A Discussion with Marilen Dañguilan, Country Director of Population Services Pilipinas, Inc
January 18, 2019
Background: Dr. Dañguilan has played central roles in the complex negotiations around women’s rights and especially health in the Philippines. On January 18 she met in Washington D.C. with Cameron Pulley (WFDD). The context was research on religious dimensions of development in the Philippines, and its focus on gender and health issues. In the discussion she highlights the deep inequities in health care as her driving motivation. Her focus on policy arose from her frustrations as a medical doctor witnessing the impact of poverty on health care. She speaks of the impact of these inequities on women and the fallacy of arguments that problems arise from culture. Rather they result from health workers’ attitudes toward women, especially poor women, and lack of functioning health systems. She highlights persisting gender inequalities in the Philippines that belie positive statistics on gender equity. Dr. Dañguilan shifted her focus from medical practice to changing policies and systems, both through action and as a writer. She explores the influence of one major religious institution in the Philippines, the Catholic Church hierarchy, especially on debates about reproductive health. She distinguishes sharply the institutional roles from the beliefs of adherents.
How did you come to do the work you now do?
I'm a medical doctor. I practiced for three or four years but grew tired of my work as a general physician, where patients come to you, you treat them, and then send them back to the environment that brought them to you in the first place.
The factors that led them to the hospital?
You prescribe, you give them a medicine, and then they go back to the very same conditions that caused their illnesses, for example, upper respiratory tract infection or diarrhea. If you change that, maybe you can do something else. Furthermore, poor people were not able to come to see me, even if I charged almost nothing. It's an individual effort. Maybe some doctors were satisfied doing that and were helping poor people, but they were doing so very, very few at the time.
I decided right then and there: "This is no good." What's the point of that? I decided to change things and especially focus on the living conditions of the poor. My goal was to engage in policy making.
Cory Aquino [Corazon Aquino] had just become the president of the country. Congress opened in 1987, so these were exciting times. I wrote to Senator Edgardo Angara, because he, significantly, chose to be the Chairman of the Committee on Health. He was the president of the University of the Philippines before he joined the Senate. I told him that I was a medical doctor and wanted to engage in policy making. He understood right away and asked why I was interested in the Committee on Health. I said, "Because of inequities. So many poor people can't access quality healthcare. There has to be quality healthcare.” At the time people would leave their tricycles or their land titles with private hospitals after treatment because they couldn't afford to pay. That's the kind of thing that drives me nuts.
How did your experiences growing up in the Philippines affect you? How did that lead to you become a medical doctor, and then ultimately see the much bigger structural issues?
I come from a family of doctors. My father was a doctor. My cousins were doctors, my brothers now are doctors, and so I also studied medicine, though before that I studied business. My father was a medical doctor, a general practitioner. He practiced in the province after graduating in Manila from the University of Philippines General Hospital. He went back home to the province, and he was, I think, the only practitioner there in 1947. He did not charge people that much and served many who were poor. He was working so hard and he would say, "Service is the only thing that matters." I asked, “How could we eat?” I was just a kid, asking questions like this. We had vegetables, we had eggs, we had chickens, all from the patients, but I didn't know where the cash was coming from.
What inspired you specifically to become interested in reproductive health and women's health?
When I was doing my general practice, I saw that women were dying. Just like that. They had five, seven, eight kids. They could hardly sustain themselves, even physically. Nobody among them had heard of family planning, of contraceptives. The Catholic Church hierarchy at the time was quiet about this; there was not much controversy. After medical school, I studied it more: what are the causes of maternal deaths in the Philippines? It has largely to do with the health system – the ability to of health facilities to provide emergency obstetric care to women.
I also studied the problem from the gender perspective: Why don't women go to the health centers and get access to contraceptives that were available? Why don’t they go to hospitals? Poor women don't go because the midwives in the health centers talk down at them—not even to them. Women who go to hospitals are humiliated, demeaned. Staff in hospitals, from what I gathered during focus group discussions with women in some cities and towns, get mad at the women who come in without their records. The women said they were in gurneys on the corridors. Staff would perform internal examinations on them in rooms that offered no privacy. They described their experiences with hospitals as unpleasant and at times, horrific.
In moral terms?
Yes, they get insulted for even asking for a service. When I talked to the Department of Health (that was before the post post-Marcos administration decentralization), they would say, “that’s just the way things are,” or “it’s a cultural thing." I don't believe in that excuse. No, it's not cultural, it's just laziness. It's just attitudes. It's just the way they look at women. And when I talked with the Department of Health in most recent times, during the decentralization, they said that the health facilities are the responsibility of the local government units, i.e., the governor or mayor or barangay captain.
Are women being talked down to on religious terms?
Yes, exactly. That happens up to the present day. I feel it and hear it talked about. The thing that they don't realize is that access to quality contraceptives and quality care is a matter of life and death. Apart from that, even if a woman lives, it's a matter of enjoying one's life as a human being. Think about the opportunities lost to them. They can't go to school, they can't work. They have eight kids. If the opportunity were open to these women to only have a kid or two kids, they could have achieved more—much, much more. I've met and talked to so many of them.
All three of your major book projects emphasize and investigate roles of religious actors, particularly the Catholic Church, in health governance. Why is religion so central to the health narrative in the Philippines?
I didn't plan to write those books that way when I was in London, where I took my masters at the London School of Economics, focused on social policy, health financing, and health planning, When I had to write a thesis, I remembered my women clients. That inspired my first book, Making Choices in Good Faith. It won an award, the Philippine National Book Award in1993.
My second book, in 1997, was born out of my experience after I was thrown out of the delegation to the International Conference on Population and Development (ICPD) in Cairo in1994. I was a delegate to the third preparatory committee in New York in 1994.
The conference was critical because it shifted the focus of contraceptives, family planning, and reproductive health. It refocused population “control” to reproductive health. So instead of the few talking just population control, the whole thing shifted to women's empowerment. The thought behind it was that if a woman was empowered she could have access to quality healthcare and she would be able to determine when, where, and how many kids she would have; the size of the family; who she wants to marry; who she wants to live with; etc. Women's rights are central to this. It’s no longer population control from countries who have to control the people or fertility because of poverty. That's why the ICPD Program of Action was radical at the time—because it really based everything on women's rights, particularly reproductive rights.
Yet the Philippines, according to macro-level indicators, is the most gender equal nation in Asia and the 10th most in the world...
But what does gender equal mean? Is it just a matter of numbers?
These were macro-level indicators built upon access to jobs, gender pay equality, etc. Do you feel that strategies at that time were successful in allowing or making sure that women had access to those rights and thus better able to make their own choices about reproductive health?
Theoretically yes. It may be said that we're a gender equal nation, but when governments—both national and local—do not allocate sufficient funds to establish and support health facilities that provide emergency obstetric care; when governments do not provide the funds necessary for women to access contraceptives, then governments don’t give priority to women’s reproductive health. How could this country be “gender equal?” The Philippines has a relatively high maternal mortality ratio compared to other countries in Southeast Asia. Bangladesh is performing better than the Philippines.
So you're saying that the same barriers are still in place?
Oh man, they are there. Sometimes you see them and sometimes you don’t.
I was recently offered a post by one of the board of trustees in a semi-private group. The chairman of the board, a man, came to me saying, "Marilen, I heard that you were offered this post." I said, "Yes, I'm considering it.” He said, "We're all old, we're all senior citizens:" Raw ageism? I told him, "If I were male, you wouldn't even have dared to say that.” The chairman of the board of this group was dissuading me from applying for this post because of my age. Sexism and ageism go together.
And people don't want to talk about it though the barriers still exist.
No, they do talk about it. They're very open about it
Can we discuss the Reproductive Health Bill story? Your book provides a deep insight into the heated divides of competing moralities in the Philippines. What was the crux of the debate?
I called them sticking points. In my book there were six. The first was the perception that the RH bill, if passed to law, would open the gate to legislate on making abortion available to women.
Number two, contraceptives are “abortifacients.” That was the argument of the opposition. Because they prevent the fertilized egg from implanting in the uterus, then contraceptives cause abortions. They cited this as unconstitutional, because Section 12, Article 2 of our Constitution states that the State should equally protect the life of the mother and the unborn from conception.
Number three, that contraceptives are hazardous to women's health and to men's health.
Number four, that the RH Bill is actually a product of international agencies like USAID, the World Bank, WHO, and UNFPA.
You mean that it was pushed by foreign influence?
Yes, and that it was even approved by these groups. They referred to the “foreign influence” several times, suggesting that it was even justified and promoted by the Kissinger Report of 1974 [National Security Study Memorandum 200; “Implications of Worldwide Population Growth for U.S. Security and Overseas Interests”] that was recently declassified. That memo mentioned that there were 13 countries that were overpopulated, and that the US should think about what such huge populations would do to domestic resources and the implications of this on migration. One of the countries mentioned in this memo was the Philippines. While perspectives have changed since then, opposition to the RH Bill claimed that it was still the same: population control. That was their main issue.
Number five is that the RH bill will bring about a “demographic winter” due to de-population. And this, the opposition claimed, would lead to a “decline of nations”.
And number six is that the Philippines will not have as many people and people are our nation's biggest asset. We send them off as overseas contract workers and they remit to us billions of dollars, keeping our economy afloat.
Who were the competing groups on the ground? And where did religious groups stand?
Let's talk about the lower house, because that's where the major battles were heard. There were congresswomen and congressmen, some of whom were members of the Bishops Legislative Caucus of the Philippines, which was composed of the Catholic bishops—and key members of Congress, who really wanted the Catholic Church hierarchy on their side. So you don't know how far it goes, whether it's really the personal religious convictions of the congressmen and women or whether it’s a matter of political decisions.
That poses larger constitutional questions. The separation of church and state is clearly established in the Philippine constitution, but religious advocacy, particularly for the Catholic Church, is embedded in the actual structures of governance.
My book addresses that in three to four chapters. During Cory Aquino's time, when the drafting of the constitution happened, she had to get a whole range of actors to come in to draft the 1987 Constitution. She owed the Catholic Church a seat at the drafting table, because they had catapulted her to power during the EDSA Revolution [People Power Revolution/the Philippine Revolution of 1986]. It was the Catholic Church hierarchy who called for that revolution, when millions of people came to the streets, protested, and demanded the ousting of Marcos.
In a sense therefore, the Catholic Church and faith institutions more generally occupy a fairly uncommon place in the system of governance in the Philippines.
Yes. In the drafting of the 1987 Constitution the most influential of the commissioners belonged to Opus Dei. You should speak to Bernardo Villegas, an economist. He gave the sponsorship speech on defining human life as beginning at conception. There was a big debate on that and it was ultimately supported, notably by the Catholic priests who were members of the 1986 Constitutional Commission. Their powerful advocacy is why the 1987 Constitution is not secular. To my mind, there is no division of church and state in the Philippines. The 1987 Constitution has a provision that enshrines Catholic teaching and this provision calls for the State to defend the right of couples to found a family in accordance with religious beliefs and “the demands of responsible parenthood.” “Responsible Parenthood” came from Humanae vitae, the 1968 encyclical written by Pope Paul VI subtitled On the Regulation of Birth, which affirmed orthodox Catholic teaching on married love, responsible parenthood, and the rejection of artificial conception.
But the Philippines is a very religiously diverse country; it's not only the Catholic Church.
Reading the transcripts of the commissioners during the constitutional drafting, it was appalling how they treated and looked at women and the way they treated the constitution and God. They institutionalized “Responsible Parenthood.” Later, one of our presidents, Gloria Macapagal Arroyo, made “Responsible Parenthood” her mission, meaning not to give birth when you're too poor to handle the costs of childcare but being open to bringing children to the world. The biggest compromise in the RH Bill was those two words, “Responsible Parenthood.”
That represented the compromise between secular and religious dynamics in the Philippines?
When these national level bills become law, how does it actually affect health governance and access to health services for Filipinos in their everyday lives at the local level?
The local government code mandates the local government units at the provincial, municipal, city, and barangay levels to provide health services to their constituents. Those health services are enumerated in the local government code and they are mandated to provide them. What happens at the local government level is a very fascinating topic for me. I have been following local governments and talking with local officials and staff. Local governments feel they are autonomous and can act without the direction of the national government. The local governments have their own budgets. But still, to a certain extent, they're dependent on the national budget. So, in that way, the center of governance is still at the national level, which can exert some control over local government units.
The local government units are responsible for setting their own priorities and, in most cases in the last ten years, reproductive health or healthcare in general was simply not their priority. Firstly, they didn't know how to approach the issues. Secondly, they thought building a hospital was enough—without thinking about the importance of systems that underlie it. Thirdly, budget, technical, and skilled staff were limited. That’s why health has not been a priority. Many local governments prioritize the building of farm to market roads, irrigation canals, in general.
To give you a specific example, the governor of Occidental Mindoro told me in 2012, "Health is not my priority. My priority is to be the garlic capital of the country.” Another local leader I talked with said, "It’s not my priority because we don't know how to do that. Besides, the private sector can fill in the gaps." The private sector provides at least 60 percent, even 65 percent of healthcare. But there’s more to it than that.
How does that play into the deep economic divides in the Philippines? If the only health clinic in your area is private and you are in deep poverty, healthcare may simply be unaffordable.
Exactly. That’s why we have our social health insurance system, PhilHealth, that helps augment health care expenditures. Out-of-pocket health expenditures are still high – in 2017, about 55 percent of health expenditures were household out-of-pocket payments. Government schemes and compulsory contributory health care financing schemes account for about 33 percent in 2017. There’s another point though: private facilities charge premium prices for quality health care. But that’s just the point: quality health care should not be only for those who can pay but also for those who are poor, who are unable to pay. And there are hospitals in the country that have shown that providing quality health care to the poor could be done.
Can we discuss implementation of the RH Law under the Duterte administration? Why did the administration feel they needed to issue the 2017 executive order, mandating that all women have access to family planning methods by the end of the year?
Duterte’s doubling-down on this is only because for so long—far too long—contraceptives provided by the government sector have not really been systematically available down to the local government units. When Gloria Macapagal Arroyo was in office for nine years, three terms, she did not push for artificial contraceptives or what we call the modern methods of contraception. Rather, she pushed for “natural,” Catholic Church approved contraception, which may not be consistently effective.
How did the Catholic Church influence implementation?
Their power and influence were strongest not in implementation, but in the policy itself.
Remember that Gloria Macapagal Arroyo actively courted the Catholic Church hierarchy. She even put a special office directly under her to monitor the two religions that she thought were the most critical to her administration, the Catholic Church and Iglesia Ni Cristo. That office’s purpose was openly to cater to the needs of the priests and adherents of Iglesia Ni Cristo.
She gave the churches food and other forms of support for their social outreach services: whatever they needed. She courted the Church and Iglesia Ni Cristo because she needed their support and she got it. And the Catholic Church hierarchy showed their support by not joining the cause for impeachment against her in 2005.
Are you referring to the Hello Garci scandal?
Yes, that was the first impeachment case brought against her. The Catholic Church hierarchy played a role in stopping it from going to trial, because they were political allies. She gave them a great deal, not only in terms of resources, but in terms of favorable policies, through the Department of Health. For the first time ever, in the early 2000s, there was a natural family planning directive from the Department of Health and a presidential announcement that she would not push for modern methods of artificial contraception. She said she would leave artificial methods to local government units to decide.
And these policies were in a sense endorsed by the Catholic Church?
Of course. They hated artificial contraception. The Catholic Church hierarchy publicly congratulated her for her actions.
Why do you think that the Iglesia Ni Cristo was the second group that President Arroyo targeted, although they represent only about two percent of the population?
Because it's powerful and they vote as a block. And I think it is more than two percent. Whatever the numbers, they're politically powerful, beyond the influence of their constituency alone. They come in millions to vote as a block. Let’s say a politician is barely ahead leading. If your margin is only like a million, it’s easily offset if you've got the Iglesia Ni Cristo block.
Even though Iglesia Ni Cristo has a relatively smaller population of adherents than for example, Islam, it has a strong political lobby.
In general though, politicians in the Philippines see Iglesia Ni Cristo, an unambiguously religious group, as a contingent of the electorate that they must actively court. But they don't think of other religious groups in the exact same manner. There is no such thing as the Catholic vote, that we know. But there is such a thing as an Iglesia Ni Cristo block vote.
I’ve heard many stories from people who are Iglesia Ni Cristo members. They say they have very strong social networks, which provide educational benefits, health benefits, and livelihoods to their members. Moreover, Iglesia Ni Cristo members form entire communities of just Iglesia Ni Cristo members. That's why I simply cannot believe they are just two percent of the total population.
Did the Iglesia ni Cristo take a strong stand on the RH Bill?
Yes, they were in favor of it. As far as I know, all presidential candidates except for Cory Aquino have made a point to seek the endorsement of the Iglesia Ni Cristo head.
Do any other religious groups have similarly consequential political influence? Not Aglipayan?
No, not by a long shot. Politically, Aglipayan is like a whimper compared to Iglesia Ni Cristo. Between the “Catholic vote” and “Iglesia vote,” I'd go for the Iglesia vote any time. There's no such thing as a Catholic vote: it's too fragmented.
Is there also no such thing as, for example, a Muslim, Protestant, Evangelical, or Baptist vote?
Not even El Shaddai (a large charismatic Catholic movement in the Philippines) operates as a religious voting bloc. Voting behavior among adherents was monitored, but it was discovered that El Shaddai members would go for anyone who pleases them as individuals. I don't know exactly how the Iglesia Ni Cristo is able to enforce voting behavior among its adherents. A close contact of mine, an Iglesia Ni Cristo member, told me “It's really in our culture.” I responded, "But nobody will know who you voted for." She replied, "I just cannot vote against the Iglesia Ni Cristo voting recommendations." She told me that she was told, and that all members were told, to vote for Duterte and Marcos. I said, "But you can vote for who you believe in. If you believe in Mar Roxas why don't you vote for him? Nobody will see you inside the voting booth." She said, "I don't know but I have a feeling they will always know and you know what punishment I could get out of that." Do you know? I don’t—it’s interesting.
Final question. WFDD’s report will likely serve as an introduction point for most people to the expansive literature on religion and development in the Philippines. What do they really need to think about?
They need to think not particularly about the religions themselves, but the institutions. Inside the Catholic Church, for example, there is faith and there are institutions. And the institutions can be very strong. This may even be considered something apart from, for example, Iglesia Ni Cristo’s faith. In the Catholic Church, there is hierarchy; priests and the bishops may often act as a part of the institution. But Catholic religious beliefs are something else.
So, we should retain that understanding of the divide between faith and institutional religion across all faith communities. For example, it's the religious institution within the Catholic faith that holds the proactive power.
Yes, it's the institution. It’s the fact that they have institutionalized themselves into the fundamental structures of Filipino governance. They are seen as a strong force. They have a long history of influencing policy making, at least since Spanish colonial times, about 500 years ago.