The sexual and reproductive health of migrants and mobile populations: Pandemic challenges in the Philippines
Unpaid care work continues during crises and emergencies. On Friday, 13 March 2020, thousands of people gathered at bus stations all across Metro Manila in a bid to return to their respective provinces, following the government’s announcement that a strict ‘community quarantine’ would be imposed. Women’s rights organisations, service providers, and support groups urged the government to ensure ‘continued and unhampered delivery’ of life-saving and essential sexual and reproductive health services during the lockdowns and beyond. Photo by Larry Monserate Piojo (@larrymonseratepiojo; https://larrymonseratepiojo.com/), reproduced with permission.
In the Philippines, national and local border closures, mobility restrictions, and the threat of harsh penalties for breaking state-imposed COVID-19 protocols are creating additional access barriers to critical health and social services, including sexual and reproductive health (SRH) services. In particular, there is currently no policy in place that specifically addresses the unmet SRH needs of migrants and mobile populations during the pandemic. Sexual and reproductive health and rights are influenced by unjust allocations of power and resources that can diminish a person’s ability to ‘have a satisfying and safe sex life and… have the capability to reproduce and the freedom to decide if, when and how often to do so’.
In 2022, as COVID-19 cases surge once more due to the Omicron variant, the Philippines’ fragmented and overburdened health system will have to cope with the additional and overwhelming health and social needs of locals and returning overseas Filipino migrants. Women, adolescents, and persons with diverse sexual orientations and gender identities/expressions are particularly at risk as COVID-19 mobility restrictions or community quarantines continue to limit access to SRH services or information needed to report gender-based violence.
The shortage of health workers disrupts health services, especially in rural areas. This hampers, for instance, pregnant and recently pregnant people’s access to facilities offering antenatal check-ups and delivery. Additionally, during the early stages of the pandemic, the Philippine Obstetrical and Gynecological Society and the Philippine Society for Gynecologic Endoscopy issued a statement supporting the suspension of elective gynecologic surgeries unless deemed urgent, because of the shortage of personal protective equipment and limited testing capacity to screen patients.
The World Health Organization reported global disruptions in HIV, hepatitis and sexually transmitted infections (STIs) services during the first few months of the pandemic. The Philippines was among the 16 countries with increased service disruptions related to STIs, including drug and testing kit shortages. Currently, granular data on STIs and migration in the Philippines are limited or not publicly accessible.
While not all migrants are at an increased risk of HIV as a result of their mobility, increased access barriers to HIV screening, testing, and treatments during the pandemic pose additional risks to those who require care. Compared to pre-pandemic levels, HIV testing decreased by 61% in 2020 due to travel restrictions and physical distancing. As of August 2021, 875 confirmed HIV-positive persons reported to the HIV/AIDS & ART Registry of the Philippines, 6% of whom worked overseas within the past five years. This emphasises the need to revisit and evaluate the Philippine HIV and AIDS Policy Act to determine how to make it more responsive to the needs of migrants and mobile populations in the context of protracted pandemics and emergencies.
The lockdowns in the Philippines and the resulting loss of jobs forced millions of urban workers to return to their home provinces to survive. The consequences of this ‘reverse migration’ on reproductive health were not thoroughly considered. In the early stages of the pandemic, the delivery of contraceptives alongside other essential goods like food, water, and hygiene kits was not prioritised.
The government institutionalised the ‘Balik Probinsya, Bagong Pag-asa’ (Return to the Province, New Hopes) programme to ‘decongest Manila’ by incentivising informal settlers to return to their home provinces. However, there is little to no evidence to suggest that this programme is an effective or even appropriate response to the precarious social conditions of people living in poverty. Furthermore, without additional safety nets and support, healthcare responsibilities are transferred to local health centres, especially in geographically isolated and disadvantaged areas, which are even less equipped to handle sudden migration flows and the resulting complex health needs.
Overseas Filipino workers (OFWs) are among those impacted by the pandemic. The Philippines had a drastic decrease of 75% in OFW deployment, whilst nearly 800,000 of the already deployed OFWs returned to the Philippines by the end of 2020 due to work dismissals and non-renewal of contracts. Approximately 81% of the OFWs who returned could not find new formal employment, and women were forced to take on even more unpaid care work, including childcare, laundry, and cooking. These figures highlight the need to develop gender-responsive protocols during public health emergencies and other disasters. We hope that the proposed Gender Responsive and Inclusive Pandemic Management Act will be enacted into law soon. Civil society groups, service providers, and women’s rights organisations have supported this measure and provided additional evidence of unmet SRH needs owing to the compounded impacts of disasters and armed conflict in the country.
Mobility restrictions, including new protocols that prohibit unvaccinated people from using public transportation, inadvertently limit health-seeking behaviour and prevent people from travelling to receive the care they need. These incoherent policies and regulations are detrimental to SRH rights, most especially for women and girls living in poverty.
Promising prospects, room for reforms
There are, however, some potentially promising law and policy reforms. While birth rates are still high when compared to regional neighbours, there was a notable decline in the number of births in the Philippines in 2020, contrary to previous government projections. The Commission on Population and Development (PopCom) attributes this decline to the ‘combined impacts of fewer marriages, women delaying pregnancies during the pandemic, and the increase in women using modern family planning methods’. Additionally, a new policy requiring government agencies and development partners to address the rising number of adolescent pregnancies as a ‘national priority’ will introduce new ways of coordinating and scaling up interventions to address health inequities.
In December 2021, the prohibition on child marriage was signed into law. It requires the Department of Health to ensure access to SRH and mental health services to prevent child marriage, the drivers of which include poverty and gender stereotypes, as well as protracted displacement due to disasters and violent conflict. Notably, the law expressly requires government agencies to ‘guarantee’ the ‘full and active participation’ of women, girls, and youth organisations at every stage of consultations and implementation, which necessarily includes routine service provision and advice to address SRH care needs.
Addressing the scarcity of evidence
Our search of the literature from March 2020 to January 2022, which included peer-reviewed journals and grey literature such as news articles and working papers, reveals an obvious scarcity of articles discussing the intersections of migration, SRH rights, and the COVID-19 pandemic. It is therefore critical to investigate these issues further to build a robust evidence base for inclusive, appropriate, and gender-responsive health and social policies that will protect migrant health and rights throughout their life course, taking the current pandemic and future emergencies into account. There remains an urgent need to holistically engage with migration health, both domestically and internationally, and work with affected communities to support progress towards global health and development targets for sexual and reproductive health and rights.
Acknowledgements: This essay forms part of a broader multi-country research project, supported by Migration Health South Asia (MiHSA). The authors would like to extend our sincerest gratitude to Salma Angkaya-Kuhutan of Holdwater, Inc., Prof John Coggon, Maheswari Muragaiya, and Dr Aye Thida for their valuable technical feedback during the writing process.
Patricia Miranda is a licensed attorney in the Philippines, migrant, and campaigner working on the intersections of gender equality and human rights in healthcare regulations. She is currently an LLM Health, Law, and Society student at the University of Bristol, funded through Wellcome’s Humanities and Social Science Master’s Programme Award in conjunction with the University of Bristol Law School. Find her on Twitter @pa3ciamiranda.
Fatima Angkaya is a medical doctor in the Philippines and Saudi Arabia, and has spent over 10 years in medical research at King Saud University in Saudi Arabia. Her experience with patients is in clinical research and healthcare settings, working as a clinician in the Philippines, a researcher in Saudi Arabia, and in an assisting role in Australia. Currently, she is a nursing student at the University of New England Sydney. Contact her on LinkedIn.