder analysis • Provide recommendations toward the project design and implementation

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

5. METHODOLOGY The study was designed by Oxfam Canada and implemented under the supervision of Oxfam in the Philippines. The design, refining and finalization of the study tools were conducted in a participatory manner i.e. in consultation with the Oxfam in the Philippines project’s team and partners. The study used a Mixed Methods Approach in line with feminist research methods.29 Geographic areas for the study were selected based on the focus areas the project partners identified where the SHE Project activities will be implemented. The study consisted of three key components: • Desk Review • Primary data collection • Analysis, validation and reporting

5.1 DESK REVIEW The desk review comprised two components: rapid policy analysis of relevant SRHR-related policies in the Philippines; and stakeholder analysis.

POLICY ANALYSIS: The desk review consisted of collecting, thematically analyzing, organizing and synthesizing available documents including, a) National and local Health Policy (HP) and other relevant governmental documents (relevant laws in particular), b) past and current SRHR project plans and reports, and c) literature review of previous studies. The desk review helped develop a better understanding of the current situation and gaps in SRHR.

STAKEHOLDER ANALYSIS: The stakeholder analysis was conducted to accompany the law and policy analysis, informed by a stakeholders’ workshop and mapping of various actors. The mapping included individuals, institutions and agencies, as well as groups or collectives engaged with SRHR, women’s rights, and gender equality issues. Identified stakeholders were classified accordingly with their attributes: (1) name of stakeholder; (2) basic characteristics; (3) interest in/how affected they are by the issue; (4) policy positions; (5) capacity and motivation to bring about policy change; and (6) possible actions to address stakeholder interest. Overall, the stakeholder analysis included an examination of 68 stakeholders, broken down as follows30:

TABLE 2: BREAKDOWN OF STAKEHOLDER ANALYSIS NUMBER OF STAKEHOLDERS

LEVEL

TYPE OF STAKEHOLDER

National level

Individual

Local level

Individual

National

Institutional

Local Level

Institutional or agency

50% national and 50% local level

Collective

29 Global Affairs Canada. Feminist International Assistance Gender Equality Toolkit for Projects https://international.gc.ca/world-monde/ funding-financement/gender_equality_toolkit-trousse_outils_egalite_genres.aspx?lang=eng 30 Stakeholder Analasys and list of organizations is available upon request.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

5.2 PRIMARY DATA COLLECTION Primary data collection took place from November 2018 to April 2019. The primary data collected followed two main approaches to ensure data was collected from all key stakeholders identified by the partners. • Quantitative data collection • Qualitative data collection To ensure data quality, the data collection team was recruited based on required qualifications, namely graduates from universities with health-related courses and with at least two years of research experience. The team was trained for two days on data collection procedures and interviewing skills and attitudes, study protocols, dealing with survey questionnaires, ethical principles, and introduced to manuals for data editing for completeness, consistency and accuracy during interviews. A four-hour training session was also conducted to provide background information on the HP review. The data collection team supervisors, all with background training in HP analysis, supervised the data collection. A Data Collection Manual was drafted for training and reference of field personnel. The manual contained information on the following: a) roles of data collectors and proper interviewing and editing skills, b) concepts relevant to the SHE project, c) data collection forms and procedures, d) baseline study sites, sampling design and sample size, and e) data collection instruments (survey questionnaires, etc.). The above-mentioned training also included conducting of mock interviews, mock-run exercises and discussions of potential problems and issues with data collection. Data collection supervisors were trained in field editing procedures.

5.3 STUDY SITES The SHE Project is being implemented in six regions of the Philippines: Bicol, Eastern Visayas, Autonomous Region in Muslim Mindanao (BARMM), Zamboanga Peninsula, Northern Mindanao and Caraga. Within these regions, partners will be working in 13 provinces, 21 municipalities and 250 barangays that are included in the study. The geographical spread of target municipalities presented a challenge in carrying out the primary data collection. Therefore, five provinces were selected for the baseline due to the time and budget limitations. The selection of the provinces and subsequent municipalties and barangays took into consideration the geographical diversity of the provinces to ensure a statistically significant representative sample was selected. Please see Table 3 for a list of the study sites.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

TABLE 3: GEOGRAPHIC LOCATIONS FOR PRIMARY DATA COLLECTION REGION

PROVINCE

TOPOGRAPHY

MUNICIPALITIES

BARANGAYS

Eastern Visayas -Region 8

Northern Samar

Coastal

San Isidro

Balite, Palanit

Coastal

Victoria

San Lazaro, Zone III

Samar

Coastal

Santa Margarita

Ilo, Monbon

Northern Mindanao Region 10

Bukidnon

Landlocked

Sumilao

Poblacion, San Vicente

Landlocked

Dangcagan

Barongcot, Lourdes, Poblacion

Caraga Region 13

Agusan del Norte

Landlocked

Santiago

San Isidro, Tagbuyacan

Coastal

Jabonga

Baleguian, Libas

BARMM

Tawi-Tawi

Island

Bongao

Karungdung, Simandagit

Island

Sapa-Sapa

Pamasan, Butun

5.4 QUANTITATIVE DATA COLLECTION Household Survey: The structured survey consisted of six main sections: (1) respondents’ profile and socio economic characteristics; (2) knowledge on sexual and reproductive health; (3) practice of sexual and reproductive health; (4) attitudes toward SRHR on women’s sexual, reproductive, and economic autonomies; (5) implementation of SRHR policies; (6) personal life and personal experiences including GBV. The questionnaire was adapted for mobile data collection using SurveyCTO and translated into Waray, Bisaya (Cebuano), Bahasa Sama and Tausug for ease of use of the enumerators.

The study sample included face-to-face (F2F) interviews with 1,920 respondents. The sample size was calculated using descriptive cross-sectional design using a confidence level of 95%, and a 7.5% margin of error. The sample was also adjusted for any design error (10%) and a 90% response rate. The target number of respondents is shown in Table 4. During data collection, however, an additional barangay in Dangcagan, Bukidnon was selected because of difficulties in finding eligible respondents in one of the sample barangays. The research team chose an efficient, multi-stage sampling design as it allowed concentrated data collection covering a large area. A three-stage stratified cluster probability sampling design supported the selection of the respondents. The stratification variable was geographical classification, namely coastal, island and landlocked. In each stratum, the primary sampling units (PSUs) were the randomly-selected municipalities. The secondary sampling units (SSUs) were also randomly drawn from the list of barangays, and finally, clusters of households were randomly selected from each barangay (tertiary sampling units - TSUs). The first three sampling units had a sampling frame, which was a listing of municipalities and barangays. For the selection of clusters of households, the team used a spot map of the barangay. Households were grouped and the selection of clusters of households was random. Within a sample household, two adolescents (15-19 years old), male and female, and two adults (20-49 years old), male and female, were randomly selected. When there were no household members in one of the age/gender groups, the needed respondent was invited to participate from the adjacent house on the right. If no one was at home at the moment of the survey, the next house on the right was selected.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

TABLE 4: SAMPLE SIZE PER AREA AREA

NO. OF BARANGAYS

NO OF HOUSEHOLDS

NO. OF INTERVIEWS (4 RESPONDENTS)

NO OF HOUSEHOLDS PER BARANGAY

Samar

120

480

Bukidnon

107

428

Tawi Tawi

160

640

Agusan del Norte

372

Total

480

1,920

TABLE 5: DISTRIBUTION OF RESPONDENTS BY AREA PROVINCES

AREA

TARGET NUMBER OF INTERVIEWS

ACTUAL NUMBER INTERVIEWED

Bukidnon

Dangcagan

216

223

Sumilao

216

212

Agusan del Norte

Santiago

216

198

Samar

Santa Margarita, Samar

158

162

Northern Samar

San Isidro,

158

157

Victoria

158

156

Agusan del Norte

Jabonga

158

173

Tawi Tawi

Bongao

320

321

Sapa Sapa

320

321

1920

1923

TOTAL

TABLE 6: DISTRIBUTION OF RESPONDENTS BY AGE AND GENDER GROUPS CATEGORY

NUMBER

PERCENT

15 to 19 years old, male

516

26.8

15 to 19 years old, female

485

25.2

20 to 49 years old, male

454

23.6

20 to 49 years old, female

468

24.3

Total

1,923

100.0

The data collection tools underwent validation processes using face validity and content validity. Face validity was based on operational definitions of SRHR services, which were the results of the literature reviews and expert interviews. Content validity was done by five content experts in reproductive health, psychology, anthropology, sociology and SRHR methodology. The validated questionnaire was translated into Filipino, and was pretested for cognitive clarity of the survey questions. Respondents during the pretest were asked to comment on the clarity and cultural acceptability of the questions. The questionnaire was translated to Waray, Bisaya (Cebuano), Bahasa Sama and Tausug for the survey. The questionnaires were also tested for reliability.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT â&#x20AC;&#x201C; BASELINE STUDY 2019

5.5 QUALITATIVE DATA COLLECTION Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs): The KIIs and FGDs included

five types of groups: a) coordinators and heads of offices at the regional, provincial, municipal and barangay levels, for both governmental units and non-government organizations (NGOs), b) health providers, c) community leaders, d) religious leaders, and e) selected volunteers and advocates of SRHR. Sixteen FGDs were conducted with 128 people in total and 78 people were interviewed as key informants. The numbers of KIIs or FGDs were capped when the saturation point and maximum variance point was reached. Saturation is reached when the last KII or FGD conducted did not bring new ideas or themes to the study. Please see Table 7 and 8 below for more details.

TABLE 7: KII RESPONDENTS BY LEVEL LEVELS

TARGET RESPONDENTS FOR KII

Central office

Department of Health - Family Health Office and National Center for Disease Prevention and Control, Department of Social Welfare and Development point person, Philippine Commission on Women point person

Regional offices

DOH regional director, GIDA coordinator, Women’s and Family Health coordinator

Provincial offices

Governor, Provincial Health Officer, Provincial Health Team Leader, Provincial DSWD Officer, Provincial health board member

Municipal offices

Mayor, Municipal Health Officer, Development Management Officer, Municipal DSWD Officer

TABLE 8: FGD TARGET PARTICIPANT PER SOCIAL GROUP OF INTEREST FOCUS GROUP

PARTICIPANTS

NUMBER OF FGD

Community leaders

Men

1 per municipality

Women

1 per municipality

Boys

1 per municipality

Girls

1 per municipality

Health providers

RHU staff and other local health providers

2 per municipality

Religious leaders

Men

1 per municipality

Women

1 per municipality

Other gender identities

1 per municipality

Diverse gender identities

Personal stories: In the collection of “I stories”, 9 girls (14 to 18 years old) and 4 women (30 to 39 years

old) with first-hand experience of SRHR issues were selected based on the recommendations of the partner organizations. They were invited to share their stories through an interview. The facilitator took notes and, depending on the answers, probed with questions to identify the full impact. Respondents were asked if they would give consent for their name to be used on their story or if they would prefer to remain anonymous. In the case of teenagers or minors, one of the parents or the guardian provided consent to the interview. Some interviews were conducted in respondents’ respective residences where the parents and/or guardians were present. However, for ethical reasons, these interviews were not included in the Appendix.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

5.6 DATA COLLECTION AND ANALYSIS Collection: Prior to data collection, courtesy calls were made to the respective governors, mayors and

barangay captains to seek permission and guidance for the conduct of the survey and to explain the purpose of the study. A data collection team was composed of two interviewers and one supervisor. As mentioned earlier, the team used SurveyCTO, which enables mobile-based data collection. The data was collected in a comfortable and secure location of the respondents’ choice and collected ensuring confidentiality. Each survey was no more than 60 minutes. The supervisors were required to spot check to ensure data quality. Once data was reviewed by the interviewer and supervisors, it was uploaded to the Oxfam server and immediately encrypted. Only one Oxfam data manager had access to names of respondents. Only coded data was used for the analysis, and this was accessible only to the data manager and a statistician. Problems and issues encountered in the field were relayed immediately to the central office for information and action. Audio recordings and other related data-collection tools and documents collected were stored in a secure cabinet with lock and key.

Analysis: For the survey, descriptive statistics like the mean and standard deviation for normally distributed quantitative variables, median and range for non-normally distributed quantitative variables, and absolute and relative frequencies for qualitative variables were computed per sex using EPI INFO 7 and Stata Version 12. For the qualitative analysis, FGD/KII – thematic/cluster-based analysis was conducted.

Data retention, protection and security: Oxfam has a safe mechanism for data storage by encrypting

servers to protect the data. All data transfer is also encrypted from point to point and can only be downloaded (encrypted) by data managers. Only data managers have access to encryption keys. All data has been stored in an Oxfam server for future analysis; once the project ends, raw data and data sets will be stored for five years. All data will be deleted after that. For physical data, all hard copies of consent forms, respondents’ profiles and other related documents will be kept in a metal-locked cabinet for the whole life of the project and will be destroyed five years after the project ends. Only the project manager will have access to these documents during the life of the project.

5.7 ETHICAL CONSIDERATIONS Best practices and ethical guidelines were followed for data collection. These guidelines were prepared by Oxfam Canada and drew heavily from the WHO 1991 Guidelines Putting Women First31 for data collection with adults and UNICEF’s 2013 Ethical Research Involving Children (ERIC)32 Compendium for data collected from children (individuals below the age of 18). The data collectors oriented the respondents on the research title, project leader, study objectives and procedures, including the study sites and sample size. They were informed that their participation would be based only on their informed consent and that they could withdraw anytime without any prejudice on the health services and benefits they were presently receiving. Respondents were also informed that all information they provided during the interview would be kept confidential, as well as the potential risks for participating in the study. These include, but are not limited to, the breach of privacy for minors through parental knowledge of a child’s attitudes, norms and behaviours related to SRHR. All efforts were taken to ensure confidentiality of information and reduce any possible risks of asking sensitive questions about life experiences on GBV. To minimize risks, data collectors (who are nurses) were trained to screen for any cases that might be sensitive to that and were instructed to debrief participants, 31 WHO, Putting Women First (2001), https://www.who.int/gender/violence/womenfirtseng.pdf, 32 UNICEF, Ethical Research Involving Children (2013), https://childethics.com/wp-content/uploads/2013/10/ERIC-compendiumapproved-digital-web.pdf,

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

if needed, to ensure that they undertood that they could refuse to answer any questions if they felt unconfortable with. For the safety of the data collectors, the local data collection team (two interviewers and one supervisor, aided by a barangay tanod/health worker) stayed together until all targeted respondents in the household were interviewed. Respondents were asked what language they preferred for interviews. The data collectors spoke local languages, althought not all were fluent in all four languages, and they had no issue conducting the HHS. The Informed Consent Form (ICF) was introduced for each respondent to read and understand. If they agreed to participate, they were asked to sign their approval on the ICF. Study participants were also given a copy of the signed ICF.

5.8 LIMITATIONS OF THE STUDY • All data and statistics in this report are not comparable to country level statistics; the study was carried out in sample groups in targeted project areas and the statistics are therefore not reflective of standardized national data. Although the baseline uses some of the same indicators as national statistics, the values are representative only for the project’s regions. • In the initial sampling design, the “youth group” was defined to be 15 to 17 years old, since 18 years old is the legal age to marry in the Philippines. However, given that the national statistics define “youth” as individuals 15 to 19 years old, the age range was changed to match with the national definition of youth.33 • In addition, the Household Survey (HHS) was limited to what the respondents could remember from the last 12 months. Some studies have found that 20% of critical details of an event are irretrievable after a year from its occurrence.34 Recall bias may result in either underestimating or overestimating values. To minimize recall bias, the data collectors were instructed to give the respondents enough time before answering and to probe to help the respondents report accurate recalls. Self-reported answers may be exaggerated or downplayed. Respondents may be too embarrassed to reveal private details; various biases may affect the results, such as social desirability bias. This is particularly likely when talking about issues that are highly sensitive, like SRHR and VAWG.

33 Statistical analysis of questionnaire reflects the change in the age group (ref. OXFAM Canada and FDR analysis) 34 E Hassan. Recall Bias can be a Threat to Retrospective and Prospective Research Designs (2005), The Internet Journal of Epidemiology. Volume 3 Number 2.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

6. LITERATURE REVIEW This section presents a partial literature review that was undertaken as part of this baseline study. Primarily, this section will provide literature reviewed in line with the Pillar One of the project.35 Section 7 presents the primary data collected under Pillar One. Given that data for the Pillar Two was entirely based on the literature review, the synthesis for that has been excluded from this section. According to the 2017 National Demographic and Health Survey (NDHS),36 17% of currently married women at the national level have an unmet need for family planning (FP) services. This indicator may be higher in reality, as the Young Adult Fertility and Sexuality Survey (YAFS4) shows that young adults have a tendency to live as common-law partners and not get married.37 The NDHS 2017 reports that 48.7% of sexually active women have an unmet need for FP. The indicator value is highest in the project’s target regions, specifically in the regions of Zamboanga Peninsula (24.6%) and Bicol (21.3%). The trend of unmet needs38 shows that most of the SHE Project target regions’ unmet needs for FP are above the country’s average. A key SRHR challenge within the Philippines, given existing legal constraints under the RH Law, is that adolescents may have sex, but are not old enough to access contraceptives. This is contributing to the fact that the Philippines has one of the highest rates of teenage pregnancy in the world. The NDHS 2017 statistic indicator for adolescent fertility points to the fact that 9% of girls 15 to 19 years old have begun childbearing, and this rate has not changed from 2013 to 2017. This indicator only captures live births among teenagers, not all pregnancies. There are no national statistics for teen abortion (since it is illegal), or those who have accessed post-abortion care. Since abortion is highly stigmatized and punishable by law, it is extremely challenging to directly estimate the number of abortions in the Philippines, as both women and providers are likely to not report the procedure. The most recent study on national abortion incidence in the Philippines used indirect estimation techniques and hospital records to estimate a rate of 27 abortions per 1,000 women of reproductive age in 2000, with lower and upper estimates of 22 and 31 abortions per 1,000 women.39 Notably, this rate was considerably higher than a more recent estimate of the unsafe abortion rate in Southeastern Asia as a whole (22 abortions per 1,000 women), indicating that the Philippines may have more unsafe abortions than some neighboring countries. Projections based on the 2000 national abortion rate, and taking into account population increases, estimated that 560,000 abortions occurred in 2008 and 610,000 abortions in 2012.40 Teenagers in the highest two wealth quintiles start childbearing later than those in the lowest quintiles.5 Some 12% of girls in poverty have had a live birth, compared to only 2.9% of girls in the richest quintile. Pertinent to GBV, the NDHS 2017 reports that one in five women have experienced emotional violence, 14% have experienced physical violence, and 5% have experienced sexual violence. Girls and young women (20 to 24 years old) are more likely (21.2% and 22.1% respectively) to experience emotional violence than older women. In contrast, older women (40 to 49 years old) are more likely (18%) to have experienced physical violence from the age of 15 than girls (13%). Incidents of violence are highest in the regions of Caraga (51.8%), followed by Zamboanga Peninsula (43.4%), Bicol (43.4%) and Eastern Visayas (43.2%).41 When disaggregated by the type of violence, sexual violence is the least reported, almost silent in the BARMM region with 0.9%; and emotional violence is the most recognized and reported, with the Caraga region leading with 44.7%. 35 Refer to the ToC section 36 NDHS (2017) 37 Young Adult Fertility and Sexuality Survey, YAFS4. 38 NDHS (2017) 39 Guttmacher Institute (2013), https://www.guttmacher.org/report/unintended-pregnancy-and-unsafe-abortion-philippines-contextand-consequences 40 Center for Reproductive Rights (2017), https://www.reproductiverights.org/sites/crr.civicactions.net/files/documents/GLP-Philippinesfact-sheet-2-22-17.pdf 41 NDHS (2017), “One in Four Women have Ever Experienced Spousal Violence”, press release https://psa.gov.ph/content/one-fourwomen-have-ever-experienced-spousal-violence-preliminary-results-2017-national.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

In 2000, at the national level, one case of HIV &AIDS was diagnosed per day, but in 2015, there were 25 new cases daily. UNAIDS reported 32 new cases per day in 2017 and warned of the growing epidemic in the Philippines.42 Based on NDHS 2017, 94% of women aged 15to 49 had heard about HIV at the national level. This percentage is lowest in ARRM, at only 59%. On the other hand, at the national level, only 62% of WRA knew that condom use and having an uninfected partner could prevent HIV. This indicator is even lower in Zamboanga Peninsula and Northern Mindanao at 56%, and only 33% in BARMM.43 Based on the December 2018 HIV & AIDS and ART Registry of the Philippines Report, the majority of the newlydiagnosed cases are in highly urbanized regions (37% NCR, 17% Calabarzon, 11% Central Luzon, 8% Central Visayas). However, regions covered by the SHE project are mostly GIDA and rural areas, where newly diagnosed cases in December 2018 ranged only from <1% to 3% (3% Northern Mindanao, 2% Bicol Region, 2% Zamboanga Peninsula, 1% Caraga, 1% Eastern Visayas and <1% BARMM).44 This leads to the understanding that the prevalence of HIV & AIDS will be lower in SHE Project sites. The NDHS 2017 highlights that 81% of currently-married women who are using contraceptives made the decision to use contraceptives jointly with their husbands. About 3% made the decision themselves, and in 6% of cases, the husbands made the decision. Among currently-married women who are NOT using contraceptives, 74% made the decision not to use contraceptives jointly with their husband, 20% made the decision themselves, and for 6%, husbands made the decision.45 The NDHS 2017 also points to the fact that 73% of WRA who are currently using contraceptive methods were informed about the potential side effects of the method they were using, while 65% were informed about what to do if they experienced side effects. Among WRA who are NOT using contraception, 83% did not discuss family planning with a health care provider in the past 12 months, either during a home visit or at a health facility. Some 60% of WRA who are not using contraception in Zamboanga Peninsula had no discussion of family planning with a fieldworker or at a health facility, as compared with 91% of women in NCR. Knowledge and use of contraceptives is particularly relevant because, from the HHS, the average age that women and men started to have their first sexual intercourse was approximately 20 years old. This is higher than the average age stated by girls or boys, at approximately 16 years old. What is also noteworthy from the responses is that some women had their first sexual intercourse at the age of 11, a time where children have just started their adolescence.46 The Philippines has been highly criticized for having the lowest age of consent to sexual activity at 12 years old.47 Women who have given birth in the five years preceding the 2017 NDHS were asked a number of questions about their maternal care.48 Mothers were asked whether they had obtained antenatal care during the pregnancy for their most recent live birth and whether they had received tetanus toxoid injections while pregnant. Tetanus toxoid injections are given during pregnancy to prevent neonatal tetanus, a major cause of early infant death in many developing countries, often due to failure to observe hygienic procedures during delivery. In the Philippines, 79.8% of womenâ&#x20AC;&#x2122;s most recent live birth was protected against neonatal tetanus. The coverage is lower in Caraga at 72% and BARMM at 65.7%. Bicol region has the highest coverage at 88.7%

42 UNAIDS (2018), UNAIDS Data 2018, p. 161, http://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf 43 Department of Healh, Philippines (2008), https://www.aidsdatahub.org/sites/default/files/publication/EB_HIV_December_AIDSreg2018.pdf 44 ibid 45 ]NDHS (2017). 46 See Appendix A, Table 11. HHS Age at first intercourse 47 UNICEF (2016), A Systematic Literature Review of the Drivers of Violence Affecting Children: the Philippines. p. 63. 48 NDHS (2017).

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT â&#x20AC;&#x201C; BASELINE STUDY 2019

For each live birth over the same period, mothers were also asked what type of assistance they received at the time of delivery and whether the birth was delivered by Caesarian section. Women who had a live birth in the two years before the survey were asked if they received a postnatal check during the first two days after birth. Access to proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that may lead to death or serious illness for the mother and/or baby.49

49 Van Lerberghe and De Brouwere (2001); WHO (2006).

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT â&#x20AC;&#x201C; BASELINE STUDY 2019

7. RESULTS OF THE STUDY This section presents findings from the baseline study in relation to the two pillars identified in the project’s ToC. A brief summary of general demographic findings from the survey conducted with adolescents, women and men in the target villages is presented below. The quantitative findings from target areas on specific topics are presented together with qualitative findings under different sub-topics to demonstrate similarities or differences of responses.50 Findings provided here are representative of the districts and villages in which the data collection was undertaken. Generalizations of the findings to the regions in which these provinces are located, should be done with a degree of caution. Moreover, generalizations should not be made at all to the broader population as the findings are not representative of the national population.

Baseline Participants: From November 2018 to April 2019, 2,173 persons (50% female and 50% male)

participated in this Baseline Study. A representative sample of 1,923 people from 480 households (HH) was selected for the HH survey. Overall, 80 key informants were interviewed through KIIs, 128 people participated in FGDs, 13 women provided their “I Stories”, and 28 persons, 20 women and 8 men, participated in the stakeholder workshop and baseline validation workshops. The section below provides a basic demographic profile of the household survey (HHS) respondents.

DEMOGRAPHIC PROFILE OF SURVEY RESPONDENTS The respondents of the HHS were women (24.3%), girls (25.2%), boys (26.8%) and men (23.6%). All respondents live in rural settings and are either Catholic (54.1%) or Muslim (33.4%). The vast majority practises their religion (93.1%). Some (23.2%) have finished primary school and (59.8%) have a high-school education. The average age of the respondents was 16 years old in the 15 to 19 age group, and 36 years old in the 20 to 49 age group. 34% of respondents are married and 6.6% are in common-law relationships. Most youth declared themselves as unemployed (54.9%). The primary source of income for 10.6% of respondents was farming or agriculture, followed by fishing or aquaculture (6.6%), followed by unskilled labor (4.4%). The estimated overall household income for 38.3% of the respondents was PHP2,000 to PHP5,000 ($50-125 CAD) per month. When employed respondents were asked how important their income is for the household, 28.9% said it was the largest part of the household income.51

7.1 ULTIMATE OUTCOME: IMPROVING SRHR IN THE PHILIPPINES The ultimate outcome (1000) of the SHE Project is to “improve sexual and reproductive health and rights for women and girls in remote, conflict-affected and disadvantaged areas of the Philippines”. The results of the HHS point to the fact that women have a higher unmet need for FP (32.3%) than girls (13.3%). The unmet need indicator value found by the HHS for women follows the same tendency, as reported by the NDHS 2017 for regions, but the proportion for girls is significatively lower than in national statistics. The NDHS 2017 reports that younger married women (15 to 19) have the highest rate of unmet needs (28%) compared to other age groups. No region-disaggregated data was available for this age group. 50 In many of the figures presented with the analysis, take note that the legend will contain an option “Blank” and “PNTA”. “Blank” means that no answer was provided at all and “PNTA” means the respondent actually stated that they preferred not to answer that question (OXFAM Canada comment) 51 See Appendix A: Table 1. SHE HHS Distribution of respondents by socio-demographic profile

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

TABLE 9: HHS DISTRIBUTION OF RESPONDENTS “WHO USED FPM BEFORE” BY WHETHER “THEY ARE CURRENTLY USING A FPM NOW” TO AVOID OR DELAY GETTING PREGNANT INDICATOR

GIRLS (15 to 19)

WOMEN (20 to 49)

BOYS (15 to 19)

MEN (20 to 49)

Met Need for FP

13 (86.7%)

171 (67.3%)

6 (40.0%)

82 (68.3%)

Unmet Need for FP

2 (13.3%)

82 (32.3%)

8 (53.3%)

34 (28.3%)

Prefer Not to Answer (PNTA)

1 (0.4%)

1 (6.7%)

4 (3.4%)

Total

15 (100.0%)

254 (100.0%)

15 (100.0%)

120 (100.0%)

Source: SHE Project HHS. X2=17.08, p-value=0.008

“Fulfilling SRHR is not a health issue, it is a social and economic development issue…” — FGD Participant According to the SHE HHS, among overall SHE Project target population, 7.4% of girls and 5.1% of women were pregnant on the day of the survey.52 The NDHS 2017 underlines that 1.5% of women were pregnant at the national level, which is a much lower value in comparison to the SHE HHS. Furthermore, the SHE HHS also found that 73% of the girls surveyed have already been pregnant. In comparison, the NDHS asked the respondent whether she had a live birth in the last year. A comparative analysis of the national NDHS data and SHE HHS data points to the fact that the SHE HHS found higher rates because it targeted the lowest wealth quintiles in rural and poor areas.

I Story: Teen Pregnancy Name: Rea Age:53 17 years old Region: Northern Mindanao She was asked to draw something that symbolizes how she felt after knowing she was pregnant, Rea drew a sad face. She did not want to be pregnant at all when she was 16. She was nine months pregnant at the time of the interview and was expected to deliver on April 14/2019. When asked where she plans to give birth since her due date is nearing, she just shrugged and said she still has not planned it. The nearest hospital is 30 to 45 minutes away by motorcycle. There is a birthing clinic in the community but since she is not a member of Philhealth, she cannot avail of the free service. Rea lives with her parents and younger sister. She is the 10th child among 11 siblings comprised of 6 girls and 5 boys. The youngest is 14 years old. Her other siblings have their own families and live independently. The father of her child is her nephew, the son of her eldest sister, who goes to their home every night to watch TV and sometimes sleeps over. He raped her. He is 20 years old, lives a few houses away, and has a wife and a 4 year old daughter. His wife lives in Cagayan de Oro with their daughter. She works as a household helper while he works in construction.

52 As recorded on the day of the survey 53 Name has been changed to protect identity

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

The first rape happened in August last year. They had just finished watching Probinsyano, a very popular television drama series in the Philippines. Her parents slept in the only bedroom in the house while they slept in the sala. That night she felt different, her nephew was a bit more touchy than usual. They were already preparing for sleep when her nephew lay down beside her. She tried to stop him but he was stronger than her. He covered her mouth to prevent her from screaming. After raping her he went back to his spot and went to sleep. She went to school the next morning without telling anyone. She felt very angry. Her nephew threatened to kill her if she did not keep silent. After the incident, Rea stayed away from her friends and kept to herself. She was fearful that it might happen again. She felt very ashamed and thought of herself as unclean after the rape. A few days after, her nephew raped her again. Again, no one noticed that this was happening inside their home. The rape only stopped when her nephew’s wife came home from Cagayan de Oro. In September, her monthly period stopped. She knew that she was pregnant. She knew that having sex will lead to pregnancy. She learned this from her Science teacher in school who also taught them about contraceptives. Suspecting that she was pregnant, she left home to go to her brother’s place in Barangay Banadero, which is 25 minutes away (13 km away) from her place. She stopped going to school. Her brother asked her about her sudden appearance in his house and she responded that she wanted to look for work. During her stay there, his sister-in-law noticed that she was pregnant because she was devouring the mangoes given to them. When her brother found out about it, he became very angry at their nephew. She felt very relieved when her brother knew because carrying the predicament by herself was a heavy burden. The family wanted to file charges but her nephew had left already. Rea’s brother instructed her to take an herbal pill that supposedly induces abortion. The herbal pill is a tiny bitter pill (smaller than breath mints) wrapped in transparent colored cellophane. The seller instructs buyers of the pill to take five tablets before meals every day for five days for the pregnancy to be terminated. Efficacy is higher during the first trimester of pregnancy. She was disappointed and sad because it was not effective. She never wanted to push through with the pregnancy. She could not imagine how she would raise the child by herself. In December of last year, Rea went back home. She did not go back to school because the school is a 3 km walk from her home. She has not seen any of her friends. She goes to the health center for her prenatal check ups on the first Wednesday of the month. The midwife who sees her advised her to use contraceptives, either pills or an implant to prevent another pregnancy. She receives free vitamins such as ferrous sulfate and calcium, and has been oriented on how to prepare for the birth of her child. She was also informed about what and how she would feel before giving birth. After giving birth, Rea wants to go to Manila to look for work and dreams of completing her education. She would like to be a chef someday. She hopes that one of her siblings can help her find a job. She is banking on her mother to help her raise the baby. She already has some clothes for her baby and has chosen a name for her/him.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

In order to explore SRHR issues more meaningfully, nine girls who were pregnant or have been pregnant in the last two years, and four women who have had personal experiences with SRHR concerns were interviewed. Some of the major themes arising from these in-depth interviews include: • A sense of “fatalist reality”: because many girls were (or have been) pregnant, teenage pregnancy was at the time perceived as a normal (and in some cases inevitable) event by the girls themselves • Respondents didn’t make a link between VAWG (such as rape) and cases of girls as young as 12 years old becoming pregnant: SHE research found some girls who were 11 years old at first intercourse, without any discussion arising regarding the minimum age of consent (which is 12 years old in the Philippines). • Inequitable relationships, including cases of VAWG, such as emotional and physical violence and rape • Lack of knowledge or misinformation regarding effective contraceptive and/or safe abortion methods • Barriers to accessing formal and informal SRH resources from the barangay health centers, including the incomplete services of the centers and unavailability of doctors • Health services were limited to those who have PhilHealth cards, or can pay for them. Services were limited to prenatal care and no psychological support was offered. • Family, community, and/or social pressures persitently appear as an issue in some cases of unwanted pregnancies • It is difficult for girls to make future plans and have overall productive life scenarios because of earlyage pregnancies Some girls interviewed mentioned that they had considered abortion, despite knowing it was illegal. In the HHS, 3.3% of the total number of respondents knew someone who had an abortion in the previous 12 months. When asked about the possible reasoning for having abortions, they said that the “girl was too young” or that “she was not ready to be a mother.”

In a FGD, a girl stated, “for women, consciously avoiding having a boyfriend is a way to ensure that they finish schooling.” According to a male religious leader, “most women stay longer in school than men, because men tend to think that they no longer need it as they are already working (mostly tumatagal sa school is babae kasi sa isip ng mga lalaki hindi na kailangan magaral kasi may work naman sila).” 7.2 PILLAR ONE: ENGAGING COMMUNITY MEMBERS TO SUPPORT GENDER-RESPONSIVE SERVICES AND PROMOTE NORMS THAT IMPROVE HEALTH-SEEKING BEHAVIOR 7.2.1 KNOWLEDGE, SKILLS AND CAPACITY OF WOMEN, GIRLS AND BOYS REGARDING THEIR SRHR In the HHS, the level of knowledge about SRHR issues and services varied among boys, men, girls and women, which demonstrates inconsistency in the information available to various gender and age groups. For example, more than 70% of the target population knew about HIV &AIDS and a bit more than half (54.2%) knew that a simple test is needed to find out whether a person is HIV positive.54 However, incorrect knowledge is high among all age and gender groups. A significant proportion of men (41.4%) and boys (35.9%) believe that HIV&AIDS can be cured; women (31.05%) and girls (23.5%) hold the same belief. A total of 36.8% of all groups did not know if HIV&AIDS can be cured.55 54 See Appendix A, Table 2. SHE HHS. People can take a simple test to find out whether they have HIV. 55 See Appendix A, Table 3. SHE HHS. It is possible to cure AIDS by age and sex

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

Additionally, a knowledge gap related to sexually-transmitted illnesses existed among the target population. Besides HIV&AIDS, a higher percentage of men (74.8%) and boys (60.6%) had heard of other sexuallytransmitted illnesses (STIs) compared to women (64.3%) and girls (51.2%).56 Most people knew (69.8%) that STIs can be treated in a government health facility.57 However, incorrect knowledge is also common among all age and gender groups. Nearly half of all respondents did not know the symptoms if a man has an STI, and 57% did not know the symptoms if a woman has an STI. Only 2.7% of all respondents could identify three symptoms in men, and 2.1% of all respondents could identify three symptoms in women.58 Increasing knowledge and access to accurate information is relevant given the increase in HIV prevalence. Considering the knowledge of contraceptives, men (51.5%) and women (47.4%) were more aware about places to obtain contraceptives than boys (34.1%) and girls (24.3%).59 The barangay’s health centers were the most frequently-used locations to obtain family planning methods (FPMs) for boys (50.6%), men (44.9%), girls (43.2%) and women (40.1%). In addition, women (27.9%) were using Rural Health Units (RHU) more often than girls (21.2%), boys (13.1%) and men (12.8%). Midwives were a source of knowledge for contraceptives for girls (18.6%) and women (15.3%) as well as for men (12.4%) and boys (11.4%). From the private sector angle, pharmacies served mostly boys (13.6%) and men (12.8%).60 Although services are mostly free, from those who received any service, women (8.1%) and men (3.9%) mentioned that they paid some fees. When asked to choose from a list and images of 15 methods, the pill, the male condom and the hormonal injection were known by a high proportion of respondents. The pill, the intrauterine device (IUD) and implants were identified in the validation workshops as the most common contraceptives used at the community level. Female sterilization was the least known and used method, in both the HHS and validation workshops. Women and girl respondents knew more than men and boys about each method with the exception of the male condom. More than 90% of all the respondents knew about the male condom, but boys (44.2%) and men (42.3%) stated that they had used condoms, while girls (37.5%) and women (33.1%) said they had ever used one. No one knew about the female condom.61 In general, respondents were unsure where to obtain support in instances of GBV. From the overall HHS data, five women, one boy and four men personally sought support for physical, sexual, psychological or economic types of abuse. All males went to a government health facility, mainly to the Department of Social Welfare and Development (DSWD) and health centers. Three women did the same; however, two did not receive assistance. None of them went to the police or other legal authorities. Boys or men paid as much as PHP10,000 to obtain help. All girls or women, on the other hand, paid nothing, but did not mention how their personal situations were handled by the authorities.62 See Table # below for other actions taken by respondents after experiencing GBV. During the FGDs with government officials, it became evident that public servants possessed inconsistent information about SRHR services, including how SRHR was related to gender roles, power relations and negative attitudes and social norms. For instance, some of the respondents in this group considered SRHR to be a youth issue (i.e. for individuals 18 years or younger). They stated that programmatic design should focus on this age group. In addition, respondents stated that SRHR was all about youth development such as the anatomy and physiology of adolescents (i.e. reproductive bodies). Meanwhile, for some of the Barangay Captains, SRHR was considered to be a women’s concern, and not that of men, because SRHR was perceived as being all about family planning. Police officers were not aware of this concept at all, with the exception of VAWG laws and regulations. 56 See Appendix A, Table 4. SHE HHS. Distribution by whether they have heard of other STIs apart from HIV/AIDS 57 See Appendix A, Tables 5 and 6. SHE HHS Distribution by knowledge on health facilities for STI treatment 58 See Appendix A, Table 7 and 8. SHE HHS. Distribution of Number of Symptoms of STI identified 59 See Appendix A, Table 13.SHE HHS. Distribution by knowledge of where to obtain a family planning method 60 See Appendix A, Table 14. Distribution by who knew where to obtain FPM by facility where current family planning method was obtained 61 See Appendix A, Tables 15 to 19. 62 See Appendix A, Table 20. SHE HHS. Distribution by whether they sought support for physical, sexual, psychological or economic abuse

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

7.2.2 ATTITUDES AND BEHAVIOURS MODELLED BY VARIOUS GENDER AND AGE GROUPS AND INFLUENCERS IN SUPPORT OF SRHR The quality of information was the key in shaping decision-making regarding contraceptives, family planning and SRHR services. For example, respondents felt embarrassed to buy or obtain condoms. However, they generally agreed with statements that condoms are an effective method of preventing pregnancy, an effective way of protecting against HIV &AIDS and STIs, suitable for casual relationships or steady, loving relationships, and if unmarried couples want to have sexual intercourse before marriage, they should use condoms. A fair proportion of boys (42.5%) and men (44.3%) agreed that if a girl or woman suggests using condoms to her partner, it indicates that she does not trust him. Some women (29.6%) and girls (22.8%) hold the same belief. There was a sufficient number of boys (32.4%) and men (39.5%) who agreed with the statement that condoms reduced sexual pleasure. Some girls (13.7%) and women (27.6%) also agreed with the statement.63 These types of beliefs may shape the decision to use or not use condoms at a given moment. When exploring the decisions around contraceptives, the HHS specifically asked “Have you ever used anything or tried in any way to delay or avoid getting pregnant?” Among those who had had sexual intercourse previously, women (58.7%) and girls (35.1%) had made the decision to avoid getting pregnant followed by men (32.5%) and boys (13.6%). Not using a contraceptive is also a decision. More than half of the girls (54.1%) who already had intercourse in their lives had never used contraceptives. Boys (62.7%) and men (51.2%) had a higher proportion among age and sex groups of not using contraceptives compared to women (39.9%).64 From the FGDs’ results, it was evident that the behaviour of not using contraceptives is linked to how knowledge shapes the attitudes of both youth and adults. Both mothers and fathers were of the same opinion: educating children about sex is not a task that parents and other family members find easy. Parents feel uncomfortable talking to children about the subject. Perhaps they are reluctant to expose their own lack of knowledge about anatomy, physiology or lack of sexual education. They worry about how much information to give and at what age to give it, based on the belief that giving this information will lead young people to experiment with sex. Many parents did not receive sexuality education themselves, and some of their fears arose from their own negative sexual experiences. Adult family members, therefore, tend to shy away from actively educating youth about issues relating to sexuality.

One mother suggested, “I cannot see myself teaching my daughter about sex. Even menstruation; I am not able to tell her everything” (her daughter is now 16 years old).

A father lamented, “My teenage son knows about sex from his male friends, but I did not tell him anything about sex with girls. Boys will be boys…” FGD Respondents Some FGD respondents held a strong opinion of SRHR as private and personal. They believed that conversations about SRHR should not take place publicly, and should only be discussed with “appropriate” individuals, like health service providers (e.g. doctors and nurses). They believed that discussing SRHR with 63 See Appendix A, Table 22. SHE HHS. Distribution of respondents by attitudes and beliefs about condoms 64 See Appendix A, Table 23. SHE HHS. Distribution by those who had sexual intercourse by whether they have ever used a family planning method.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

adolescents, given their perceived vulnerability and lack of knowledge, might encourage them to indulge in promiscuous sex, forced sex/marriage or premarital sex, and that issues like HIV & AIDS, including STIs, should not be taught in schools. These respondents also believed that the Church must be the initiator of discussions on SRH. There was a consistent undertone that religious leaders are both competent and reliable facilitators and counsellors. When asked how to break down this barrier with regard to discussing sex with adolescents, the parents stated that there is a need for parent education programs. The goal is to improve adults’ skills for educating and communicating with youth, especially about sexuality, reproductive health and related services. This is particularly important for the sexual and reproductive health elements of the project, because 88.7% of the women and 73.0% of the girls who have had sexual intercourse had also been pregnant. The average age when they became pregnant is 16.9 years for girls and 21.3 years for women (the lowest age for pregnancy reported in the HHS was 12 years old). The average number of times these girls became pregnant was 1.6 (the highest number of pregnancies for one girl was 6). For women, the average number of pregnancies is 4.3 (the highest number of pregnancies for one woman was 14). In all, 5.2% of the female (both girls and women) respondents were pregnant at the time of the HH survey. During their most recent pregnancy, 37.3% of the women did not wish to become pregnant in the first place and 32% would have preferred to get pregnant at a different time. In addition, 16% of girls did not want to get pregnant and 24% said that they would have preferred to get pregnant at a different time. Among women and girls who were pregnant at the time of the interview, 52.6% indicated they would want to have another child, and that they would want to wait an average of 16 months after the birth of their child to become pregnant again. Most of the women and girls (59.9%) who were not pregnant at the time preferred not have any more children. Those who wanted to have another child and who were not pregnant at the time indicated they would like to wait an average of 26 months. In brief, all women and girls who wished to conceive again, wanted to wait one or two years.65 These above-highlighted results of the HHS are consistent with one of the KII comments: “BARMM has one of the highest levels of unmet need for contraception in the Philippines. One in four married women would like to stop having children or would like to delay their next birth, but are not using any contraceptive method”.66 The baseline found that the NDHS 2017 points to the same tendency at the national level: if all married women who say they want to space or limit their births were to use family planning methods, the CPR would increase from 54% to 71%.67 Some women (14%) and girls (3.7%) who had been pregnant had one or more pregnancies that did not end in a live birth, and 3.2% of the total number of respondents knew someone who had an abortion in the previous 12 months.68 They could not provide a clear account of the kind of services they received for stillbirth, termination of early pregnancies or post-abortion care. As to the reasons for abortion, respondents stated that the partner left the woman or girl, the girl was not ready or was afraid to become a parent, or that the girl was too young.

One male respondent said, “My friend had penetrative vaginal sex at an early age, like 10 years old, and he is now 18. He impregnated one of his girlfriends at the age of 16 years old and they got married. Now they are divorced…”FGD respondent 65 66 67 68

See Appendix A, Tables 27 to 29. Interview with a Health official in Tawi Tawi. NDHS (2017) See Appendix A, Tables 25 and 29.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

Most respondents agreed with the statement that it is acceptable that girls and women choose who and when they marry. Most disagreed with the statement about girls and women marrying before they turn 12, 16 or 18. When the married respondents of the HHS were asked whether their parents or family members arranged their marriage, more than half said no (63.4%). Therewas, however, 28.4% whose marriages were arranged by their parents, and 7.8% that were arranged by their family members.69 Among 5.1% of arranged marriages, parents or family members did not ask for the respondents’ permission. Among those whose permission was asked, 1.5% did not give their consent and were still forced to marry their spouse. Although occurrences of early and forced marriage are acknowledged, the majority of participants stated that they had not experienced any form of GBV (physical, economic or psychological) in the past 12 months. Respondents mostly claimed that they had not been involved in relationships wherein one partner committed intimate partner violence.70 However, in the HHS, six (0.8%) of the male respondents mentioned that they frequently yelled, cursed or insulted their spouse, and another six did not allow their spouse to work or earn a living. These above-reported biases in connection to women’s autonomy or economic opportunities are key considerations for projects aimed to eliminate GBV.71

TABLE 10: SHE HHS - DISTRIBUTION BY THEIR ACTIONS AFTER EXPERIENCING INTIMATE PARTNER VIOLENCE ACTION (*Multiple responses)

BOYS-MEN (n=970)

GIRLS-WOMEN (n=950)

Turn away, run away or shield your body when abused physically

2 (0.2%)

22 (2.3%)

Tell relatives or friends what happened and ask them to intervene

56 (5.8%)

36 (3.8%)

Go to the hospital, health care center or doctor

3 (0.3%)

8 (0.8%)

Go to police or courts

9 (0.9%)

5 (0.5%)

Go to village elders/community leaders

30 (3.1%)

3 (0.3%)

Seek advice from lawyer

1 (0.1%)

10 (1.0%)

Seek help or counselling from religious leaders (e.g. priests, imams)

19 (2.0%)

4 (0.4%)

Go to the person’s employer and ask them to intervene

1 (0.1%)

Go to a women’s shelter or help center

8 (0.8%)

61 (6.4%)

Keep quiet

30 (3.1%)

33 (3.5%)

Don’t know

189 (19.5%) 86 (9.0%)

Prefer not to answer (PNTA) 138 (14.2%) 103 (10.8%) At the time of the HHS, more than 90% of the respondents agreed and strongly agreed that survivors of rape, incest or sexual violence should have access to information and services. These respondents believed that medical and legal information and medical and psychological counselling should be available and accessible to survivors. They also agreed with the statement that laws and policies should protect women’s security against domestic violence. In their view, public servants, barangay officers and medical workers need training to respond to sexual violence cases appropriately.

Participants in the stakeholder workshop noted that a report from the Philippines Commission on Human Rights (CHR), highlights the importance of working on social attitudes as a way to improve access to SRHR 69 See Appendix A, Table 32. SHE HHS Distribution by Arranged Marriage 70 The term “intimate partner violence” describes physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner. 71 NDHS (2017)

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

services. CHR reports that the quality and provision of services at local levels are most often based on the personal views of the local health workers, where the line is drawn based on whether one is pro-life (anticontraception) or pro-choice (pro-contraception). This discretionary application of the law has led to uneven implementation of the RH Bill where pro-life government health workers deny access to services due to their personal beliefs. This underscores the importance of changing mindsets and attitudes in SRHR advocacy.72

7.2.3 COMMUNITY ATTITUDES RELATED TO SRHR The baseline data allows comparing attitudes towards SRHR among different age and gender groups. Oxfam Canada’s SRHR Community Attitudes Index, gives us a snapshot of respondents’ feelings regarding key aspects of SRHR and related issues, and measures three dimensions of women’s autonomy: (1) women’s reproductive autonomy, (2) women’s sexual autonomy, and (3) women’s economic autonomy.

Community attitudes toward reproductive autonomy Table 11 below, illustrates that the proportion of positive attitudes reduces as the statements become more sensitive to social norms. The target population has higher positive attitudes toward having services available and accessible to women and girls (83%), than toward women and girls deciding on whether to have a baby or not (66%), a drop in almost 20 points in positive attitudes. Some 38% of respondents viewed the termination of an unplanned pregnancy positively, and 36% viewed this negatively; the rest of the respondents preferred not to answer or neither agreed nor disagreed with the statement. Respondents generally agreed with all of the statements on access to information and services on family planning. By getting the average of the percent responses, it was discovered that the statement “it is acceptable that counseling on reproductive health is accessible to women” is highest in girls, women and boys. Men, on the other hand, have the highest rating in the statement “it is acceptable that family planning services are accessible to women.” In all categories of respondents, the statement “it is acceptable that family planning services are accessible to girls” had the lowest average.

TABLE 11: ATTITUDES TOWARD WOMEN’S REPRODUCTIVE AUTONOMY Women’s Reproductive Autonomy (Variables and Indicators)

Attitudes

Index value

Positive

Negative

Access to information and services on family planning

83.32%

-5.39%

0.78

Family planning services are available for Women and Girls

83.49%

-5.61%

0.78

Family planning services are accessible for Women and Girls

82.66%

-5.98%

0.77

Counseling on reproductive health is accessible for Women and Girls

83.80%

-4.59%

0.79

Decision on whether and when to practice contraception

76.10%

-8.03%

0.68

Women and Girls using a contraceptive method

76.10%

-7.83%

0.68

Women and Girls choosing a contraceptive method

76.10%

-8.23%

0.68

Decision on whether and when to have children/become pregnant

57.20%

-21.43%

0.36

Women and Girls: Deciding how many children to have

66.73%

-14.28%

0.52

Women and Girls: Deciding when to have a baby

66.58%

-13.18%

0.53

Women and Girls: Deciding to terminate an unplanned pregnancy

38.30%

-36.85%

0.01

72 Stakeholder analysis workshop discussion

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

Community attitudes toward sexual autonomy Women’s sexual autonomy in the project’s focus areas is one of the most sensitive topics. The WHO defines sexual autonomy as women’s ability to resist unwanted sex and the ability to make healthy decisions about sexuality.73 HHS results (below) highlight three indicators to measure this dimension: 1. access to information and services on sexual health to make informed choices; 2. sexual negotiation and communication to maintain healthy sexual relationships; and 3. decisions related to sexual initiation and when to have sex.

TABLE 12: ATTITUDES ON WOMEN’S SEXUAL AUTONOMY Women’s Sexual Autonomy

Attitudes

Variables and Indicators

Positive

Index value

Access to information and services on sexual health

84.54%

-4.28%

0.80

Counselling on sexual health is available to girls and women

83.73%

-4.39%

0.79

Counselling on sexual health is accessible to girls and women

85.36%

-4.16%

0.81

Sexual negotiation and communication

57.43%

-27.21%

0.30

Partner/Husband has a STI/HIV

63.20%

-25.25%

0.38

Partner/Husband does not want to use condom

53.55%

-23.95%

0.30

Partner/Husband has sex with other persons

54.53%

-30.83%

0.24

Woman has just given birth

59.00%

-28.78%

0.30

Woman is tired

55.90%

-26.85%

0.29

Woman is unwell/sick

58.83%

-27.83%

0.31

Woman is not in the mood

54.33%

-26.45%

0.28

Woman is menstruating

60.13%

-27.78%

0.32

Decision on sexual initiation

20.04%

-60.15%

(0.40)

Showing sexual desire

18.16%

-62.64%

(0.44)

Showing sexual interest

18.99%

-60.84%

(0.42)

Initiating sexual relations

18.30%

-62.21%

(0.44)

Enjoying sexual relations

24.71%

-54.91%

(0.30)

(a woman can refuse sex if…)

Attitudes toward women’s sexual autonomy follow the same trends as attitudes towardwomen’s reproductive autonomy. The trend is that positive attitudes reduce as the statement became more sensitive. There is a high proportion of people with positive attitudes toward women and girls having access to sexual health services, but there is a significantly lower proportion of positives attitudes toward sexual negotiation and communication. In addition, the attitudes are quite negative for decisions on sexual initiation. Comparing the two dimensions, there are stronger positive attitudes toward reproductive autonomy than toward sexual autonomy. Most respondents (both genders and all ages), indicated that it was justifiable for a woman to refuse sex given all the mentioned reasons although there was generally a lesser proportion of boys-men than girls73 WHO (2010), Measuring sexual health: conceptual and practical considerations and related indicators, Geneva, p. 15

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

women agreeing with each one. The statement with the highest average was that the “partner/husband has STI/HIV.” On the other hand, the statement with the lowest average is the reason “not in the mood” for girls or women and “partner/husband has sex with other persons other than his wife/wives” for boys or men. Based on the desk review and as anticipated, more girls, women, boys or men agreed with the statements referring to their persona. Respondents mostly agreed with statements about them being able to freely choose whom and when they marry, and that counseling on sexual health should be available to them. More women agreed that a person, regardless of gender, should be able to seek support if they are being forced to marry. Regarding decisions on sexual initiation, more boys and men agreed that it is acceptable for girls and women to show sexual desire or sexual interest, and to initiate or enjoy sexual relations. Girls and women, on the other hand, mostly disagreed with all of the above statements. The index values are the lowest for this dimension of attitudes towards SRHR. The average aggregated positive attitude is 54%. Men and boys present the same tendency: they have slightly higher positive attitudes and slightly lower negative attitudes than women and girls. As with women’s reproductive autonomy, there is a high positive attitude toward the availability and accessibility of information and services. However, there is a significant drop in positive attitudes and a visible increase of negative attitudes toward statements about sexual negotiation and sexual initiation.

Community attitudes toward women’s economic autonomy Most respondents agreed with all the statements related to a woman’s economic activity. Specifically, the average responses of girls, women or boys were highest on the statement regarding access to employment. For men, the statement with the highest average response was on women’s purchases for daily household expenses. In contrast, girls, women, boys or men, gave the lowest average score on making decisions about when a son gets married. Comparing the two previous dimensions to women’s economic autonomy, the first notable element is that there are no strong negative attitudes toward women taking economic initiative, and about 13% of respondents stand in the middle. It seems fine for women to work outside of the home, manage their own bank accounts, make decisions regarding family purchases and decide what to do with their own money. This enables women to increase their economic share of the assets, and ensures access and ability to pay for health services.

7.2.4 CAPACITY OF THE PUBLIC AND PRIVATE HEALTH SYSTEMS TO PROVIDE COMPREHENSIVE AND GENDER-RESPONSIVE SRHR INFORMATION AND SERVICES Challenges at the local level were either undersupply (or in some cases, stockout) or oversupply. In some areas, unused supplies remain untouched and reach expiration dates while at the same time, there are demands for some commodities that are not available or not distributed by the DOH.74 Under the RPRH Law, it is the responsibility of the national government to procure RH products and commodities. However, local government units are not always consulted with regard to the preferred methods of clients in their area. The DOH projects service needs based on the population and most recent surveys (e.g. NDNS, FHS), where sample sizes/number of respondents are based on the most recent census. According to local health officers, this may not reflect actual needs and preferences of clients at the local level. During several FGDs, men seemed unaware of services offered in health centers. Women connected health centers with services for pregnant women and contraceptives. LGBTQI members said they could get HIV/AIDS services from the government. People were aware of the availability of prenatal care in health centers as well as maintenance medicine for hypertension. Hospitals are seen as too expensive. 74 Baseline Stakeholder analysis workshop

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

During a FGD in Jabonga, one female respondent highlighted that when children are sick, the tendency is for the mother to take care of them, as fathers are too busy with work. Women were also more aware of the availability of family planning counseling and supplies such as IUDs in health centers (HS). One female religious leader said she got her IUD from a HS. Condoms and other contraceptives are distributed in these facilities, even to high school students. Youth counseling on use of contraceptives is also available in HS. Men and women participants both were unsure of the availability of services for HIV clients and thought there were no services for GBV survivors. According to one health provider, HS can serve patients with hypertension, chickenpox, diabetes, tuberculosis, ulcers and urinary tract infections. Pills and condoms are available for gay people as the health centers do not discriminate, according to a health worker. However, one respondent, identifying as LGBTQI, made a contrary statement suggesting that HIV patients go straight to the hospital instead of to health centers. In addition, it was evident that sufficient care during pregnancy and delivery is important for the health of both the mother and the baby.75 Antenatal care (ANC) from a skilled provider is important to monitor pregnancy and reduce morbidity and mortality risks for the mother and child during pregnancy, at delivery, and during the postnatal period (42 days after delivery).

7.3 PILLAR TWO: BUILDING KNOWLEDGE AND CAPACITY OF INSTITUTIONS AND ALLIANCES TO INFLUENCE CHANGE 7.3.1 CURRENT CONTEXT OF HEALTH SERVICES PROVISION IN THE PHILIPPINES The literature review points to the fact that, at the local level, there is a separation of jurisdiction, roles and responsibilities between the Provincial Department of Health Office (PDHO),76 including its regional and provincial offices, and the LGU in the provision of SRHR services.77 Hierarchically, the PDHO is accountable to the DOH (as a part of the central government), for health policy development, while the LGU is charged with the development of its own health policy initiatives and is responsible for setting an agenda. In other words, at the policy level, the government expects that health challenges can be tackledby the combined efforts of health workers, health agencies and local government officials. However, given resource constraints, the local government finds the mandate difficult to fulfil.78 Previously, a centralized national health system,79 became many independent local health systems in accordance with the more recent Local Government Code. In spite of that, the DOH still remains the institutional authority to provide coherence and direction of the nationâ&#x20AC;&#x2122;s health system. The DOH-LGU separation of jurisdiction, roles and responsibilities could be utilized to the advantage of the SHE Project. These advantages are summarized below: 1. (Policy Review) Close monitoring and evaluation of specific SRHR programs and activities can be conducted. 2. ( Governance and Leadership) Specific resources can be easily identified and sourced out for project management. 3. ( Fiscal Accountability) Human Resources are clearly designated, including specific roles and responsibilities assigned to implement programs and activities with fiscal transparency. 4. ( Socio-Political) Political influences might have less effect on the implementation and progress of SRHR activities and programs. 75 FDG respondents 76 The Provincial Department of Health Office, which is accountable to the DOH, should not be mistaken for the Provincial Health Office which is under the Provincial Local Government Unit. The Rural Health Units are under the Municipal/City Local Government Unit. 77 KII sessions with IPHO, MHOs, PHNs and LGU Mayors held on 29 November 2018. 78 Teresa Montemayor (2018), Philippines News Agency. Improvement of health systems also LGUs role: DOH http://www.pna.gov.ph/ articles/1046023 79 Before the Local Government Code of 1991

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT â&#x20AC;&#x201C; BASELINE STUDY 2019

Potential disadvantages of the DOH-LGU separation of jurisdiction, roles and responsibilities are as follows: • ( Policy Review Development) Separate SRHR-related policies would entail a separate health agenda that would produce several policy evaluation tools that can be detrimental to the demand side of the policy (e.g., clients, including women and girls, among others). Convoluted monitoring and evaluation tools will prosper if the separation of SRHR programs and activities continues. • ( Governance and Leadership) Non-coordination of similar SRHR-related health policy directives, programs and activities will result in mismanagement in terms of resources, delays in implementation and poor evaluation and monitoring schemes. • (Socio-Political) Due to the division of SRHR programs and activities between DOH-LGUs, the influence of partners’ health agendas (e.g. NGOs, international donors) may run supreme and forcefully influence policy directions despite cultural norms and practices. • (Socio-Political) Separate implementation of SRHR activities at the barangay level will yield fatigue among the target clients. • (Policy Review) Convoluted monitoring and evaluation tools will prosper if separation of SRHR programs and activities continues.80 • ( Public Good/ Accountability) There is no accountability mechanism in place if the separation of SRHR activities continues through the duration of the SHE Project. Because of the potential disadvantages described above, which point to the inefficient set-up or existing dichotomy among jurisdictions and mandates, policy initiatives and developments have proven to be ineffective, as they mainly exist on paper. During FGDs, participants identified a number of challenges to implementing SRHR services at the local barangay level: 1. There are no barangay health stations nor an adequate infrastructure for FPM, VAWG, Nutrition, and Adolescent Sexual and Reproductive Health programs and services. Village residents need to go to the town centres to obtain such services, which can take almost a full day’s travel time. In addition, there are no safe spaces for VAWG survivors. 2. Human Resources for SRHR are very limited. There is a frequent turnover of public nurses, doctors, medical technologists and social workers at the barangay and municipal levels. Therefore, constant training is needed. 3. Budget allocation for new programs is limited, especially at the municipal level. Priority is given to programs that have been regularly-fixed in their annual funding allocation. 4. Budget priorities are given to MCH and FP, but not enough or none for VAWG, Nutrition, RH/STI and men’s involvement in SRH. The majority of gender funds are being used for FPM services and commodities. 5. The job of social workers, barangay health workers and population officers involves certain risks e.g. case detection for VAWG. It is difficult for these workers to follow-up on some of the cases because of the community’s attitudes. Thus, some of the cases drop off the radar of relevant officers. 6. The lack of interagency cooperation and unclear pathways for referral systems are persistent problems in fully implementing SRHR elements.

80 According to IPHO Director, Dr. Laja, per interview on 29 November 2018; Provincial DOH has not been following and using the DOH LGU Scorecard since 2016. They are presently developing their own scorecard.

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

7.3.2 REVIEW OF KEY LEGISLATION AND POLICIES RELATED TO SRHR IN THE PHILIPPINES The backbone legislation that supports SRHR, representing one of the biggest achievements of the women’s movement in the Philippines, is the Responsible Parenthood and Reproductive Health Act (RPRH) of 2012. However, seven years after its approval, it has not been fully implemented at all levels of the Philippine HS. The RPRH Law (as it is commonly known) states that by establishing the fact that “the state recognizes and guarantees the promotion of gender equality, gender equity, women’s empowerment and dignity as a health and human rights concern and as a social responsibility. The advancement and protection of women’s human rights shall be central to the efforts of the State to address reproductive health care”. The enactment of the RPRH Law is considered by many to be a milestone victory of WROs and CSOs promoting SRHR in the country, especially amidst a strong opposition waged by the Catholic Church in a country where 90% of the population is Catholic. It took more than 10 years of sensitization for the law to be passed, suggesting that a sustained and protracted advocacy for SRHR is a norm rather than an exception. The Catholic Church was perceived to be politically influential and powerful. Thus, legislators and senior public officials were initially reluctant to support the bill for fear that going against religious authorities would make them lose public support. The Catholic Church waged a campaign using the pulpits during mass, disseminating statements that labeled the bill as pro-abortion.81 It is expected that the Catholic Church as an institution will continue to engage in the debate and advocacy against the implementation of the RPRH Law. In order to advocate effectively for the change in norms and culture, using the RH Law as an institutional backing, there must be a strong and unified network of agencies that has thecapacity and commitment of WROs to sustain advocacy in SRHR and GBV prevention amidst an equally committed opposition.

Magna Carta of Women (Republic Act No. 9710): The legal precedent of the RPRH Law is the Magna Carta of Women (Republic Act No. 9710). It was approved in 2009 and spells out women’s rights for the context of the Philippines. The MCW establishes that the Philippine government is committed to the Convention on the Elimination of All Forms of Discrimination against Women’s (CEDAW) Committee.82 The MCW defines the role of the state as follows: “The Philippines Government shall be the primary duty-bearer in implementing the said law. This means that all government offices, including local government units and government-owned and controlled corporations shall be responsible to implement the provisions of the Magna Carta of Women that falls within their mandate, particularly those that guarantee rights of women that require specific action from the State. As the primary duty-bearer, the Government is tasked to: • refrain from discriminating against women and violating their rights; • protect women against discrimination and from violation of their rights by private corporations, entities, and individuals; • promote and fulfill the rights of women in all spheres, including their rights to substantive equality and non-discrimination.”83 In spite of this legal framework, the Philippines falls short in fulfilling its responsibilities. The illegality of abortion embedded in the Constitution,84 the illegality of divorce, one of the world’s lowest ages of sexual consent, set at 12 years old, and forced marriage, are direct violations of women’s rights. 81 CBCP news http://www.cbcpnews.com/cbcpnews/?p=1151 82 According to the decisions and recommendations of the 36th Session that took place in 2006 following by the UN Human Rights Council on its first Universal Periodic Review in 2009. 83 Philippines Statistics Authority. https://psa.gov.ph/content/q-magna-carta-women-republic-act-no-9710 84 Going back to the colonial times

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

Anti-Violence Against Women and their Children Act of 2004: Another key piece of legislation, the

Anti-Violence Against Women and their Children Act of 2004 (RA 9262), is a government initiative addressing violence against women and children, and penalizing all forms of abuse and violence. In virtue of the law, an interagency council was created involving 11 agencies, to ensure the effective implementation of the law (very similar to the NIT of the RPRH Law). Sec. 50 and 61 of rules and regulations of the VAWG law highlights specific duties and responsibilities of the following Council Members (CM): Commission on Human Rights (CHR), Civil Service Commission (CSC), Council for the Welfare of Children (CWC), DepEd, Department of Interior and Local Government (DILG), Department of Health (DOH), Department of Justice (DOJ), Department of Labor and Employment (DOLE), Department of Social Welfare and Development (DSWD), Philippine Commission on Women (PCW), National Bureau of Investigation (NBI) and the Philippine National Police (PNP). These national government agencies are tasked to work hand-in-hand to promote the law, formulate programs and projects to eliminate VAWG, develop capability programs for stakeholders, monitor all initiatives for the implementation of the law and conduct research related to VAWG. The issues in connection to the enforcement of the above law are similar to those of the RPRH Law and include mainly budget issues and the lack of accountability. As the HHS revealed, residents are unsure about a specific location for SRHR services. Moreover, in-depth interviews (I Stories) point to the fact that, in cases of GBV, girls fear being exposed to the judicial system and fear their abuser upon their return home. In addition to the Anti-Violence Against Women Law, (AVAWL) the Magna Carta of Women mandates the establishment of Violence Against Women Desks in every village throughout the country. At the time of the study, about 80% of villages have established these. The Women’s Empowerment, Development and Gender Equality Plan (2013–16) identified a number of areas where the government addresses gender inequality and deficits in women’s rights, including economic empowerment, social development, justice, peace and security, environment and climate change, and gender responsive governance. “CEDAW Working Group in the Philippines said that the State was unable to address gender equality more so with intersectional discrimination. Women faced violence to the point of death, women victims were arrested and treated as criminals, and the reproductive health needs of lesbian, bisexual and transgender women were neglected. Women with disability continued to be among the most discriminated against because they were poor and lived mainly in rural areas.”85 As indicated in the literature review section, the data in the Philippines in limited in showcasing the inability of the government to provide access to SRHS. Thus, this Baseline study aims to set an initial foundation for the targeted data collection that could help to advance SRHS.

7.3.3 ONGOING DEBATE IN RELATION TO ABORTION IN THE PHILIPPINES Prevention and Management of Abortion and its Complications (PMAC): The RPRH Law also

stipulates that the country should ensure that women have access to humane, non judgmental and quality post-abortion care, even when abortion is illegal. In 2000, the DOH released a policy to pilot a post-abortion program in selected DOH facilities. However, despite the recommendation to scale up the program, the implementation phase suffered due to lack of funding, lack of political support and persistent negative attitudes toward women who have undergone abortions.86 Abortion stigma was reinforced by institutions, including the Philippine Obstetrical and Gynecological Society (POGS). POGS’ 2011 Ethical Guidelines described abortion as illegal and immoral. The Guidelines failed to explain the exception to the criminal prohibition, making the statement of total illegality factually incorrect.87 In 2016, the DOH introduced the National Policy on the Prevention and Management of Abortion Complications. The policy clearly stated that no women and girls should be denied appropriate care and access to information about it if they are suspected to have induced abortion.88 This policy was replaced by a much 85 UN-OHCHR https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=20238&LangID=E 86 Philippine new postabortion care policy https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/ijgo.12530 87 ]Ibid 88 Ibid

SEXUAL HEALTH AND EMPOWERMENT (SHE) PROJECT – BASELINE STUDY 2019

less extensive policy in 2018 (to which WROs did not contribute). While WROs were involved in the formulation of the 2016 policy, they were left out of the process in 2018; this illustrates the challenging landscape in which WROs operate in the Philippines89) The contextualization of the International Law into the Philippine context contributes to a challenging environment for the SHE advocacy. Section 2, Article II of the Philippines’ 1987 Constitution stipulates that the country “adopts the generally accepted principles of international law as part of the law of the land…” As a rule, international laws become part of the laws of the Philippines. However, there are instances when this process is not fully followed. One of the best examples is the Philippines accepted definition of the SRHR. The Philippine Reproductive Health Act90 does make use of the international definition, but it excludes both abortion and access to abortifacients because these are deemed illegal (as defined under the Revised Penal Code).91 Tireless efforts of CSOs and WROs over the past years had strengthened the RPRH Law with the establishment of the enabling legal framework. It provides more pathways to address issues in connection to the SRHR and GBV prevention in the Philippines. This legal framework seeks to provide accessible reproductive health care and recognizes the right of an individual to make decisions concerning “responsible parenthood.”92 In Section 3 of the Guiding Principles for Implementation, the RH Law defines RH care as the “access to a full range of methods, facilities, services and supplies that contribute to reproductive health and well-being by addressing reproductive health-related problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations.”93 It also specifies the elements of RH care, which are the following: • Family planning information and services, which shall include as a first priority, making women of reproductive age aware of their menstrual cycles and fertile periods; • Prioritizing maternal, infant and child health and nutrition, including breastfeeding; • Prescription of medication for the management of abortion complications and post-abortion care; • Adolescent and youth reproductive health guidance and counseling; • Prevention, treatment and management of reproductive tract infections, HIV/AIDS, and other STIs; • Elimination of violence against women and children and other forms of sexual and gender-based violence; • Education and counseling on sexuality and RH; • Treatment of breast and reproductive tract cancers and other gynecological conditions and disorders; • Male responsibility and involvement and men’s reproductive health; • Prevention, treatment and management of infertility and sexual dysfunction; • RH education for adolescents and; • Mental health aspects of RH care. The RH law reinforces the country’s current abortion ban as outlined in the Constitution. However, it reiterates the right of women to access post-abortion care and be treated in a “humane, non-judgmental, and compassionate manner”.94 The law highlights the illegality of possible “abortifacients,” but leaves room for the Food and Drug Administration (FDA) to determine which contraceptives can be considered “abortifacient.”95 89 Upreti, Melissa, and Jacob, Jihand. The Philippines Rolls Back Advancements in Poost Abortion Care Policy. International Journal of Gynecology and Obstetrics. Abastract. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3252764 90 Republic Act 10354 91 The Philippines Penal Code. Articles 256, 258 and 259, Act No. 3815 92 RPRH Law 93 RPRH Law 94 Department of Health, Philippines, “An Act providing for a National Policy on Responsible Parenthood and Reproductive Health”, https://www.doh.gov.ph/sites/default/files/policies_and_laws/ra_10354.pdf. 95 RPRH Law

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There are still gaps in policy and practice that are highlighted as follows: 1. Fragmented and isolated demand generation activities for SRHR services; 2. Mismatch between the supply and demand for SRHR services; 3. The lack of a comprehensive communications plan for the RPRH Law; 4. Challenges documenting incidence of pregnancy in the 10-14 age group, as well as the generation, consolidation and recording of this data; 5. Challenges with regard to information and education on RH, including the implementation of comprehensive sexuality education, inclusion of out-of-school youth as recipients/beneficiaries, and ensuring that the peer education modules throughout the country are of the same standard and use a gender lens; and 6. Challenges in addressing concerns regarding adolescent reproductive health, as minors do not have complete access to RH products and services, and those at the 15-19 age group have the largest unmet need for contraception.

7.3.4 BARRIERS TO IMPLEMENTATION OF RELEVANT POLICIES One of the key challenges is the lack of oversight by Congress and the government of the implementation and enforcement of the RH Law and its translation into policy and action. In 2015, the Department of Health created the National Implementation Team (NIT). This is a multisectoral and interagency body involving 15 agencies with the mandate to monitor the implementation of the RPRH Law. Representatives from the following agencies participate in the NIT: 1) Office of the Secretary, DOH; 2) DOH Central Office; 3) POPCOM; 4) FDA; 5) Disease Prevention and Control Bureau, DOH; 6) National Economic and Development Agency (NEDA); 7) Department of Education (DepEd); 8) DSWD; 9) DILG 10) Philippine Health Insurance Corporation; 11) National AntiPoverty Commission; 12) Philippine Commission on Women; 13) National Council on Disability Affairs; 14) Union of Local Authorities of the Philippines; as well as 15) members of Civil Society Organizations and individuals invited by the Secretary of Health. It remains a worthy point of access or “accountability” engagement for CSOs and development partners for the advancement of SRHR in the country, since a multiplicity of individual and agency-based perspectives and strategies abound within the NIT. At the national level, the Philippines has a set of laws in place that provides a good platform for advancing SRHR. However, as already noted above, these laws are not fully implemented, and their efficient enforcement has been questioned by lobby groups. For instance, the Federal Government approved one of the policies on January 9, 2017, with Executive Order (EO) No. 12, to “Attaining and Sustaining ‘Zero Unmet Need for Modern Family Planning (FP)’” through the strict implementation of the RPRH Law.96 However, these decisions on paper are insufficient. The Philippines government needed to reaffirm its commitment through the implementation of the RPRH Law, Health Agenda and the signed international commitments under CEDAW and the SDGs. For instance, “Articles 5 and 12” of the CEDAW Review of 2015 inform that “the Committee considers that article 5, read together with articles 12 and 16, requires States parties to eliminate gender stereotypes that impede equality in the health sector and in marriage and family relations. In paragraph 28 of its general recommendation No. 24, the Committee recognizes the link between article 5 (b) and article 12, in that it requires States parties to ensure that family education includes a proper understanding of maternity as a social function. The Committee is of the view that gender stereotypes may affect women’s capacity to make free and informed decisions and choices about their health care, sexuality and reproduction and, in turn, also affect their autonomy to determine their own roles in society.

96 Department of Health Philippines (2017), Progress report on EO12 implementation. Zero Unmet need policy.

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“… the Committee finds that the implementation of Executive Orders Nos. 003 and 030 with regard to the delivery of reproductive health services and commodities in Manila reinforced gender stereotypes prejudicial to women, given that they incorporated and conveyed stereotyped images of women’s primary role as child bearers and child rearers, thereby perpetuating discriminatory stereotypes already prevalent in Filipino society. Such stereotypes further contributed to the belief that it was acceptable to deny women access to modern methods of contraception because of their natural role as mothers. They had the effect of impairing the enjoyment by women of their rights under article 12 of the Convention. The Committee concludes that the State party has violated its obligations under article 5 of the Convention.“97 In addition, the existing national policies on SRHR (see appendix B) reinforce the principles of the laws of providing primary health care and universal health care. The responsibilities in providing health human resources and facilities are mostly lodged under the DOH and the LGUs. Service delivery largely depends on the implementation of the smaller agencies and the localization of the policies from the DOH in the local government sector.

Present Islamic Fatwa (comments from Tawi Tawi) Islamic leaders in Mindanao, including Muslim Religious Leaders and legal experts, endorsed a new Fatwa, or formal legal opinion, clarifying issues of EFM in the context of Islam. The Fatwa on the Model Family in Islam urges Muslim youth to “get married when necessary conditions are met”, but clarifies that the urgency is not applicable to the pre-puberty or childhood stage. Although the generally accepted marrying ages for Muslims are 20 years old for males and 18 years old for females, the Fatwa says that “Islam does not precisely fix any marriageable age” and in instances where the bride is under 18, the couple can practise contraception to delay her pregnancy. Religious leaders know that a comprehensive health and gender education for the youth can provide adequate guidance on how Muslim boys and girls should responsibly approach sexuality, adolescent reproductive health and gender equality. To this end, the Fatwa also reaffirmed women’s sublime status in Islam and affirmed, “gender-based violence and other forms of abuses against women are absolutely against the principle of the Shari’ah.” Pills and implants for women are allowed as a FPM but females and male sterilization are not allowed because they are irreversible. One RHU policy will not permit a woman or girl to alone seek or avail the services of FPM if the partner does not agree; the RHU will check first that both partners agree before they provide any service.

7.3.5 CIVIL SOCIETY INVOLVEMENT IN SRHR-RELATED ADVOCACY AND INFLUENCING The SRHR issues do not seem to garner as much adverse attention from the current administration compared to human rights repression and governance/corruption issues. The President himself has declared support for the implementation of the RH Bill and has even ordered the full implementation of the RH Law.98 Moreover, the President has been extremely vocal in his resistance to the Catholic Church’s anti-RH methods and its anti-abortion statements.99 97 CEDAW/C/OP.8/PHL/1 , paras. 42-43,paras. 49-52. https://undocs.org/CEDAW/C/OP.8/PHL/1 98 2016 State of the Nation Address, President Rodrigo Duterte 99 Aljazeera (2019), https://www.aljazeera.com/news/2019/01/philippines-duterte-launches-tirade-catholic-church-190111062513610.html

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On the other hand, the President’s controversial sexist remarks100 and offensive actions against women public servants such as the Vice President Robredo and Department of Justice Leila de Lima currently incarcerated,101 contributes to the prevalence of norms and attitudes that tolerate GBV and dilutes the primacy of women’ rights issues. While the opportunities for SRHR advocacy remain open and the issue itself seems less problematic, the restrictive reform environment, with overt State attacks against human rights defenders, including women, will likely create difficulties for WROs’ advocacy more broadly. The space for advocacy in SRHR for WROs remains open, especially at the local level where grassroots NGOs and POs remain relatively influential. WROs are currently engaged in the following advocacy issues: • Budget allocation for RH education and incorporating it in the elementary and high school curriculum • Increased budget for contraceptives • Ending discretionary provision of services at the local level • Promoting teenage access to services without parental consent • Changing mindsets on child and forced marriages in indigenous peoples and Muslim communities Lastly, there is another challenging factor in connection with the level of capability and resources currently afforded to WROs. WROs are currently undermined in the public opinion and under-resourced, which significantly weakens their prospects to engage more effectively in the advocacy, especially with respect to the RH Bill. Moreover, it is observed that international donors and funders have now turned their attention to other development priorities. In the same vein, local governments have shifted their partnership focus from advocacy toward service delivery, an area where WROs’ capabilities are still emerging. Against this backdrop, WROs were in the front and center of advocacy activities in pushing for the RH Law:102 • CSOs, including WROs, helped established the broad and multi-stakeholder coalition composed of member-organizations who brought in different sets of expertise – lobbying, education and campaign, grassroots organizing, etc. – that were all instrumental to waging a prolonged campaign. For example, PLCPD utilized its expertise in legislative advocacy while Likhaan and DSWP offered its grassroots and campaign capabilities. • WROs collected stories of women and girls from communities and elevated them to the policy discussions thereby drawing the extent of unmet SRH needs to the attention of legislators and government policy makers. This also disputed the opposition stance that the problem was not as significant as made out to be. • WROs with nationwide and grassroots reach helped drum up public support for the bill. They used all available resources to undertake a massive education and information campaign that took on various forms – house-to-house, community dialogues, SRHR education. It involved clarifying the misconceptions around the Bill and helping individuals understand the merits of the law to their lives. Likhaan even provided capacity-building for community women to engage in the RH policy debate. Seeking widespread support was important because it was believed that the 90% nominal Catholics were all in support of the Catholic Church’s position.

100 The Guardian (2019), https://www.theguardian.com/world/2019/mar/12/rodrigo-duterte-calls-women-at-gender-equality-eventbitches-philippines 101 Aljazeera (2017), https://www.aljazeera.com/news/2017/02/leila-de-lima-arrested-philippines-170224003808389.html 102 Philippines Legislators’ Committee on Population and Development (2015), Kagampan: A compendium of reflections on the struggle for the RH law in the Philippines

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• WROs, especially in academia, helped draw international and national studies103 that provided the scientific arguments countering the main premise from the opposition that artificial contraception was abortifacient. • Influential champions from the WRO community directly engaged with the Legislators and senior government officials and provided them with technical support. • WROs, who were experienced in legislative lobbying, helped think through the tactics and campaign strategies especially as opposition legislators mounted delaying tactics. WROs became adaptive to opportunities and challenges.104 To date, some WROs such as Likhaan are members of the RPRH Law National Implementation Team established by the DOH. These efforts demonstrate the influencing tradition of the WROs, and their potential to further opportunities to advocate better local regulations or even proposed amendments to the law for improved implementation on the ground. Some WROs who are engaged in advocacy for access to safe abortion and de-stigmatised post-abortion care include EnGendeRights, Catholics for Reproductive Health, Women’s Global Network for Reproductive Rights, and the Center for Reproductive Rights. International agencies such as UN Women have been notably less visible although the CEDAW Committee has released a report requesting the Philippine Government to reconsider its stance on abortion.105 In his 2017 State of the Nation Address, President Duterte declared support for family planning but firmly not for abortion. Given the President’s low tolerance for criticism, a visible campaign for abortion may be vulnerable to political reprisal. In this context, the SHE project considers advocacy around safe abortion and post-abortion care – even if acceptable by international standards – as beset with political and reputational risks, and should be handled delicately.

103 Sylvie Estrada-Claudio (2015),Voices and choices in reproductive rights: Scholarship and activism,ANU Press 104 Ateneo School of Government (2016), Advancing reproductive health rights, Case Study Summary, GovernmentWatch 105 CEDAW/C/OP.8/PHL/1 , paras. 49-52. These recommendations from the CEDAW Committee’s 2015 inquiry were reiterated in its 2016 Concluding Observations of the Philippines, CEDAW/C/PHL/CO/7-8

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8. RECOMMENDATIONS The following recommendations are based on the overall research; they are organized to follow the project’s ToC. Recommendations related to the Pillar One (Outcome 1100): 1. This baseline provides an evidence that teen pregnancy is a primary concern. It is recommended that the project redefines its target age/sex groups to add the 10 to 14 age group and develop outreach and information strategies to cover their needs. A specific needs assessment should also be undertaken on information and access to SRHR services for ages 10 to 19. 2. Addressing VAWG is also a priority; particularly emotional, physical and sexual violence might be under reported in the national statistics. It is recommended that the project provides accurate information about the rights of and services available to survivors of violence. 3. Given the lack of resources and the constraints of local government units to address both teen pregnancy and VAWG, it is recommended that the project add a “follow up” component to the referral mechanism already planned. The project might explore using the the Field Health Service Information System (FHSIS) to identify the number of cases reported. 4. Baseline data shows that most women did not wish to get pregnant in their most recent pregnancy. It is recommended that the project highlight women’s reproductive and sexual autonomy in its influencing strategies. 5. A clear empowerment framework for girls and women needs to be drafted to guide the influencing strategies to change attitudes of the target population and health service providers. Recommendations related to Pillar Two (Outcome 1200): 6. Given the lack of information and research on SRHR issues, it is recommended that topics such as identifying the impact on women and girls of abortion and post-abortion care, rape, and VAWG should be a priority for the learning and knowledge generation the project is funding. Further research on behaviour modelling is needed, specifically identifying reference groups for girls such as peers, family members and religious leaders. 7. The national reports on the state of international agreements like the CEDAW and the Millenium Goals provide an opportunity for the project to leverage its national influencing strategies. Project partners could produce shadow reports on those indicators relevant for international reporting. 8. The baseline study found an existing dichotomy among jurisdictions and mandates, policy initiatives and developments among national agencies and local governments. It is recommended that WRO/CSO design and establish social accountability strategies and mechanisms, from the local level up to the national level, to ensure the implementation of laws and policies and that SRHR services reach those who need them. At the local level, interagency actions should be promoted to reinforce local WROs’ agendas to eliminatr VAWG, and prevent GBV. 9. It is recommended that project partners actively consolidate, support and tap the existing networks in advocacy, as they are a storehouse of lessons and strategies. As evidenced by the stakeholder analysis, it may be that the existence of a strong informal network of advocates and champions on SRHR, antiGBV, and gender equality, is what sustains the advocacy in times of backlash when there appear to be elements that threaten to derail or impede the progress made on these issues.

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REFERENCES Amin, A. (2015). “Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women living with HIV,” Journal of the International AIDS Society, 18(6Suppl 5). (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672401/). Anderson, R., Panchaud, C., Remez, L. & Singh, S. (2014). Measuring Adolescent Women’s Sexual and Reproductive Health Within A Rights-Based Framework: Developing and Applying an Index New York: Guttmatcher Institute, p. 36. Castro, L.V. (2014). “Measuring Women’s Empowerment and Women’s Autonomy in the Philippines”. United National Statistics. https://unstats.un.org/UNSD/gender/Mexico_Nov2014/HighLevelPanel%20 Philippines%20paper.pdf Crossman, A. (2018). “How to Construct an Index for Research,” ThoughtCo. ThoughtCo.com/index-for-research-3026543. David, C.C., Albert, J.R.G. & Vizmanos, J.F.V. (2017) “Sustainable Development Goal 5: How does the Philippines Fare on Gender Equality? Philippine Institute for Development Studies”, Discussion Paper Series No. 2017-45. Demographic Research and Development Foundation. (2014) “Young Adult Fertility and Sexuality Survey”, https://www.drdf.org.ph/yafs4/key_findings. Department of Health. “Philippine Health Agenda Framework”, A.O. No. 2016-0038. https://www.doh.gov.ph/philippine_health_agenda. Dhaher, E. (2008). “Reproductive Health Human Rights: Women’s Knowledge, Attitude and, Practices toward Reproductive Health Rights in Palestine”. Doctoral Thesis, University of Bielefeld, Germany. p. 259. Likhaan Center for Women’s Health. (2014). “Country profile on universal access to sexual and reproductive health: Philippines”. https://arrow.org.my/wp-content/uploads/2015/04/Country-Profile-SRH-Philippines.pdf. Lobusta Mikaela S.; Molod, Charisse L.; Santos, Arantxa Stefi L.. (2014). r.a. 9262: anti-violence against women and children law: an assessment Philippine Statistics Authority. (2017). Philippines National Demographic and Health Survey 2017. PSA, Quezon City, Philippines. UNAIDS. (2018). “UNAIDS Data 2018”. http://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf. Upadhyay, U.D., Dworkin, S.L., Weitz, T.A. & Greenfoster, D. (2014). Development and Validation of a Reproductive Autonomy Scale, Studies in Family Planning, 45(1), 19-41.

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