quantitative research about medicine in the philippines

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• Published: 05 March 2020

Quantitative ethnopharmacological documentation and molecular confirmation of medicinal plants used by the Manobo tribe of Agusan del Sur, Philippines

• Mark Lloyd G. Dapar 1 , 3 ,
• Grecebio Jonathan D. Alejandro 1 , 2 , 3 ,
• Ulrich Meve 3 &
• Sigrid Liede-Schumann 3  

Journal of Ethnobiology and Ethnomedicine volume  16 , Article number:  14 ( 2020 ) Cite this article

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The Philippines is renowned as one of the species-rich countries and culturally megadiverse in ethnicity around the globe. However, ethnopharmacological studies in the Philippines are still limited especially in the most numerous ethnic tribal populations in the southern part of the archipelago. This present study aims to document the traditional practices, medicinal plant use, and knowledge; to determine the relative importance, consensus, and the extent of all medicinal plants used; and to integrate molecular confirmation of uncertain species used by the Agusan Manobo in Mindanao, Philippines.

Quantitative ethnopharmacological data were obtained using semi-structured interviews, group discussions, field observations, and guided field walks with a total of 335 key informants comprising of tribal chieftains, traditional healers, community elders, and Manobo members of the community with their medicinal plant knowledge. The use-report (UR), use categories (UC), use value (UV), cultural importance value (CIV), and use diversity (UD) were quantified and correlated. Other indices using fidelity level (FL), informant consensus factors (ICF), and Jaccard’s similarity index (JI) were also calculated. The key informants’ medicinal plant use knowledge and practices were statistically analyzed using descriptive and inferential statistics.

This study enumerated the ethnopharmacological use of 122 medicinal plant species, distributed among 108 genera and belonging to 51 families classified in 16 use categories. Integrative molecular approach confirmed 24 species with confusing species identity using multiple universal markers (ITS, mat K, psb A- trn H, and trn L-F). There was strong agreement among the key informants regarding ethnopharmacological uses of plants, with ICF values ranging from 0.97 to 0.99, with the highest number of species (88) being used for the treatment of abnormal signs and symptoms (ASS). Seven species were reported with maximum fidelity level (100%) in seven use categories. The correlations of the five variables (UR, UC, UV, CIV, and UD) were significant ( r s ≥ 0.69, p < 0.001), some being stronger than others. The degree of similarity of the three studied localities had JI ranged from 0.38 to 0.42, indicating species likeness among the tribal communities. Statistically, the medicinal plant knowledge among respondents was significantly different ( p < 0.001) when grouped according to education, gender, social position, occupation, civil status, and age but not ( p = 0.379) when grouped according to location. This study recorded the first quantitative ethnopharmacological documentation coupled with molecular confirmation of medicinal plants in Mindanao, Philippines, of which one medicinal plant species has never been studied pharmacologically to date.

Documenting such traditional knowledge of medicinal plants and practices is highly essential for future management and conservation strategies of these plant genetic resources. This ethnopharmacological study will serve as a future reference not only for more systematic ethnopharmacological documentation but also for further pharmacological studies and drug discovery to improve public healthcare worldwide.

Introduction

The application of traditional medicine has gained renewed attention for the use of traditional, complementary, and alternative medicine (TCAM) in the developing and industrialized countries [ 1 , 2 ]. Conventional drugs these days may serve as effective medicines and therapeutics, but some rural communities still prefer natural remedies to treat selected health-related problems and conditions. Medicinal plants have long been used since the prehistoric period [ 3 ], but the exact time when the use of plant-based drugs has begun is still uncertain [ 4 ]. The WHO has accounted about 60% of the world’s population relying on traditional medicine and 80% of the population in developing countries depend almost entirely on traditional medical practices, in particular, herbal remedies, for their primary health care [ 5 ]. Estimates for the numbers of plant species used medicinally worldwide include 35,000–70,000 [ 6 ] with 7000 in South Asia [ 7 ] comprising ca. 6500 in Southeast Asia [ 8 , 9 ]. In the Philippines, more than 1500 medicinal plants used by traditional healers have been documented [ 10 ], and 120 plants have been scientifically validated for safety and efficacy [ 11 ]. Of all documented Philippine medicinal plants, the top list of medicinal plants used for TCAM has been enumerated by [ 12 ]. Most of these Philippine medicinal plants have been evaluated to scientifically validate folkloric claims like the recent studies of [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ].

Because of the increasing demand for drug discovery and development of medicinal plants, the application of a quantitative approach in ethnobotany [ 21 ] and ethnopharmacology [ 22 ] has been rising continuously in the last few decades including multivariate analysis [ 23 ]. However, few studies of quantitative ethnobotanical research were conducted despite the rich plant biodiversity and cultural diversity in the Philippines. In particular, the Ivatan community in Batan Island of Luzon [ 24 ] and the Ati Negrito community in Guimaras Island of Visayas [ 21 ] have been documented, while Mindanao has remained less studied. Despite the richness of indigenous knowledge in the Philippines, few ethnobotanical studies have been conducted and published [ 25 ].

The Philippines is culturally megadiverse in diversity and ethnicity among indigenous peoples (IPs) embracing more than a hundred divergent ethnolinguistic groups [ 26 , 27 ] with known specific identity, language, socio-political systems, and practices [ 28 ]. Of these IPs, 61% are mainly inhabiting Mindanao, followed by Luzon with 33%, and some groups in Visayas (6%) [ 29 ]. One of these local people and minorities is the indigenous group of Manobo , inhabiting several areas only in Mindanao. They are acknowledged to be the largest Philippine ethnic group occupying a wide area of distribution than other indigenous communities like the Bagobo, Higaonon, and Atta [ 30 ]. The Manobo (“river people”) was the term named after the “Mansuba” which means river people [ 19 ], coined from the “man” (people) and the “suba” (river) [ 31 ]. Among the provinces dwelled by the Manobo , the province of Agusan del Sur is mostly inhabited by this ethnic group known as the Agusan Manobo . The origin of Agusan Manobo is still uncertain and immemorial; however, they are known to have Butuano, Malay, Indonesian, and Chinese origin occupying mountain ranges and hinterlands in the province of Agusan del Sur [ 32 ].

Manobo indigenous peoples are clustered accordingly, occupying areas with varying dialects and some aspects of culture due to geographical separation. Their historic lifestyle and everyday livelihood are rural agriculture and primarily depend on their rice harvest, root crops, and vegetables for consumption [ 33 ]. Some Agusan Manobo are widely dispersed in highland communities above mountain drainage systems, indicating a suitable area for their indigenous medicinal plants in the province [ 34 ]. Every city or municipality is governed with a tribal chieftain known as the “Datu” (male) or “Bae” (female) with his or her respective tribal healer “Babaylan” and the tribal leaders “Datu” of each barangay (village) leading their community. Their tribe has passed several challenges over the years but has still maintained to conserve and protect their ancestral domain to continually sustain their cultural traditions, practices, and values up to this present generation. This culture implies that there is rich medicinal plant knowledge in the traditional practices of Agusan Manobo , but their indigenous knowledge has not been systematically documented. Furthermore, there are no comprehensive ethnobotanical studies of medicinal plants used among the Manobo tribe in the Philippines to date.

Documenting the ethnomedicinal plant use and knowledge, and molecular confirmation of species using integrative molecular approach will help in understanding the true identity of medicinal plants in the treatment of health-related problems of the people of Agusan del Sur. This will also help the entire Agusan Manobo community to implement conservation priorities of their indigenous plant species. Furthermore, the provincial government of Agusan del Sur may enforce the proper utilization of their plant resources from IPs. Ideas and knowledge about ethnomedicinal use and practices of medicinal plants give credence to the traditional methods and preparation of herbal medicine by ethnic groups.

Despite the limited funds and qualified personnel in the region, it is very relevant to recognize the role of ethnopharmacology and species identification in the conservation of these plant genetic resources with medicinal properties. With the introduction of the application of molecular barcodes for species identification by [ 35 ], the problem of unauthenticated medicinal species can now be resolved [ 19 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ].

Significantly, researchers have recently developed the application of ethnopharmacological study into a quantitative approach with measuring values and indices to quantify the relationship between plant species and humans [ 44 , 45 , 46 , 47 , 48 ].

This study, therefore, aims to (1) conduct quantitative ethnopharmacological documentation of traditional therapy, (2) evaluate the medicinal plant use and knowledge, and (3) utilize integrative molecular approach for species confirmation of medicinal plants used by the Manobo tribe in Agusan del Sur, Philippines.

Materials and methods

Fieldwork was conducted in the province of Agusan del Sur, Philippines (8° 30′ N 125° 50′ E), bordered from the north by Agusan del Norte, to the south by Davao del Norte, and from the west by Misamis Oriental and Bukidnon, to the east by Surigao del Sur. Agusan del Sur is bounded with mountain ranges from the eastern and western sides forming an elongated basin or valley in the center longitudinal section of the land. The province is subdivided into 13 municipalities (from the largest to smallest land area): La Paz, Esperanza, Loreto, San Luis, Talacogon, Sibagat, Prosperidad, Bunawan, Trento, Veruela, Rosario, San Francisco, and Sta. Josefa; and the only component city, the City of Bayugan (Fig. 1 ). Forestland comprises almost two thirds (74%) of the province of Agusan del Sur, while alienable and disposable (A&D) areas constitute around one-third (26%) of the total land area [ 49 ]. Every city or municipality has a respective community hospital and health center with limited doctors and rural health workers. Typically, local people only visit the hospitals or health centers for surgical and obstetric emergencies. Most residents rely on their medicinal plants for disease treatment and medication due to cost and poor access to healthcare services. This study purposively covered areas of selected city and municipalities (Bayugan, Esperanza, and Sibagat) for accessibility, availability, and security reasons to barangays (villages) with Certification of Ancestral Domain Title (CADT) as endorsed by the National Commission on Indigenous Peoples—CARAGA Administrative Region (NCIP-CARAGA).

Study sites (barangays) from the only city (Bayugan), and the two selected municipalities (Esperanza and Sibagat) in the province of Agusan del Sur

Sampling and interview

Fieldwork was undertaken from March 2018 to May 2019. It consisted of obtaining free prior informed consents, observing rituals, acquiring resolutions, certifications, and permits, conducting semi-structured interviews, focus group discussions, plant and field observations, and medicinal plant collections in selected barangays (villages) of Bayugan, Sibagat, and Esperanza (Fig. 1 ). This study was initiated in coordination with the local government unit (LGU), NCIP-LGU, and Provincial Environment and Natural Resources Office (PENRO) of Agusan del Sur. Consultation meetings and discussions were carried out together with the concerned parties (tribal leaders, tribal healers, and NCIP officers) to discuss research intent as purely academic and to acquire mutual agreement and respect to conduct this study. As approved, the research intent was certified through resolution and certification duly signed by the tribal council of elders following the by-laws of NCIP for the welfare and protection of indigenous peoples, and finally certified by NCIP-CARAGA.

Ethnopharmacological data were collected through semi-structured interviews with Manobo key informants through purposive and snowball sampling who were certified Agusan Manobo . A sampling of these key informants was coordinated with the provincial and local government administration together with the assistance of the tribal leaders and NCIP focal persons in every city or municipality to each of the barangays in selecting those who have knowledge of their medicinal plants and practices. The respective barangay tribal leaders assisted interviews among respondents with no appointments made prior to the visits. The semi-structured questionnaire used was modified and adapted from the Traditional Knowledge Digital Library (TKDL) template, as suggested by the Department of Health—Philippine Institute of Traditional and Alternative Health Care (DOH-PITAHC) (see Additional file 1 ). The Ethics Review Committee of the Graduate School, University of Santo Tomas (USTGS-ERC), approved the study and the questionnaire used with a valid translation to Manobo dialect ( Minanubu ) with the help of a community member and NCIP officer. It has series of questions about the common health problems encountered by the respondents; the actions undertaken to address such problems; the medicinal plants they used (local or vernacular name); the plant’s part(s) used, forms, modes, quantity or dosage, and frequency of administration; the source or transfer of knowledge; and the experienced adverse or side effects. Interviews were accompanied by nurses and allied workers as coordinated by the rural health center to verify reported diseases accurately by the informants.

Meetings and focus group discussions were also performed to review the accuracy of acquired data among the respondents with the help of guided questions among the tribal council of elders comprising the NCIP-recognized indigenous peoples mandatory representatives (IPMRs), the tribal chieftains, the tribal healers, and the respective tribal leaders of every barangay tribal communities together with the NCIP officer.

Plant collection and identification

The collection of plant specimens was conducted through guided field walks with the aid of the traditional healers, expert plant gatherers, and members within the tribal community. The plant habit, habitat, morphological characteristics, vernacular names, and some indigenous terms of their uses were documented. Leaf samples were placed in zip-locked bags containing silica gel for molecular analysis [ 50 ] in preparation for further molecular confirmation. Voucher specimens were deposited in the University of Santo Tomas Herbarium (USTH). Putative plant identification using vernacular names was compared to the reference of local names, Dictionary of Philippines Plant Names by [ 51 ]. Plant identification was assisted by Mr. Danilo Tandang, a botanist and researcher at the National Museum of the Philippines. Specimens unidentifiable by morphology were selected for molecular confirmation. All scientific names were verified and checked for spelling and synonyms and family classification using The Plant List [ 52 ], World Flora Online [ 53 ], The International Plant Names Index [ 54 ], and Tropicos [ 55 ]. The occurrence, distribution, and species identification were further verified using the updated Co’s Digital Flora of the Philippines [ 56 ].

DNA extraction, amplification, and sequencing

Collected plant specimens with insufficient material for identification due to lack of reproductive parts and unfamiliarity were subjected to molecular confirmation. The total genomic DNA was extracted from the silica gel-dried leaf tissues of samples following the protocols of DNeasy Plant Minikit (Qiagen, Germany). The ITS (nrDNA), mat K, trn H- psb A, and trn L-F (cpDNA) markers were used for this study. Primer information and PCR conditions used for amplification using Biometra T-personal cycler (Germany) can be found in Table 1 for future parameter reference. PCR amplicons were checked on a 1% TBE agarose to inspect for the presence and integrity of DNA. Amplified products were sent to Eurofins Genomics (Germany) for DNA sequencing reactions. Sequences were then assembled and edited using Codon Code Aligner v4.1.1. All sequences were then evaluated and compared using BLAST n search query available in the GenBank ( www.ncbi.nlm.nih.gov ). The BLAST n method estimates the reliability of species identification as a sequence similarity search program to determine the sequence of interest [ 62 ] regardless of the age, plant part, or environmental factors of the sample [ 63 ].

Quantitative ethnopharmacological analysis

The use-report (UR) is counted as the number of times a medicinal plant is being used in a particular purpose in each of the categories [ 21 , 24 ]. Only one use-report was counted for every time a plant was cited as being used in a specific disease or purpose and even multiple disease or purpose under the same category [ 64 ]. Multiple use-reports were counted when at least two interviewees cited the same plant for the same disease or purpose. The use value (UV) developed by [ 45 ] is used to indicate species that are considered highly important by the given population using the following formula: UV = (ΣUi)/ N , where Ui is the number of UR or citations per species and N is the total number of informants [ 47 , 48 ]. High UV implies high plant use-reports relative to its importance to the community and vice versa. However, it does not determine whether the use of the plant is for single or multiple purposes [ 21 , 24 ]. The relative importance of the plants was also determined by calculating the cultural importance value (CIV) by using the formula: CIV = Σ[(ΣUR)/ N ], where UR is the number of use-reports in use category and N is the number of informants reporting the plant [ 48 ]. The use diversity (UD) of each medicinal plant used was determined using the Shannon index of uses as calculated with the R package vegan [ 65 ].

The ICF introduced by [ 66 ] was used to analyze the degree of informants’ agreement based on their medicinal plant knowledge in each of the categories [ 21 , 24 ]. This is computed using the formula: ICF = (Nur − Nt)/(Nur − 1), where Nur is the number of UR in each category, and Nt is the number of species used for a particular category by all informants. Fidelity level (FL) developed by [ 67 ] is calculated using the formula: FL (%) = (Ip/Iu) × 100, where Ip is the number of informants who independently suggested a given species for a particular disease, and Iu is the total number of informants who mentioned the plant for any use or purpose regardless of category. The maximum value (1.00) means a high degree of informant agreement showing the effectiveness of medicinal plants in each ailment category [ 68 ]. However, a minimum value (0.00) implies no information exchange among the informants [ 69 ]. Jaccard’s similarity index (JI) by [ 70 ] was calculated to evaluate the similarity of medicinal plant species among the three studied areas. The formula of JI is represented as follows: J = C /( A + B ), where A is the number of species found in habitat a, B is the number of species found in habitat b, and C is the number of common species found in habitats a and b. The number species present in either of the habitats is given by A + B (Jaccard).

Statistical tools

The plant URs were computed and analyzed using IBM SPSS Statistics software v.23 [ 71 ]. Descriptive and non-parametric inferential statistics Mann-Whitney U and Kruskal-Wallis tests were employed to test for significant differences at 0.01 level of significance. These two statistical analyses measure and compare the medicinal plant use and knowledge of informants when grouped according to location, education, gender, social position, occupation, civil status, and age. The basic values and indices (UR, UC, UV, CIV, UD) were correlated using the Spearman correlation coefficient to compare variables that are not distributed normally.

Integrative molecular confirmation

Selected plant samples unidentifiable by morphology were subjected to an integrative molecular identification approach as previously recommended by [ 42 ] for accurate species identification of plant samples. Selected plant samples were compared with the available morphological characteristics, interview data on vernacular names and traditional knowledge, determining scientific names based on reference of local names using the Dictionary of Philippines Plant Names by [ 51 ], and utilizing multiple molecular markers, ITS (nrDNA), mat K, trn H- psb A, and trn L-F (cpDNA) for sequencing and BLAST matching. Two sequence similarity-based methods using BLAST [ 72 ] were applied for molecular confirmation. BLAST similarity-based identification was adapted from the study of [ 42 ] with a slight modification. This identification involved using the simple method taking the top hits and optimized approach. All successfully sequenced samples were sequentially queried using megablast [ 72 ] online at NCBI nucleotide BLAST against the nucleotide database. For the simple method, all top hits within a 5-point deviation down of the max score were considered. If the max score (− 5 points) showed only a single species, then a species level identification was assigned. On the other hand, if the max score (− 5 points) showed several species but similar genus, then a genus level identification was assigned. However, if the max score (− 5 points) showed multiple species in several genera of the same family, then a family level identification was assigned. In addition, within a 5-point deviation down of the max score, the highest max score and the highest percent identity were also determined. From the top 5 hits down of the max score, an optimized method using the formula, [max score (query cover/identity)], was calculated.

The integrative molecular confirmation combined the simple and optimized BLAST-based sequence matching results with reference of local names, and comparative morphology. As a result, all species identity and generic and familial affinity were further confirmed from the recorded occurrence and distribution of putative species in the study area based on the updated Co's Digital Flora of the Philippines [ 56 ].

Demography of Informants

A total of 335 Agusan Manobo key informants (more than 10% of the total Manobo population of selected barangays) including traditional healers, leaders, council, and members were interviewed comprised with 106 female and 229 male individuals in an age range from 18–87 years old (median age of 42 years). We considered key informants those who are certified Agusan Manobo and knowledgeable with their medicinal plant uses and practices, may it be tribal officials, elders, and members of the community. Demographics by location, educational level, gender, social position, occupation, civil status, and age of participants are summarized in Table 2 .

Medicinal plant knowledge of Agusan Manobo

The majority of the respondents (90.45%) cited their acquisition of medicinal plant knowledge from their parents. They also mentioned other sources of knowledge like fellow tribe band (67.76%), relatives (64.48%), community (61.49%), and through self-discovery (47.76%). However, the descriptive and inferential statistics revealed varying factors affecting the medicinal plant knowledge among the sampled key informants.

When grouped according to location, there was no significant difference on their medicinal plant knowledge as revealed in Kruskal-Wallis test ( p = 0.379) where the city of Bayugan had the highest number of UR (Md = 112, n = 150), followed by the two municipalities, Esperanza (Md = 111, n = 95) and Sibagat (Md = 108, n = 90). These results showed an exchange of information on these adjacent localities among the Manobo community might it be the council of elders and members who are medicinal plant gatherers, peddlers, and traders.

However, when grouped according to education, respondents who had secondary level as their highest educational attainment (Md = 116, n = 167) showed the topmost medicinal plant knowledge when compared to primary (Md = 105, n = 57) and tertiary (Md = 92, n = 111) as revealed by the highly significant difference presented in Kruskal-Wallis test ( p < 0.001). These results implied that respondents who finished tertiary were more educated with modern medicine and highly acquainted with commercial drugs available over-the-counter for immediate treatment and therapy of their health problems. On the other hand, members with lower educational levels had more medicinal plant knowledge, and most traditional healers, gatherers, and peddlers finished at most on the secondary level.

When grouped according to gender, non-parametric tests revealed that men (Md = 116, n = 229) had more medicinal plant knowledge than women (Md = 104, n = 106), as demonstrated by the significant difference in both Mann-Whitney U test ( p < 0.001) and Kruskal-Wallis test ( p < 0.001). It can be observed that men had more medicinal plant knowledge in Agusan Manobo culture, an observation supported by the fact that in two of the three selected localities, the tribal healers were males, and most of the tribal officials were also males. These results revealed contrary to the previous statistical findings of [ 21 ] in the Ati culture of Visayas where women were more knowledgeable than men because they were more involved in medicinal plant gathering and peddling, and women also played a big role in caring for their sick children.

Also, knowledge of the participants when grouped according to social position varied significantly, as revealed by the Kruskal-Wallis test ( p < 0.001). These results showed that the tribal healers remained the most knowledgeable (Md = 189, n = 3), followed by the Manobo tribal officials (Md = 172, n = 93) with more medicinal plant knowledge when compared to other members of the community (Md = 104, n = 239). The medicinal plant knowledge also varied among the Manobo tribal officials, namely tribal leaders (Md = 178, n = 31), tribal IPMRs (Md = 177, n = 6), tribal chieftains (Md = 172, n = 45), Manobo tribal council of elders (Md = 164, n = 7), and Manobo NCIP focal persons (Md = 160, n = 4).

When grouped according to the occupation, non-parametric Kruskal-Wallis test also significantly revealed ( p < 0.001) that informants with occupation in farming (Md = 118, n = 205) and animal husbandry (Md = 116, n = 47) had more medicinal plant knowledge compared to employed (Md = 98, n = 49) and unemployed (Md = 96, n = 16) informants. These results suggested that Manobo people working in line with agriculture were more exposed to medicinal plant knowledge. They were farming crops or raising animals in hinterlands and mountainous areas where most medicinal plants were located. Also, when grouped according to civil status, married informants (Md = 136, n = 147) showed higher medicinal plant knowledge than single ones (Md = 92, n = 188) as revealed by the very high significant difference in both Mann-Whitney U test ( p < 0.001) and Kruskal-Wallis test ( p < 0.001). These results implied that married respondents were more exposed during community gatherings, which involved discussions about medicinal plants with regard to their uses and applications. Exchange of information could be observed when couples were present during the scheduled tribal meetings.

Finally, when grouped according to age, descriptive and inferential statistics revealed that respondents from the age group of more than 65 years old had the highest medicinal plant knowledge (Md = 173, n = 37), followed by 50–65 years old (Md = 155, n = 53), 35–49 years old (Md = 102, n = 103), and 18–24 years old (Md = 96, n = 142), as revealed by the highly significant difference manifested in Kruskal-Wallis test ( p < 0.001). These results corresponded to our expectation because older informants most likely had more knowledge of medicinal plant uses and practices based on their long-term experience. These results may also imply that younger generations were becoming more acquainted and educated with modern therapeutic treatment making them more reluctant in their traditional medicinal plant practices like gathering and peddling. This transforming awareness, social, and cultural experiences could influence their medicinal plant interest, traditional knowledge, and attitudes among the Agusan Manobo . Younger generations are becoming more privileged to be educated as part of the government scholarship programs for indigenous communities resulting in migration to urban communities.

Medicinal plants used

A total of 122 reported medicinal plant species belonging to 108 genera and 51 families were classified in 16 use categories, as shown in Tables 3 and 4 . All informants interviewed agreed about the healing power of medicinal plants, but only 58.5% of the informants use medicinal plants to treat their health conditions. While some respondents (30.75%) directly relied on seeking for tribal healers in their community, still all these Babaylans utilized their known medicinal plants for immediate treatment and therapy. The Agusan Manobo community believed that the combined healing gift and prayers of their Babaylans could increase the healing potential of their medicinal plants. However, the minority (10.75%) of the key informants depended on seeing a medical practitioner and allied health workers in the treatment of their health conditions at a nearby hospital or health center.

Integrative molecular approach

Due to inconclusive morphological identification, unfamiliarity, and confusing species identity because of local name similarity, a total of 24 medicinal plant species were confirmed by DNA sequencing and by comparing the sequences with those present in the GenBank. This method supported ethnopharmacological data to be deposited in a repository, which is essential and helpful for future researchers and investigators for use by data mining approaches [ 73 ]. The molecular data can also be useful to the growing barcoding studies of medicinal plants. Putative identification based on literature, comparative morphology, and molecular sequences using the BLAST search query were tabulated (Table 5 ). The integrative approach combined with a priori data from putative identifications based on the interview data on local or vernacular names, local plant name dictionary, and assessment of available morphological characteristics along with a posteriori data from multiple universal markers, occurrence, and distribution of putative species in the Philippines. This paper applied a more detailed taxonomic identification since all reported medicinal plant taxa were identified (nearly all to species level), as shown in Table 4 . While all generic and familial affinities of medicinal plants were confirmed, four medicinal plants were not identified up to species level due to lack of morphological characteristics, concerning especially the reproductive parts of Piper and Ficus species, several cultivars and hybrids of Rosa species, and several species and varieties of Bauhinia species. Nevertheless, all generic and familial affinities of the medicinal plants documented here were verified combining similarity matching and a priori and a posteriori data as recommended by [ 42 ] to reduce ambiguity and to make it possible assigning a single species identification of their unidentifiable specimens. All determined plant samples with confusing identity having local name similarity and local species pairing, including plant samples with inconclusive morphological identification due to lack of reproductive parts upon collection, were accurately verified using an integrative molecular approach (Table 5 ).

Plant local name similarity

Most notable medicinal plants of Agusan Manobo have confusing species identity bearing similar local names, gender identity, and local species pairing. It is popular to use medicinal plants known as “Lunas” (meaning “cure”) with several plants associated under its name. For instance, the top three medicinal plants in terms of use value and cultural importance value have local name similarity, namely Lunas tag-uli ( Anodendron borneense (King & Gamble) D.J.Middleton), Lunas bagon tapol ( Piper decumanum L.), and Lunas kahoy ( Micromelum minutum (G.Forst.) Wight & Arn.), respectively. These three medicinal plants with the initial word named “Lunas” had almost similar use-reports in nine use categories with high use diversity (UD > 2.0). Other “Lunas”-named specimens such as Lunas bagon puti ( Piper nigrum L.), Lunas pilipo ( Acmella grandiflora (Turcz.) R.K.Jansen), Lunas buyo ( Piper aduncum L.), and Lunas gabi ( Alocasia zebrina Schott ex Van Houtte) also shared similarities from the top three mentioned samples in terms of ethnomedicinal properties as a treatment for cuts and wounds. Also, another three medicinal plants were locally classified with the initial word named “Talimughat” (meaning “recover”), namely “Talimughat lingin” ( Grewia laevigata Vahl), “Talimughat taas” ( Friesodielsia lanceolata (Merr.) Steen.), and “Talimughat pikas” ( Bauhinia sp.). These three medicinal plants were noted with high fidelity for postpartum care and recovery. Plant samples with high fidelity for anemia also had similar local names which were found to be same species, namely “Mayana kanapkap” ( Coleus scutellarioides (L.) Benth . ) and “Mayana pula” ( Coleus scutellarioides (L.) Benth . ).

Some medicinal plants also have attached “genders” (male or female) in their local names, which specify the more effective plant “gender” for a specific medicinal use or purpose. Examples are “Kapayas laki” ( Carica papaya L., male), “Dupang bae” ( Urena lobata L., female), and “Gapas-gapas bae” ( Erechtites valerianifolius (Link ex Spreng.) DC . , female) as effective treatments for dengue virus, postpartum care and recovery, and gas pain and flatulence, respectively. Besides, most species with high use values had local species pairing which were classified by the tribe according to distinct white and red coloration, namely “puti” and “tapol,” respectively, with the latter as more effective than the former in treatment for various health conditions. The following recognized local species pairs as white and red plant samples, respectively, are “Alibangbang puti” ( Phanera semibifida (Roxb.) Benth.) and “Alibangbang tapol” ( Phanera semibifida (Roxb.) Benth.); “Banti puti” ( Omalanthus macradenius Pax & Hoffm.) and “Banti tapol” ( Omalanthus macradenius Pax & Hoffm.); “Lunas-bagon puti” ( Piper nigrum ) and “Lunas-bagon tapol” ( Piper decumanum ); “Tobog puti” ( Ficus fistulosa Reinw. ex Blume) and “Tobog tapol” ( Ficus cassidyana Elmer); and “Tuba-tuba puti” ( Jatropha curcas L.) and “Tuba-tuba tapol” ( Jatropha gossypifolia L.). Local species pairing of “Alibangbang puti” and “Alibangbang tapol” was found to be similar species ( Phanera semibifida (Roxb.) Benth.). Another species pair, “Banti puti” and “Banti tapol” was also found to be similar species ( Omalanthus macradenius Pax & Hoffm.). However, molecular confirmation of all species pairs by the locals did not necessarily point to the same species but were mostly referring to another species. An example study resolving species identity of Piper species used by the Agusan Manobo being a sterile species and unidentifiable by present morphology having confusing local names with the initial word “Lunas” has been molecularly confirmed lately using integrative molecular approach [ 19 ]. Thus, it is always important in any ethnomedicinal, ethnobotanical, and ethnopharmacological studies to obtain the correct identification of medicinal plants by integrating molecular data like this for accuracy, consistency, and dependable species identity for future pharmacological evaluation and natural product investigations.

Species molecular confirmation

Most of all extracted samples for molecular analysis were successfully amplified and sequenced (90%) using multiple universal markers (Table 5 ). Some medicinal plants could not be successfully amplified using the given primer due to low levels of DNA present in the samples [ 74 ] or plant secondary metabolites present as inhibitory factors [ 75 ]. Molecular data obtained were also subject to the availability of sequences of plant samples in the GenBank. The 24 species identified were tabulated in Table 6 , showing six endemic species (27.3%) [ 56 ] and conservation status of all assessed species (37.5%) [ 76 , 77 ] presented five least concern species (83.3%) and a vulnerable species, Cinnamomum mercadoi S.Vidal (16.7%). All edited sequences of each of the four DNA markers in fasta file format were attached as supplementary materials (see Additional files 2 – 5 ) for future reference.

The most certain identity confirmed by this molecular analysis is the familial and generic affinity wherein the specific epithet of each of the 24 medicinal plants presented had to be verified for its occurrence and distribution in the country. All species identified using simple and optimized BLAST-based sequence matching results were further reviewed on their present morphology using taxonomic keys and comparing images and specimens before consulting an expert. Some species names presented in BLAST search query have synonyms showing similar genus among species within 5 points deviation down of the max score. In contrast, others have several genera but under the same family. Two species with molecular data, namely Bauhinia sp. and Ficus sp., were only confirmed up to the genus level due to limited morphological material and because of a high number of varieties, species, and subspecies. A sterile Piper species was confirmed as P. nigrum based on its diagnostic characterization, which could be a new variety obtained only in the wild among the respondents and not the widely cultivated spice known as the world’s most consumed peppercorn.

Of all DNA markers used in this study, two markers, psb A- trn H and trn L-F (cpDNA) successfully amplified and sequenced all 24 uncertain species (100%). A total of 21 species (88%) were amplified and sequenced using the marker ITS (nrDNA), while the coding marker, mat K (cpDNA), recorded at least 17 amplified and sequenced species (71%). In this case, molecular data could increase its identification rate by using multiple universal markers. Several coding and non-coding regions were tested in plants, but a single locus has limited resolving capabilities for closely related species [ 79 , 80 ]. While local names are essential in ethnopharmacological studies, complexities of these local names could lead to confusion and ambiguity, hence, a need for further molecular analysis [ 19 ]. A number of ethnobotanical studies consider vernacular names coupled with morphological and molecular confirmation as part of the identification diagnostics [ 19 , 42 , 81 , 82 , 83 ].

Collection sites

The majority (57%) of the medicinal plants were collected in the wild, while some were collected within the community village (7.2%) and the houses (4.8%). Some local people were cultivating some of these medicinal plants near homes for their convenience, but collecting medicinal plants in the wild during seasonal times or in case of immediate treatment was highly encouraged for efficacy as the locals believed that the plants should grow in their natural setting rather than cultivation. Scientific studies tend to support the idea of medicinal plant collection in the wild because plant secondary metabolites will be mostly expressed in the natural setting under environmental stress and conditions, whereby they could not be comparably expressed under monoculture conditions [ 84 ]. Higher levels of secondary metabolites were also reported in wild populations where plants grow slowly, unlike in much faster-growing monocultures [ 85 ].

Plant parts used

All plant parts were used from different plant species against a variety of diseases. The most frequently used plant parts were the leaves (41.6%), followed by roots (16.1%), barks (12.0%), stems (8.5%), sap or latex (6.7%), and flowers (4.1%) (Fig. 2 ). Sometimes, more than one plant part of the same species is used in combination, like leaves, barks, stems, and roots for preparation and administration, which the locals believed to have a synergistic effect and a more effective medication.

Plant parts used by the Agusan Manobo for medicinal application. Bk, barks; Br, branches; Fl, flowers; Fr, fruits; Lf, leaves; Rt, roots; Rz, rhizomes; Sd, seeds; Sh, shoots; Sp, sap or latex; St, stems; Wh, whole plant

Preparation and administration

The primary preparation method was decoction (34.0%), followed by pounding, crushing, rubbing, grinding, and powdering (13.7%); poultice (12.3%); extracting (9.0%); directly applying or eating (8.5%); infusion (7.1%); applying as wash, bath, hot compress (5.5%); heating or warming (3.6%); tincture (2.7%); brewing (1.6%); burning (1.4%); and steaming (0.5%) as depicted in Fig. 3 . The more common route of administration was internal (60%) rather than external (40%). This result is contrary to the previous reports in the other Philippine major island ethnic tribes like the Ati Negrito community of Visayas [ 21 ] and the Ivatan community in Luzon [ 24 ] where the external application was more common. While external administration could be safer, according to the Agusan Manobo , the internal application was more common since most of their health conditions were associated internally, making decoction as their most common preparation. In cases of external diseases and illnesses, more prolonged coconut oil infusions of medicinal plant stems and barks were often applied.

Mode of preparation of medicinal plants used by the Agusan Manobo . Bn, burning; Br, brewing; Dc, decoction; Di, directly applying or eating; Ex, extracting; Ht, heating or warming; In, infusion; Pd, pounding, crushing, rubbing, grinding, powdering; Po, poultice; Sm, steaming; Ti, tincture; Ws, as wash, bath, hot compress

Use categories (UC)

Reported medicinal uses of plants in this study were grouped into 16 category names based on the citations of informants and the likeness to the use category (Table 3 ). Reported uses and diseases in medical terms were verified by the assigned local physicians and allied workers, nearby hospitals and health centers to confirm disease occurrence and epidemiology in the area. A total of 120 reported uses or diseases treated by 122 plant species were documented in the study sites.

Use-report (UR) and use value (UV)

Both UR and UV represent the relative importance of medicinal plants for certain categorized uses or diseases. High values were considered the most important species among the Agusan Manobo . Five medicinal plants with the highest URs (more than 900) as well as UVs (more than 2.5) were Anodendron borneense (UR = 1134; UV = 3.39) in 12 categories, Piper decumanum (UR = 1018; UV = 3.04) in 9 categories, Micromelum minutum (UR = 955; UV = 2.85) in 9 categories, Arcangelisia flava (L.) Merr. (UR = 922; UV = 2.75) in 10 categories, and Cinnamomum mercadoi (UR = 908; UV = 2.71) in 8 categories, as shown in Table 4 . These high UR and UV plants were the most frequently used plant species based on high fidelity level for pregnancy (FL = 88%), skin rashes and itchiness (FL = 95%), hemorrhage (FL = 97%), tumor (FL = 87%), and stomach trouble (FL = 100%), respectively, (Table 11 ).

The respondents consistently reported these in all study sites, but only harvested in the wild. Some other plants can be cultivated with high UVs, as shown in the top 20 species ranked by UV (Table 7 ). While high UV species can often be harvested for medicinal use and purpose, these important species call for conservation priority [ 86 ]. The four medicinal plants included among the top 10 recommended medicinal plants by the Department of Health (DOH) of the Philippines, were cultivated by the Agusan Manobo respondents within their community. These scientifically validated medicinal plants were also reported with high URs, namely “Bayabas” Psidium guajava L. (275) “Lagundi” Vitex negundo L. (475), “Gabon” Blumea balsamifera (L.) DC. (412), and “Tsaang gubat” Ehretia microphylla Lam. (336).

Cultural importance value (CIV)

CIV often identifies species with diverse use-reports in different use categories, which is relatively dependent on the sum of the proportion of informants who cited the medicinal plant use. The usefulness of species based on the number of informants for each species is not only accounted for this additive index but also its versatility [ 47 ]. The top 20 species ranked by CIV included some species with high UV and UD (Table 8 ).

Use diversity (UD)

UD determines medicinal plants dependent on the variety of uses in different use categories. This index considers the widespread contribution of each use category according to the number of reported diseases treated. The top 20 species with high UD did not include all high values of UV and CIV (Table 9 ).

Correlation of the basic values and indices

Table 10 presents the Spearman correlations among all the five variables used to quantify ethnopharmacological data. All correlations were moderate to strongly positive and significant at p < 0.01 ( n = 125). That is, as one variable increases, the other also increases. Of all the variables, UV is entirely dependent on UR (1.00), while UD is highly dependent on UC (0.97). However, the subjectivity of selection criteria among the use categories was avoided as the researcher consulted with physicians and other medical experts in the locality. The correlation index between UV and CIV was quite high (0.73), meaning that the relative importance of medicinal plants used among the Agusan Manobo was relatively dependent on the number of use mentions among the key informants as counted in UR. An interesting point that appeared to corroborate these data is that the number of UR was positively correlated (0.71–1.00), among other basic values and indices. These variables were correlated with the number of uses for a particular ailment and the number of categories considered. Thus, it can be argued that the relative importance of medicinal plants documented in this study was relatively dependent at least, on the number of use-reports among the key informants and the number of use categories following an objective manner. Despite the advantages and uses of these values and indices in determining the relative importance and usefulness of medicinal plants, it is practical to note that no single index can give information about the complete picture of plant importance.

Informant consensus factor (ICF)

ICF measures the agreement among informants on the use of plant species for a particular purpose or disease category. While the agreement among the key informants varies in different categories, the ICF values are all greater than or equal to 0.97 (Table 3 ). These results showed that the exchange of information could be evident among the Agusan Manobo community on their medicinal plant uses and practices. Among the 16 use categories, four categories, namely diseases of the digestive system (DDS), diseases of the skin (DOS), abnormal signs and symptoms (ASS), and other problems of external causes (OEC) had the highest ICF value of 0.99.

Fidelity level (FL)

FL implies the most preferred medicinal plant for a particular disease or purpose. FL value ranges from 1 to 100% depending on the URs cited by the informants for a given species for a particular ailment. Seven species were found with the maximum FL of 100%, including the identified species with the highest number of use mentions, Carica papaya , Premna odorata , Cinnamomum mercadoi , Tinospora crispa , Ficus concinna , Piper decumanum , and Pipturus arborescens which are used for dengue fever, cough with phlegm, stomach trouble, joint pain, fracture and dislocation, anesthetic, and herpes simplex, respectively (Table 11 ).

Jaccard’s similarity index (JI)

This is the first ethnopharmacological or ethnobotanical study of indigenous peoples in the province of Agusan del Sur. The variation of the medicinal plants used among the three studied localities was shown in JI (Fig. 4 ). The most overlap of the obtained data and the Jaccard index (similarity) was between the city of Bayugan and the municipality of Sibagat (JI = 0.42), and the least one was between both municipalities of Esperanza and Sibagat (0.38). However, the degree of similarity among the three adjacent localities was proximate with JI ranged from 0.38 to 0.42. While JI conveyed a similarity index ca. 39.7%, the actual overlap is 52.5% (64 species cited among the localities). This similarity could be observed on their comparable ecological types being upland and well-drained areas and due to the active exchange of information on the uses of medicinal plants among the communities during monthly social meetings and preparations in the province of Agusan del Sur.

Overlap in the medicinal plants collected in the three studied localities (city of Bayugan and the municipalities of Sibagat and Esperanza)

Dosage, frequency, and experienced adverse or side effects of using medicinal plants

For a detailed ethnopharmacological study, it is essential to consider the therapeutic use, medication action, and possible side effects. This study involved documenting the quantity or dosage, administration frequency, and experienced adverse or side effects, as shown in Table 4 . A particular number of plant parts were followed in their mode of preparation. Having leaves as the most frequently used medicinal plant part, 3–5 leaves (or at least an odd number) of decocted, heated, and pounded leaves should be applied. Most of the medicinal plants (82%) were reported by the key informants with no experience of adverse or side effects, while 18% of medicinal plants were experienced with adverse or side effects. There were seven medicinal plants reported to cause abortion in pregnant women once taken or applied. Other listed medicinal plants, when taken in excess, can cause other adverse or side effects. Four of these medicinal plants can cause anemia, dizziness, and weakening, while other plants can cause acid reflux and hypocupremia, burn, and allergy and are even poisonous when eaten or applied. Other reported cases concern excessive intake, which can cause blood viscosity, intestinal weakening, thrombocytopenia, and abnormalities in lactating mothers. These reported adverse or side effects were verified by the attending local medical practitioners and allied medical workers during their hospital visits and in times of emergency. It can be argued that not all medicinal plants used by the tribe are safe for use with no side effects. Thus, it is essential to obtain the reported adverse effects or possible side effects of cited medicinal plants by the informants in all ethnopharmacological studies like this.

This ethnopharmacological documentation recorded a total of 122 medicinal plant species belonging to 108 genera and 51 families across 16 use or disease categories. The majority of medicinal plants are trees (36%) and herbs (33%), which are mostly found in the wild, while some are cultivated. These are followed by 17% shrubs, 11% climbers, 2% grasses, and 1% ferns. The highest percentage of medicinal trees documented in this study is parallel with the earlier ethnobotanical studies [ 21 , 87 ]. The highest frequency of using leaves and aerial plant organs was also reported in several ethnobotanical studies in the Philippines [ 21 , 24 , 25 , 87 , 88 , 89 , 90 ] and other countries [ 91 , 92 , 93 ]. The highest frequency of decoction for preparation and administration is similar to previous ethnobotanical investigations [ 21 , 87 , 88 , 89 , 90 ].

Lamiaceae was the most represented family with 12 species, followed by Asteraceae with 11, Moraceae with eight species, and Fabaceae with six species. This result is contrary to previous ethnobotanical studies in which Asteraceae were the most represented family [ 24 , 88 , 89 , 90 ]. The Lamiaceae (mint family) possess a wide variety of ornamental, medicinal, and aromatic plants producing essential oils that are used in traditional and modern medicine, food, cosmetics, and pharmaceutical industry [ 94 ]. This family is known for effective pain modulation with potential analgesic or antinociceptive effects, which includes several aromatic medicinal spices like mint, oregano, basil, and rosemary [ 95 ]. Asteraceae (the aster, daisy, composite, or sunflower family) are the largest family of flowering plants which were reported to have pharmacological activities such as antitumor, antibacterial, antifungal, and anti-inflammatory [ 96 ] containing phytochemical compounds such as polyphenols, flavonoids, and diterpenoids [ 97 , 98 ]. The Moraceae (fig family) was reported to have wide variety of chemical constituents with potential biological activities as previously investigated by [ 99 ] in Ficus racemosa L., and [ 100 ] in Ficus carica L., and [ 101 ] in Ficus benjamina L. Fabaceae (pea family) which is the third largest family also contain various bioactive constituents with potential pharmacological and toxicological effects [ 102 ]. A member of this family which has long been cultivated and introduced in the Philippines, Gliricidia sepium (Jacq.) Kunth ex Steud., was investigated to have antimicrobial and antioxidant activities, as well as several phytochemicals present [ 13 ].

The Department of Health (DOH) of the Philippines has continually endorsed 10 medicinal plant species in its traditional health maintenance program: (1) Cassia alata L., (2) Momordica charantia L., (3) Allium sativum L., (4) Psidium guajava L., (5) Vitex negundo L., (6) Quisqualis indica L., (7) Blumea balsamifera (L.) DC., (8) Ehretia microphylla Lam., (9) Peperomia pellucida (L.) Kunth, and (10) Clinopodium douglasii (Benth.) Kuntze . Of all these 10 recommended and clinically tested medicinal plants, four species were included in this survey.

Apparently, the societal gaps which differentiate educational level, gender, position, occupation, and age among the Manobo indigenous community may result in the disappearance of their medicinal plant knowledge and traditional practices. While there was no significant difference in their medicinal plant knowledge in different locations, it is still highly important to document their medicinal plant knowledge to perpetuate their cultural tradition and medicinal practices, as well as protect and conserve these important plant genetic resources.

Many ethnobotanical studies include vernacular names as part of the putative identification. While vernacular names are useful in ethnopharmacology, pharmacognosy, and pharmacovigilance [ 83 , 103 ], reliance on these vernacular names for species identification and classification can cause ambiguity and incorrect identification resulting to research invalidation [ 104 ]. DNA-based identification is a useful tool for accurate species identification. Correct identification of a medicinal plant should be examined using molecular data [ 105 ] for consistency of species and pharmacological investigations of natural products [ 106 ]. Although plant-based drug discovery from ethnobotanical data provides future drug leads, authentication of the plant material is a great challenge and opportunity [ 107 ].

Comparison with previous ethnobotanical studies

Several ethnobotanical and ethnomedicinal studies were conducted in the Philippines, but few involve quantitative analyses in their studies. The majority of ethnobotanical studies conducted in the Philippines purposively selected key informants who are just knowledgeable of their medicinal plants like residents, traditional healers, herbalists, gardeners, traders, and elders, but a limited count of researches focused on specific IPs or tribal communities in the country.

Among the three major islands in the Philippines (Luzon, Visayas, and Mindanao), the island of Mindanao is still underdocumented despite its largest population of indigenous cultural communities/indigenous peoples (ICCs/IPs) in the country. In Luzon, four indigenous groups were documented, namely the Kalanguya tribe in Tinoc, Ifugao [ 108 ]; the Ivatan in Batan Island Batanes [ 24 ]; the Ayta in Dinalupihan, Bataan [ 109 ]; and the Ilongot-Eǵongot in Maria Aurora, Aurora [ 110 ], communities. The plant utilization among local communities was also documented by [ 25 ] in Kabayan, Benguet Province, namely Ibaloi , Kankanaey and Kalanguya in addition to the earlier recorded tribes such as the Negritos [ 111 ], the Tasadays [ 112 , 113 ], the Ifugao [ 114 , 115 ] and the Bontoc [ 116 ]. Other studies of cultural communities involve indigenous knowledge and practices for sustainable management like the Ifugao forests in Cordillera, Philippines [ 117 ].

In Visayas, only the Ati Negrito of Guimaras island [ 21 ], while in Mindanao, three tribes were studied, namely the Higaonon tribe of Iligan City [ 88 ], Subanen tribe of Dumingag, Zamboanga del Sur [ 89 ]; Muslim Maranaos of Iligan City [ 90 ]; Subanen tribe of Lapuyan, Zamboanga del Sur [ 87 ]; and Tagabawa tribe of Davao del Sur [ 118 ]. Of all reported ethnobotanical studies in Mindanao, this is the first study utilizing detailed quantitative analysis of relative importance, effectivity consensus, correlation of indices, and the extent of the potential use of each medicinal plant species among the ICCs/IPs. Moreover, this study also integrated molecular confirmation for the first time applying multiple universal markers and coalescing a priori and a posteriori data for accurate species identification to resolve complex plant local or vernacular names and sterile or non-reproductive plant specimens.

In comparison with existing ethnobotanical studies in the Philippines, a novel plant medicinal use was recorded, namely Anodendron borneense with no existing records of ethnobotanical and pharmacological investigations in the world to date. The ethnopharmacological profile of this medicinal plant is a novel finding in this study, which is consistently on the top list among the values or indices used (UR, UV, and CIV), which is only known among the Agusan Manobo in the province of Agusan del Sur, Philippines. Incorporating data of experienced adverse or side effects in this study introduces a more detailed ethnopharmacological documentation in the Philippines, which could be a reference material for future ethnomedicinal, biological, and pharmacological studies.

Limitations of the present study

Ethnobotanical research broadly encompasses like ethnopharmacology, which involves field-based investigations. However, most of the remote areas and barangays in various municipalities and cities of the Philippines were not always safe from rebels and communists against the Philippine government. Majority of the Manobo tribes documented here live in far-flung hinterlands, remote upland areas alongside rivers, valleys, and creeks having security threats from the rebel movement known as the New People's Army (NPA). Study sites included here obtained security clearance from the provincial and local government administrations to ensure safety and accessibility in the area, and the availability of key informants on the actual documentation and field walks. Language barriers were barely encountered since most respondents could speak the national Filipino language and/or the regional Cebuano or Visayan language aside from their Minanubu dialect. Phenology and year-round seasonal variations are essential factors to consider for accurate observation of the plant and collection of specimens with complete reproductive parts. Some respondents are sometimes unwilling to share their medicinal plant knowledge with others due to their previous experience being taken advantage of by business-related parties of drug and pharmaceutical companies. It was also observed that most respondents are becoming educated with the help of government education programs for IPs, which made them more resistant to allowing themselves to be the subject of study by visitors and outsiders.

In spite of that, it is very important to gain trust, confidence, and respect among the Agusan Manobo community by embracing their rich cultural tradition through ritual observation and tribal immersion within their community. Although they maintain secrecy about their medicinal plant use and knowledge, it is also beneficial to practice keeping their knowledge from possible overexploitation of their medicinal plant resources. This study is the first in the country documenting the rich ethnopharmacological practices of indigenous tribes coupled with integrative molecular confirmation of medicinal plants used. It is highly important to recognize the role of indigenous cultural communities/indigenous peoples (ICCs/IPs) in the Philippines for shared information of ethnopharmacological practices for future preservation of knowledge and conservation priorities of their plant genetic resources. This will benefit their children and future generations before their knowledge becomes lost and forgotten.

Research highlights

The current study revealed the rich ethnopharmacological practices, medicinal plant uses, and knowledge of the Manobo tribe in Agusan del Sur, Philippines.

Exchange of information among the Agusan Manobo communities was observed in different localities; however, the younger generation has a potential decline of interest due to their acquaintance of over-the-counter drugs and modern medicines.

This study reinforced the application of integrative molecular confirmation for medicinal plant species lacking reproductive parts upon collection and/or unidentifiable by present morphology (sterile or non-reproductive) plant material.

Novel medicinal use and some new ethnopharmacological information of medicinal plants were reported in this study.

The consolidated data of this quantitative ethnopharmacology study contributes to the repository of medicinal plant knowledge and the rich source of information for scientists, physicians, and experts such as botanists, taxonomists, phytochemists, pharmacists, environmentalists, conservation biologists, medical doctors, and allied professionals.

This study concluded the culturally rich ethnomedicinal knowledge and ethnopharmacological practices of the Manobo tribe in Agusan del Sur, Philippines. The results of the study revealed a high diversity of medicinal plants used by the Agusan Manobo with 122 species utilized in 16 use categories. Like any other ethnolinguistic indigenous group in the country, traditional knowledge may be lost or forgotten due to possible migration, acculturation, and declining interest of the younger generation in response to the increasing availability of commercial over-the-counter medicine. Their medicinal plants are known by a limited number of individuals, mostly by their healers, elders, and tribal officials. This quantitative ethnopharmacological documentation is the first to show the high consensus and relative importance of medicinal plants used by the Agusan Manobo and provides molecular confirmation of their medicinal plant species with uncertain identity. The combined quantitative ethnopharmacological documentation and species confirmation using an integrative molecular approach of medicinal plants used in traditional medicine is a breakthrough for obtaining more detailed and comprehensive findings that will be a valuable contribution to the repository of knowledge. The findings of this study will serve as reference material for future systematic, biochemical, and pharmacological studies. While the findings of this study are promising, regarding new potential therapeutic agents for healthcare improvement, it is of utmost concern to reconsider important medicinal plant species for conservation priorities as part of the government programs and initiatives to perpetuate the national and world heritage of traditional knowledge on medicinal plants used by many diverse cultural communities.

Availability of data and materials

The authors declare that sequencing data of 24 species identified supporting the findings of this study are available within the article and its supplementary information files.

UNESCO. Report of the IBC on traditional medicine systems and their ethical implications. 2013. https://unesdoc.unesco.org/ark:/48223/pf0000217457 . Accessed 15 Aug 2019.

WHO. World Health Organization traditional medicine strategy: 2014-2023. WHO Library Cataloguing-in-Publication Data. 2013. https://apps.who.int/iris/bitstream/handle/10665/92455/9789241506090_eng.pdf;jsessionid=8CE16D76ACA6151F5929619AA9B1A411?sequence=1 . Accessed 16 Aug 2019.

WHO. Regulatory situation of herbal medicines. A worldwide review. Geneva: World Health Organization. 1998. p. 1–5.

Jamshidi-Kia F, Lorigooini Z, Amini-Khoei H. Medicinal plants: past history and future perspective. J HerbMed Pharmacol. 2018;7:1–7. https://doi.org/10.15171/jhp.2018.01 .

Article   Google Scholar  

Farnsworth NR. Ethnopharmacology and drug development. Ciba found Symp. 1994;185:42–59. https://doi.org/10.1002/9780470514634.ch4 .

Article   CAS   PubMed   Google Scholar  

Schippmann U, Cunningham AB, Leaman DJ. Impact of cultivation of medicinal plants on biodiversity: global trends and issues. In: FAO, biodiversity and the ecosystem approach in agriculture, forestry and fisheries. Satellite event on the occasion of the Ninth Regular Session of the Commission on Genetic Resources for Food and Agriculture, Rome, 12-13 October 2002. Inter-Departmental Working Group on Biological Diversity for Food and Agriculture, Rome, Italy. 2002. p. 143–167.

Karki M, William JT. Priority species of medicinal plants in South Asia. In: Report of an Expert Consultation on Medicinal Plants Species Prioritization for South Asia held on 22-23 1997 New Delhi, India; 1999.

Madulid DA, Gaerlan FJM, Romero EM, Agoo EMG. Ethnopharmacological study of the Ati tribe in Nagpana, Barotac Viejo. Iloilo. Acta Manil. 1989;38:25–40.

Google Scholar  

Burns G. Nature-guided therapy: brief integrative strategies for health and well-Being. Taylor & Francis. 1998. https://doi.org/10.4324/9781315803586 . Accessed 18 Aug 2019.

Book   Google Scholar  

Dela Cruz P, Ramos AG. Indigenous health knowledge systems in the Philippines: a literature survey. Paper presented at the 13th CONSAL Conference, Manila, Philippines; 2006.

Eusebio J, Umali B. Inventory, documentation and status of medicinal plants research in the Philippines. Medicinal Plants Research in Asia, Volume 1: The framework and project workplans. In Batugal, A., Kanniah, J., Young, L.S. & Oliver, J. edition. International Plant Genetic Research Institute-Regional Office of Asia, the Pacific and Oceana (IPGRI-APO), Serdang, Selangor, DE, Malaysia; 2004.

Tan JG, Sia IC. The best 100 Philippine medicinal plants: The National Library Cataloguing in Publication; 2014.

Abdulaziz AA, Dapar MLG, Manting MME, Torres AJ, Aranas AT, Mindo RAR, Cabrido CK, Demayo CG. Qualitative evaluation of the antimicrobial, antioxidant, and medicinally important phytochemical constituents of the ethanolic extracts of the leaves of Gliricidia sepium (Jacq.). Pharmacophore. 2019;10:72–83.

Añides JA, Dapar MLG, Aranas AT, Mindo RAR, Manting MME, Torres MAJ, Demayo CG. Phytochemical, antioxidant and antimicrobial properties of the white variety of ‘Sibujing’ ( Allium ampeloprasum ). Pharmacophore. 2019;10:1–12.

Dapar MLD, Demayo CGD, Senarath WTPSK. Antimicrobial and cellular metabolic inhibitory properties of the ethanolic extract from the bark of ‘Lunas-Bagon’ ( Lunasia sp.). Int J Pharm Sci Res. 2018;9:88–97. https://doi.org/10.13040/IJPSR.0975-8232.9(1).88-97 .

Article   CAS   Google Scholar  

Dela Peña JF, Dapar MLG, Aranas AT, Mindo RAR, Cabrido CK, Torres MAJ, Manting MME, Demayo CG. Assessment of antimicrobial, antioxidant and cytotoxic properties of the ethanolic extract from Dracontomelon dao (Blanco) Merr. & Rolfe. Pharmacophore. 2019;10:18–29.

Nadayag J, Dapar MLG, Aranas AT, Mindo RAR, Cabrido CK, Manting MME, Torres AJ, Demayo CG. Qualitative assessment of the antimicrobial, antioxidant, and phytochemical properties of the ethanolic extracts of the inner bark of Atuna racemosa . Pharmacophore. 2019;10:52–9.

Uy IA, Dapar MLG, Aranas AT, Mindo RAR, Manting MME, Torres MAJ, Demayo CG. Qualitative assessment of the antimicrobial, antioxidant, phytochemical properties of the ethanolic extracts of the roots of Cocos nucifera L. Pharmacophore. 2019;10:63–75.

Dapar MLG, Demayo CG, Meve U, Liede-Schuman S, Alejandro GJD. Molecular confirmation, constituents and cytotoxicity evaluation of two medicinal Piper species used by the Manobo tribe of Agusan del Sur. Philippines. Phytochem Lett. 2020;36:24–31. https://doi.org/10.1016/j.phytol.2020.01.017 .

Tan MA, Lagamayo MWD, Alejandro GJD, An SSA. Anti-amyloidogenic and cyclooxygenase inhibitory activity of Guettarda speciosa . Molecules. 2019;24:4112. https://doi.org/10.3390/molecules24224112 .

Article   CAS   PubMed Central   Google Scholar  

Ong HG, Kim YD. Quantitative ethnobotanical study of the medicinal plants used by the Ati Negrito indigenous group in Guimaras island. Philippines. J Ethnopharmacol. 2014;157:228–42 https://doi.org/10.1016/j.jep.2014.09.015 .

Article   PubMed   Google Scholar  

Bruni A, Ballero M, Poli F. Quantitative ethnopharmacological study of the Campidano Valley and Urzulei district, Sardinia. Italy. J Ethnopharmacol. 1997;57:97–124. https://doi.org/10.1016/S0378-8741(97)00055-X .

Rivera D, Obón C, Inocencio C, Heinrich M, Verde A, Fajardo J, Palazón JA. Gathered food plants in the mountains of Castilla-La Mancha (Spain): ethnobotany and multivariate analysis. Econ Bot. 2007;61:269–89.

Abe R, Ohtani K. An ethnobotanical study of medicinal plants and traditional therapies on Batan island, the Philippines. J Ethnopharmacol. 2013;145:554–65 https://doi.org/10.1016/j.jep.2014.09.015 .

Balangcod TD, Balangcod KD. Plants and culture: plant utilization among the local communities in Kabayan, Benguet Province Philippines. Indian J Tradit Know. 2018;17:609–22.

ILO. Indigenous peoples development programme (IPDP). 2014. https://www.ilo.org/wcmsp5/groups/public/%2D%2D-asia/%2D%2D-ro-bangkok/%2D%2D-ilo-manila/documents/publication/wcms_245610.pdf . Accessed 18 Aug 2019.

PSA. 2010 census of population and housing: definition of terms and concepts. Quezon City, Philippines: Philippine Statistics Authority; 2016.

NCIP. Primer on census for indigenous peoples. Quezon City, Philippines: National Commission on Indigenous Peoples; 2010.

UNDP. Indigenous peoples in the Philippines. 2010. http://www.ph.undp.org/content/philippines/en/home/library/democratic_governance/FastFacts-IPs.html . Accessed 17 Aug 2019.

NCCA. Manobo. 2015. http://ncca.gov.ph/about-culture-and-arts/culture-profile/manobo/ . Accessed 18 Aug 2019.

Felix MLE. Exploring the indigenous local governance of Manobo tribes in Mindanao. Phil J Pub Adm. 2004;48:125.

ILO. The road to empowerment: strengthening the indigenous peoples rights act. Vol. 1: New ways, old challenges. Manila, International Labour Office; 2007.

Opeña LR, Taguchi AS. Bukidnon folk literature. In Dialogue for development. Edited by Francisco R. Demetrio. Cagayan de Oro: Xavier University; 1975.

Dapar MLD, Demayo CG. Folk medical uses of Lunas Lunasia amara Blanco by the Manobo people, traditional healers and residents of Agusan del Sur, Philippines. Sci Int (Lahore). 2017;29:823–6.

Herbert P, Cywinska A, Ball S. Biological identifications through DNA barcodes. Proceedings of the Royal Society of London B: Biological Sciences. 2003;270:313–21. https://doi.org/10.1098/rspb.2002.2218 .

Newmaster SG, Grguric M, Shanmughanandhan D, Ramalingam S, Ragupathy S. DNA barcoding detects contamination and substitution in North American herbal products. BMC Med. 2013;11:222. https://doi.org/10.1186/1741-7015-11-222 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Buddhachat K, Osathanunkul M, Madesis P, Chomdej S, Ongchai S. Authenticity analyses of Phyllanthus amarus using barcoding coupled with HRM analysis to control its quality for medicinal plant product. Gene. 2015;573:84–90. https://doi.org/10.1016/j.gene.2015.07.046 .

Cabelin VLD, Santor PJS, Alejandro GJD. Evaluation of DNA barcoding efficiency of cpDNA barcodes in selected Philippine Leea L. (Vitaceae). Bot Lett.: Acta Botanica Gallica; 2015. https://doi.org/10.1080/12538078.2015.1092393 .

Vassou SL, Kusuma G, Parani M. DNA barcoding for species identification from dried and powdered plant parts: a case study with authentication of the raw drug market samples of Sida cordifolia . Gene. 2015;559:86–93. https://doi.org/10.1016/j.gene.2015.01.025 .

Cabelin VLD, Alejandro GJD. Efficiency of mat K, rbc L, trn H- psb A, and trn L-F (cpDNA) to molecularly authenticate Philippine ethnomedicinal Apocynaceae through DNA barcoding. Pharmacogn Mag. 2016;12 10.4103%2F0973-1296.185780 .

Olivar JE, Alaba JPE, Atienza JF, Tan JJ, Umali M, Alejandro GJD. Establishment of standard reference material (SRM) herbal DNA barcode library of Vitex negundo L. (lagundi) for quality control measures. Food Addit Contam Part A. 2016;33:741–8. https://doi.org/10.1080/19440049.2016.1166525 .

Ghorbani A, Saeedi Y, de Boer HJ. Unidentifiable by morphology: DNA barcoding of plant material in local markets in Iran. PLoS One. 2017;12. https://doi.org/10.1371/journal . pone.0175722.

Alfeche NKG, Binag SDA, Medecilo MMP, Alejandro GJD. Standard reference material (SRM) DNA barcode library approach for authenticating Antidesma bunius (L.) Spreng. (bignay) derived herbal medicinal products. Food Addit Contam Part A. 2019;1–10. https://doi.org/10.1080/19440049.2019.1670868 .

Prance GT, Baleé W, Boom BM, Carneiro RL. Quantitative ethnobotany and the case for conservation in Amazonia. Conserv Biol. 1987;1:296–310. https://doi.org/10.1111/j.1523-1739.1987.tb00050.x .

Phillips O, Gentry AH. The useful plants of Tambopata, Peru: I. statistical hypotheses tests with a new quantitative technique. Econ Bot. 1993;47:15–32. https://doi.org/10.1007/BF02862203 .

Reyes-García V, Huanca T, Vadez V, Leonard W, Wilkie D. Cultural, practical, and economic value of wild plants: a quantitative study in the Bolivian Amazon. Econ Bot. 2006;60:62–74. https://doi.org/10.1663/0013-0001 (2006)60[62:CPAEVO]2.0.CO;2.

Tardio J, Pardo-de-Santayana M. Cultural importance indices: a comparative analysis based on the useful wild plants of Southern Cantabria (Northern Spain). Econ Bot. 2008;62:24–39. https://doi.org/10.1007/s12231-007-9004-5 .

Bussmann RW, Paniagua Zambrana NY, Sikharulidze S, Kikvidze Z, Kikodze D, Tchelidze D, Khutsishvili M, Batsatsashvili K, Hart RE. A comparative ethnobotany of Khevsureti, Samtskhe-Javakheti, Tusheti, Svaneti, and Racha-Lechkhumi, Republic of Georgia (Sakartvelo). Caucasus. J. Ethnobiol Ethnomed. 2016;12:43. https://doi.org/10.1186/s13002-016-0110-2 .

PENRO. Agusan del Sur. 2018. http://www.denrpenroads.com/index.php/about/background . Accessed 20 Aug 2019.

Chase MW, Hills HH. Silica gel: an ideal material for preservation of leaf samples for DNA studies. Taxon. 1991;40:215–20. https://doi.org/10.2307/1222975 .

Madulid DA. A dictionary of Philippines plant names. Vol. I: local name- scientific name. Vol. II: scientific name-local name. Makati City, Bookmark; 2001.

The Plant List. Version 1.1. 2013. http://www.theplantlist.org/ . Accessed 26 Oct 2019.

WFO. World Flora Online. 2019. http://www.worldfloraonline.org . Accessed 27 Oct 2019.

IPNI. The International Plant Names Index. 2019. https://www.ipni.org . Accessed 25 Oct 2019.

Tropicos, 2019. Missouri Botanical Garden. 2019. http://www.tropicos.org . Accessed 24 Oct 2019.

CDFP; Pelser PB, Barcelona JF, Nickrent DL. Co's digital flora of the Philippines. 2011 onwards. www.philippineplants.org . Accessed 28 Oct 2019.

Alejandro GD, Razafimandimbison SG, Liede-Schumann S. Polyphyly of Mussaenda inferred from ITS and trn T-F data and its implication for generic limits in Mussaendeae (Rubiaceae). Am J Bot. 2005;92:544–57. https://doi.org/10.3732/ajb.92.3.544 .

White TJ, Bruns T, Lee S, Taylor J. Amplification and sequencing of fungal ribosomal RNA genes for phylogenetics. In: Innis M, Gelfand D, Sninsky J, White T, editors. PCR Protocols: a guide to methods and applications. San Diego.: Academic Press; 1990. p. 315–22.

CBOL Plant Working Group. A DNA barcode for land plants. Proceedings of the National Academy of Sciences of the United States of America. 2009;106:12794–12797. https://doi.org/10.1073/pnas.0905845106 .

Kress WJ, Wurdack K, Zimmer E, Weight L, Janzen D. Use of DNA barcodes to identify flowering plants. Proc Natl Acad Sci U S A. 2005;102:8369–74. https://doi.org/10.1073/pnas.0503123102 .

Taberlet P, Gielly L, Pautou G, Bouvet J. Universal primers for amplification of three non-coding regions of chloroplast DNA. Plant Mol Biol. 1991;17:1105–9. https://doi.org/10.1007/BF00037152 .

McGinnis S, Madden T. BLAST: at the core of a powerful and diverse set of sequence analysis tools. Nucleic Acids Res. 2004;32. https://doi.org/10.1093/nar/gkh435 .

Techen N, Parveen I, Pan Z, Khan IA. DNA barcoding of medicinal plant material for identification. Curr Opin Biotechnol. 2014;25:103–10. https://doi.org/10.1016/j.copbio.2013.09.010 .

Amiguet VT, Arnason JT, Maquin P, Cal V, Vindas PS, Poveda L. A consensus ethnobotany of the Q'eqchi’ Maya of southern Belize. Econ Bot. 2005;59:29–42. https://doi.org/10.1663/0013-0001(2005)059[0029:ACEOTQ]2.0.CO;2 .

Oksanen J, Guillaume BF, Kindt R, Legendre P, Minchin PR, O’Hara RB, Simpson GL, Solymos P, Stevens MHH, Wagner H. Vegan: Community Ecology Package. R package version 2.3-0; 2015. http://CRAN.R-project.org/ package=vegan. Accessed 25 Jan 2020.

Trotter RT, Logan MH. Informants consensus: a new approach for identifying potentially effective medicinal plants. In: Etkin NL, editor. Plants in indigenous medicine and diet. Bedford Hill, NY.: Redgrave Publishing Company; 1986. p. 91–112.

Friedman J, Yaniva Z, Dafnib A, Palewitch D. A preliminary classification of the healing potential of medicinal plants, based on a rational analysis of an ethnopharmacological field survey among Bedouins in the Negev Desert. Israel. J Ethnopharmacol. 1986;16:275–87. https://doi.org/10.1016/0378-8741(86)90094-2 .

Heinrich M, Ankli A, Frei B, Weimann C, Sticher O. Medicinal plants in Mexico: healers’ consensus and cultural importance. Soc Sci Med. 1998;47:1859–71. https://doi.org/10.1016/s0277-9536(98)00181-6 .

Abu-Irmaileh BE, Afifi FU. Herbal medicine in Jordan with special emphasis on commonly used herbs. J Ethnopharmacol. 2003;89:193–7. https://doi.org/10.1016/s0378-8741(03)00283-6 .

Jaccard P. Nouvelles recherches sur la distribution florale. Bull Soc Vaudoise. Sci Nat. 1908;44:223–70. https://doi.org/10.5169/seals-268384 .

IBM Corp. Released 2015. IBM SPSS statistics for Macintosh, version 25.0. Armonk, NY: IBM Corp.

Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ. Basic local alignment search tool. J Mol Biol. 1990;215:403–10. https://doi.org/10.1016/S0022-2836(05)80360-2 .

Verpoorte R. Repository for ethnopharmacological survey data? J Ethnopharmacol. 2008;120:127–8. https://doi.org/10.1016/j.jep.2008.08.020 .

Rogers HJ, Parkes HC. Direct PCR amplification from leaf discs. Plant Sci. 1999;143:183–6. https://doi.org/10.1016/S0168-9452(99)00048-5 .

Li Y, Zhao H, Yan X, Li M, Chen P, Zhang S. A universal method for direct PCR amplification of plant tissues. Anal Methods. 2017;9:1800. https://doi.org/10.1039/C6AY03156K .

De Kok RPJ. The genus Premna L. (Lamiaceae) in the Flora Malesiana area. Kew Bull. 2013;68:55–84.

Bramley GLC. The genus Callicarpa (Lamiaceae) in the Philippines. Kew Bull. 2013;68:369–418.

IUCN. The IUCN red list of threatened species. Version 2019-3. 2020. https://www.iucnredlist.org . Accessed 21 Feb 2020.

Fazekas AJ, Burgess KS, Kesanakurti PR, Graham SW, Newmaster SG, Husband BC, Percy DM, Hajibabaei M, Barrett SCH. Multiple multilocus DNA barcodes from the plastid genome discriminate plant species equally well. PLoS One. 2009;3:1–12. https://doi.org/10.1371/journal.pone.0002802 .

Kress W, Erickson D. DNA barcodes: genes, genomics, and bioinformatics. Proc Natl Acad Sci USA. 2008;105:2761–2.

Bussmann RW, Sharon D, Vandebroek I, Jones A, Revene Z. Health for sale: the medicinal plant markets in Trujillo and Chiclayo. Northern Peru. J Ethnobiol Ethnomed. 2007;3:37. https://doi.org/10.1186/1746-4269-3-37 .

Kool A, de Boer HJ. Krug̈er Å, Rydberg A, Abbad A, Bjor̈k L. Martin G. Molecular identification of commercialized medicinal plants in Southern Morocco. PLoS One. 2012;7:1–12. https://doi.org/10.1371/journal.pone.0039459 .

De Boer HJ, Ouarghidi A, Martin G, Abbad A, Kool A. DNA barcoding reveals limited accuracy of identifications based on folk taxonomy. PLoS ONE. 2014;9 https://dx.doi.org/10.1371%2Fjournal.pone.0084291 .

Schippmann U, Leaman D, Cunningham AB. Cultivation and wild collection of medicinal and aromatic plants under sustainability aspects. In: Bogers, R.J., L.E. Craker, and D. Lange (eds). Medicinal and aromatic plants. Springer, Dordrecht. Wageningen UR Frontis Series no. 17; 2006.

Uniyal RC, Uniyal MR, Jain P. Cultivation of medicinal plants in India. New Delhi, India: TRAFFIC India and WWF; 2000.

Albuquerque UP, Lucena RFP, Monteiro JM, Florentino ATN, Almeida CFCBR. Evaluating two quantitative ethnobotanical techniques. Ethnobot Res App. 2006;4:51–60.

Pizon JRL, Nuñeza OM, Uy MM, Senarath WTPSK. Ethnobotany of medicinal plants used by the Subanen tribe of Lapuyan, Zamboanga del Sur. Bull Env Pharmacol Life Sci. 2016;5:53–67. https://doi.org/10.13140/RG.2.1.4828.1121 .

Olowa LF, Torres MAJ, Aranico EC, Demayo CG. Medicinal plants used by the Higaonon tribe of Rogongon, Iligan City, Mindanao. Philippines. Adv Environ Biol. 2012;6:1442–9.

Morilla LJG, Sumaya NHN, Rivero HI, Madamba MRSB. Medicinal plants of the Subanens in Dumingag, Zamboanga del Sur, Philippines. International Conference on Food, Biological and Medical Sciences; 2014. https://doi.org/10.15242/IICBE.C0114577 .

Olowa L, Demayo CG. Ethnobotanical uses of medicinal plants among the Muslim Maranaos in Iligan City, Mindanao. Philippines. Adv Environ Biol. 2015;9:204–15.

Namukobe J, Kasenene JM, Kiremire BT, Byamukama R, Kamatenesi-Mugisha M, Krief S, Dumontet V, Kabasa JD. Traditional plants used for medicinal purposes by local communities around the northern sector of Kibale National Park Uganda. J Ethnopharmacol. 2011;136:236–45. https://doi.org/10.1016/j.jep.2011.04.044 .

Ahmad L, Semotiuk A, Zafar M, Ahmad M, Sultana S, Liu Q, Zada MP, Abidin SZU, Yaseen G. Ethnopharmacological documentation of medicinal plants used for hypertension among the local communities of DIR Lower Pakistan. J Ethnopharmacol. 2015;175:138–46 https://doi.org/10.1016/j.jep.2015.09.014 .

Polat R, Cakilcioglu U, Kaltalioʇlu K, Ulusan MD, Türkmen Z. An ethnobotanical study on medicinal plants in Espiye and its surrounding (Giresun-Turkey). J Ethnopharmacol. 2015;163:1–11. https://doi.org/10.1016/j.jep.2015.01.008 .

Mamadalieva NZ, Akramov DK, Ovidi E, Tiezzi A, Nahar L, Azimova S, Sarker SD. Aromatic medicinal plants of the Lamiaceae family from Uzbekistan: ethnopharmacology, essential oils composition, and biological activities. Medicines. 2017;4 https://dx.doi.org/10.3390%2Fmedicines4010008 .

Uritu CM, Mihai CT, Stanciu G, Dodi G, Alexa-Stratulat T, Luca A, Leon-Constantin M, Stefanescu R, Bild V, Melnic S, Tamba BI. Medicinal plants of the family Lamiaceae in pain therapy: a review. Pain Res Manag. 2018. https://doi.org/10.1155/2018/7801543 .

Koc S, Isgor BS, Isgor YG, Moghaddam NS, Yildirim O. The potential medicinal value of plants from Asteraceae family with antioxidant defense enzymes as biological targets. Pharm Biol. 2015;53:5. https://doi.org/10.3109/13880209.2014.942788 .

Shing B, Sahu PM, Sharma MK. Anti-inflammatory and antimicrobial activities of triterpenoids from Strobilanthes callosus Ness. Phytomedicine. 2002;9:355–9. https://doi.org/10.1078/0944-7113-00143 .

Ertürk Ö, Demirbağ Z. Scorzonare mollis Bieb (Compositae) bitkisinin antimikrobiyal aktivitesi. Çevre Koruma. 2003;12:27–31.

Ahmed F, Urooj A. Traditional uses, medicinal properties, and phytopharmacology of Ficus racemosa : a review. Pharm Biol. 2010;48:672–81. https://doi.org/10.3109/13880200903241861 .

Mawa S, Husain K, Jantan I. Ficus carica L. (Moraceae): phytochemistry, traditional uses and biological activities. Evid-Based Compl Alt. 2013. https://doi.org/10.1155/2013/974256 .

Imran M, Rasool N, Rizwan K, Zubair M, Riaz M, Zia-Ul-Haq M, Rana UA, Nafady A, Jaafar HZE. Chemical composition and biological studies of Ficus benjamina . Chem Cent J. 2014;8:12 https://dx.doi.org/10.1186%2F1752-153X-8-12 .

Article   PubMed   PubMed Central   CAS   Google Scholar  

Wink M. Evolution of secondary metabolites in legumes (Fabaceae). S Afr J Bot. 2013;89:164–75. https://doi.org/10.1016/j.sajb.2013.06.006 .

Farah MH, Olsson S, Bate J, Lindquist M, Edwards R, Simmonds MS, Leon C, de Boer HJ, Thulin M. Botanical nomenclature in pharmacovigilance and a recommendation for standardization. Drug Saf. 2006;29:1023–9. https://doi.org/10.2165/00002018-200629110-00002 .

Bennett BC, Balick MJ. Does the name really matter? The importance of botanical nomenclature and plant taxonomy in biomedical research. J Ethnopharmacol. 2014;152:387–92. https://doi.org/10.1016/j.jep.2013.11.042 .

Sanubol A, Chaveerach A, Sudmoon R, Tanee T, Liehr T. Verification of selected Piper species (Piperaceae) using morphological characters, molecular data, and chemical constituents. Malay Nat J. 2014;66:60–81.

Thomford NE, Senthebane DA, Rowe A, Munro D, Seele P, Maroyi A, Dzobo K. Natural products for drug discovery in the 21st century: innovations for novel drug discovery. Int J Mol Sci. 2018. https://doi.org/10.3390/ijms19061578 .

Jachac SM, Saklani A. Challenges and opportunities in drug discovery from plants. Curr. Sci. 2007;92.

Balangcod TD, Balangcod AKD. Ethnomedical knowledge of plants and healthcare practices among the Kalanguya tribe in Tinoc, Ifugao, Luzon. Philippines. Indian J Tradit Know. 2011;10:227–38.

Tantengco OAG, Condes MLC, Estadilla HHT, Ragragio EM. Ethnobotanical survey of medicinal plants used by Ayta communities in Dinalupihan, Bataan. Philippines. Pharmacogn J. 2018;10:859–70. https://doi.org/10.5530/pj.2018.5.145 .

Balberona AN, Noveno JJ, Angeles MGB, Santos RI, Cachin EJDJ, Cruz KGJ. Ethnomedicinal plants utilized by the Ilongot-Eǵongot community of Bayanihan, Maria Aurora, Aurora. Philippines. IJAT. 2018;14:145–59.

Fox RB. The Pinatubo Negritos : their useful plants and material culture. Philippine J Sci. 1952;81:173–391.

Yen DE, Nance J. The ethnobotany of the Tasaday : the useful plants. Philippine J Sci. 1974;103:97–140.

Yen DE, Nance J. Further studies on the Tasadays . Panamin Foundation Research Series No. 2. Makati (Panamin Foundation Philippines). 1976. p. 191.

Conklin HC. Ifugao ethnobotany 1905-1965: the 1911 Beyer-Merrill report in perspective. Econ Bot. 1967;21:243–72. https://doi.org/10.1007/BF02860375 .

Beyer HO, Merrill ED. Ifugao economic plants (Typescript). 1911. p. 29.

Bodner CC, Gereau RE. A contribution to Bontoc ethnobotany. Econ Bot. 1988;42:307–69. https://doi.org/10.1007/BF02860159 .

Camacho LD, Gevaña DT, Carandang SP, Camacho SC. Indigenous knowledge and practices for the sustainable management of Ifugao forests in Cordillera, Philippines. Int J Biodivers Sci Ecosyst Serv Manag. 2015. https://doi.org/10.1080/21513732.2015.1124453 .

Waay-Juico MC, Cortuna GE, Evangelista SHM, Gatal RRD, Licuanan CIKS, Tapia FGC. Ethnobotanical practices of Tagabawa tribe on selected medicinal plants at barangay Jose Rizal, Sta. Cruz, Davao del Sur Philippines. JOCAMR. 2017;4:1–12. https://doi.org/10.9734/JOCAMR/2017/38301 .

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Acknowledgements

We are very grateful to the entire Agusan Manobo community of Bayugan City, Esperanza, and Sibagat, Agusan del Sur, for their active participation and support in the conduct of the study. The first author would like to thank his scholarship grant from the Department of Science and Technology—Accelerated Science and Technology Human Resource Development Program—National Science Consortium (DOST-ASTHRDP-NSC) and the Alexander von Humboldt Foundation as a Junior Researcher. The second author thanks the Department of Health—Philippine Institute of Traditional and Alternative Health Care (DOH-PITAHC) for the funding and the Alexander von Humboldt Foundation for a renewed research stay at the University of Bayreuth (Germany) in 2019.

The authors would like to express their heartfelt thanks and gratitude for the financial support of the Department of Health—Philippine Institute of Traditional and Alternative Health Care (DOH-PITAHC).

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MLD proposed the research study, carried out the fieldwork, molecular work, and wrote the manuscript as the major contributor of the study. DT assisted with species identification and authentication at the Philippine National Herbarium. GJA evaluated the data of fieldwork and molecular work for inclusion in the manuscript. UM and SCS reviewed, analyzed, and gave critical comments. All authors have read and approved the final manuscript.

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All necessary approval, free prior informed consent, permit, and certification were secured from the local government units (LGUs), provincial government administration, PENRO-LGU and NCIP-LGU of Agusan del Sur, and regional agencies of CARAGA administrative region (Region XIII) obtaining DENR-CARAGA wildlife gratuitous permit (no. R13-2019-12) and NCIP-CARAGA certification (no. R13-2019-01). This study secured ethics approval from USTGS-ERC (protocol no. GS-2019-PN007). The purpose of the study was discussed to the tribal communities headed by the respective tribal chieftains, and they agreed to provide information following ritual observation as part of cultural immersion.

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Additional file 1:.

Semi-structured questionnaire with Manobo dialect (Minanubu) translation

Additional file 2:

Fasta file of ITS (nrDNA) sequences

Additional file 3:

Fasta file of matK (cpDNA) sequences

Additional file 4:

Fasta file of psbA-trnH (cpDNA) sequences

Additional file 5:

Fasta file of trnL-F (cpDNA) sequences

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Dapar, M.L.G., Alejandro, G.J.D., Meve, U. et al. Quantitative ethnopharmacological documentation and molecular confirmation of medicinal plants used by the Manobo tribe of Agusan del Sur, Philippines. J Ethnobiology Ethnomedicine 16 , 14 (2020). https://doi.org/10.1186/s13002-020-00363-7

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DOI : https://doi.org/10.1186/s13002-020-00363-7

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• Agusan Manobo
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• Use diversity

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ORIGINAL RESEARCH article

Ethnobotanical documentation of medicinal plants used by the indigenous panay bukidnon in lambunao, iloilo, philippines.

• 1 The Graduate School, University of Santo Tomas, Manila, Philippines
• 2 Biology Department, School of Health Science Professions, St. Dominic College of Asia, City of Bacoor, Philippines
• 3 Department of Plant Systematics, University of Bayreuth, Bayreuth, Germany
• 4 College of Science and Research Center for the Natural and Applied Sciences, University of Santo Tomas, Manila, Philippines

The Panay Bukidnon is a group of indigenous peoples living in the interior highlands of Panay Island in Western Visayas, Philippines. Little is known about their ethnobotanical knowledge due to limited written records, and no recent research has been conducted on the medicinal plants they used in ethnomedicine. This study aims to document the medicinal plants used by the indigenous Panay Bukidnon in Lambunao, Iloilo, Panay Island. Semi-structured interviews were conducted with 75 key informants from June 2020 to September 2021 to determine the therapeutic use of medicinal plants in traditional medicine. A total of 131 medicinal plant species distributed in 121 genera and 57 families were used to address 91 diseases in 16 different uses or disease categories. The family Fabaceae was best represented with 13 species, followed by Lamiaceae with nine species and Poaceae with eight species. The leaf was the most frequently used plant part and decoction was the most preferred form of preparation. To evaluate the plant importance, use value (UV), relative frequency citation (RFC), relative important index (RI), informant consensus factor (ICF), and fidelity level (FL) were used. Curcuma longa L. had the highest UV (0.79), Artemisia vulgaris L. had the highest RFC value (0.57), and Annona muricata L. had the highest RI value (0.88). Diseases and symptoms or signs involving the respiratory system and injury, poisoning, and certain other consequences of external causes recorded the highest ICF value (0.80). Blumea balsamifera (L.) DC. and Chromolaena odorata (L.) R.M. King & H. Rob were the most relevant and agreed species for the former and latter disease categories, respectively. C. odorata had the highest FL value (100%) and was the most preferred medicinal plant used for cuts and wounds. The results of this study serve as a medium for preserving cultural heritage, ethnopharmacological bases for further drug research and discovery, and preserving biological diversity.

Introduction

About 370–500 million indigenous peoples live in 90 countries worldwide, making up 5% of the global population. They represent 5,000 distinct and diverse cultures, but they also account for 15% of the extremely poor and deprived communities from social services and economic resources ( United Nations Development Programme, 2019 ).

In the Philippines, there are 110 ethnolinguistic groups with more than 14 million people spread across the archipelago, with the highest population in Mindanao (63%), followed by Luzon (32%) and Visayas (3%) ( National Commission on Indigenous Peoples, 2011 ), who occupy around 13 million hectares (ha) (45%) of the national land territory ( National Economic Development Agency, 2017 ). The Bukidnon is the major indigenous group in the Central and Western Visayas in terms of population size, followed by the Ati/Ata (Negritoes). In Panay Island in Western Visayas, the Bukidnon population is about 112,000. The province of Iloilo is one of the four provinces in Panay Island, together with Aklan, Antique, and Capiz. It has the highest Bukidnon population with 62,245 individuals ( National Commission on Indigenous Peoples, 2019 ). Bukidnon, which literally translates to the “mountain people,” were once coastal dwellers, but due to the piratical raids from Mindanao and political suppressions during the reign of the Spanish government, they moved to the hinterlands of the island ( Magos, 2004 ). This was depicted in their epic tradition of chanting called Sugidanon ( Magos, 1999 ). To distinguish the Bukidnon in Panay from the other Bukidnon groups in Mindanao, Negros, and other neighboring islands, the “ Panay ” is added ( Gowey, 2016 ). Other authors used Mundo ( Beyer, 1917 ), Monteses “mountaineer” ( Ealdama, 1938 ), Sulod or Sulodnon “enclosed by the mountains” ( Jocano, 1968 ; German, 2010 ), Tumandok “native of the place” ( Talledo, 2004 ), and Bukidnon ( Smith, 1915 ; Magos, 1999 ) to designate the Panay Bukidnon people.

The Panay Bukidnon primarily utilized the forest resources, rivers, and streams for their food and livelihood. They also engaged in slash and burn farming and building boats to transport their goods to the lowlands. In the 1970s, when logging activities were prohibited by the Philippine government, they shifted to other means of living, including farming various crops ( Magos, 1999 ). Their social organization is relatively similar to the lowlanders. Their community membership pattern is composed of the baylan/babaylan, mirku (herb doctor), parangkutun (advisor), and the husay (arbiter). The baylan is considered the most important status in society and regarded with high respect. The baylan is the one who communicates with the spiritual world, interprets dreams, and handles religious performances. He or she may also administer herb medicine to the sick and practice folk medicine and physical therapy. Their language is Kiniray-a , a dialect that is similar to Ilonggo/Hiligaynon. Today the Panay Bukidnon settled in the interior “barangays” (villages) of at least 24 municipalities of the four provinces of Panay ( Provincial Planning Development Office, 2018 ; National Commission on Indigenous Peoples, 2020 ) and most of their communities are located in the mountainous areas of the Central Panay Mountain Range.

Iloilo province is situated in the southeastern part of Panay Island in Western Visayas. It is geographically located at the center of the archipelago, and it is known as the “Heart of the Philippines.” Its excellent port facility and strategic location made the province the center of trade during the 1890s when the sugar industry was booming and it was once given the title of “Queen City of the South.” It is also known for the “ Dinagyang Festival, ” one of the most spectacular religious and cultural celebrations in the country in honor of Senior Sto. Nino (Child Jesus) ( Province of Iloilo, 2015 ). The province has a total land area of 491,940 ha, 24% of which is classified as forestland, while 76% is classified as alienable and disposable land ( Department of Environment and Natural Resources, 2019 ).

Several ethnobotanical surveys in Panay Island have been conducted on the Ati (Negritoes) indigenous groups ( Madulid et al., 1989 ; Ong and Kim, 2015 ; Cordero et al., 2020 ; Cordero and Alejandro, 2021 ), but there is no study focused exhaustively on the medicinal plants used by the Panay Bukidnon in ethnomedicine. Nevertheless, several plants were listed with medicinal purposes in the anthropological case studies documented in the interior barangays of Tapaz, Capiz in Central Panay in 1945–1959 ( Jocano, 1968 ). Given the absence of recent research about the ethnobotanical knowledge of Panay Bukidnon , it is therefore urgent to document this indigenous knowledge before it is forgotten. The documentation of traditional knowledge will serve as a medium for preserving cultural heritage, ethnopharmacological bases of drug research and discovery, and preserving biological diversity. Thus, this study is the first attempt to extensively survey the ethnobotanical knowledge in one of the indigenous Panay Bukidnon communities in the province of Iloilo in Panay Island, Western Visayas, Philippines.

Materials and Methods

Study area and permits.

The town of Lambunao is a first-class municipality in the third district of Iloilo province, with a population of 81,236 individuals as of May 2020 ( Philippine Statistics Authority, 2021 ). It is the largest municipality in the province in terms of land area (40, 709 ha), about 26.12% of which are forestlands, and the rest are alienable and disposable land. It is bounded by the municipalities of Calinog in the North, Duenas and Pototan in the East, Janiuay and Badiangan in the South, and Janiuay and Valderrama, Antique, in the west ( Figure 1 ). It is a mountainous municipality and has the highest elevation (194 m a.s.l.) in the province. The climate of the area has two pronounced seasons: dry from the months of November to April and wet for the rest of the year. Seven out of its 73 barangays are inhabited by the Panay Bukidnon people. Brgy. Caguisanan, which lies between 11°05′37.6″N and 11°04′42.3″N latitude and 122°24′26.6″E 122°26′51.6″E longitude, has a land area of about 5.20 km 2 . According to the recent survey, it is one of the seven indigenous Panay Bukidnon barangays with a population of 1,842 in 394 households. The main source of livelihood in the barangay is farming of various crops such as rice, banana, corn, and other vegetables. Some of the younger generations are professionals working in various private and government sectors and some are working as overseas Filipino workers abroad. The landscape of the study site is dominated by hills and mountains with scattered rice terraces, grasslands, and patch forests.

FIGURE 1 . Position of the study area in Panay Island (Philippines).

Certification Precondition was acquired from the National Commission on Indigenous Peoples (NCIP)-Region VI/VII and the researchers have satisfactorily complied with the requirements for securing the Indigenous Knowledge and Systems Practices (IKSPs) and Customary Laws (CLs). It was issued in compliance with Section 59 of the Republic Act No. 8371 “The Indigenous Peoples Rights Act (IPRA) of 1997.” Several meetings were conducted: Pre-FPIC (Free and Prior Informed Consent) Conference; Disclosure Conference with the Indigenous Peoples (IP) Community and Presentation of Application; Community Decision Meeting; Memorandum of Agreement Preparation and Signing; and Output Validation Meeting. A Wildlife Gratuitous Permit was issued by the Department of Natural Resources Region (DENR) VI before conducting the study.

Data Collection

Fieldworks and interviews were conducted from June 2020 to September 2021. Interviews were carried out using semi-structured questionnaires, ethically reviewed, and approved ( Supplementary Material S1 ). A purposive sampling technique was used, and the principal key informants were determined during the community decision meeting in the presence of the NCIP officers, barangay officials, IP leader, and council of elders. The informants were composed of the tribal leader, council of elders, herb doctors ( mirku/surhano/albularyo ), midwife ( paltera ), and other members of the community who have indigenous knowledge of using medicinal plants in treating and addressing health problems and conditions. A total of 75 informants, 31 males and 44 females, aged between 24 and 89 years old, were interviewed at their own convenience in their community during the study. Questions regarding personal information and the medicinal plants they used when they experienced any health-related problems were asked during the surveys. The information about the demographic profile of the participants, such as age, gender, civil status, educational attainment, and occupation, is shown in Table 1 . The plant part used, mode of preparation, and administration were also recorded during the interviews. A focus group discussion was conducted with the 10 members of the council of elders to verify the acquired data among the informants during the output validation meeting. The meeting was facilitated by the NCIP officers, IP leader, and Brgy. Captain.

TABLE 1 . Demographic profile of the Panay Bukidnon informants in Lambunao, Iloilo, Philippines.

Plant Collection and Identification

Collecting medicinal plant samples was carried out with the help of the informants, if available in their immediate surroundings or their home gardens right after the interview. Some field collections were assisted by the informants who have the knowledge of the location of some plants that were not available in the home gardens. Plants were also photographed for documentation purposes. Voucher specimens were prepared using three to five branches with preferably reproductive parts (flowers and fruits), inserted in newspapers, and positioned in a way that best represents the plant in the wild. The plants were poisoned with a generous amount of denatured alcohol in polyethylene bags. Poisoned specimens were then transferred to a new newspaper and placed in a presser. Pressed and dried plant specimens were then mounted on herbarium sheets with proper documentation labels. Voucher specimens were accessioned and deposited in the Herbarium of the Northwestern University Luzon (HNUL). Identification of the collected medicinal plants was made using different online databases such as Co’s Digital Flora of the Philippines, ( https://www.philippineplants.org/ ), Phytoimages ( http://www.phytoimages.siu.edu ), Stuartxchange ( http://www.stuartxchange.org/ ), and Plants of the World Online ( http://plantsoftheworldonline.org/ ), then verified by Mr. Danilo Tandang, a botanist at the Philippine National Museum Herbarium and Mr. Michael Calaramo of the Herbarium of Northwestern University Luzon (HNUL). For the validation of the family and scientific names, Tropicos ( Tropicos, 2021 ), World Flora Online ( World Flora Online, 2021 ), and International Plant Names Index ( International Plant Names Index, 2021 ) were used. To identify the geographical distribution and endemicity of the medicinal plants, Co’s Digital Flora of the Philippines ( Pelser et al., 2011 ) and Plants of the World Online ( Plants of the World Online, 2021 ) were used.

Data Analyses

There were five values used to quantify the plant importance: use value (UV), relative frequency of citation (RFC), relative importance index (RI), informant consensus factor (ICF), and fidelity level (FL). The UV was calculated to determine the relative importance of the medicinal plant species using the following formula: UVs = Ui / N , where U i is the number of use reports cited or mentioned by each informant for a particular species and N is the total number of informants ( Phillips and Gentry, 1993 ). A use report was considered every time an informant cited or mentioned a plant being used for any medical condition or purpose. RFC was used to determine the culturally important medicinal plants using the following formula: RFCs = FCs / N , where FC s is the number of informants who cited or mentioned a plant species (frequency citation) and N is the total number of informants who participated in the study. The values range from 0 to 1, 1 being the highest and indicating that all informants cited or mentioned a particular plant species ( Tardío and Pardo-De-Santayana, 2008 ). RI was used to assess the relative importance of medicinal plants by use category using the following formula: RIs = [ RFCs ( max ) + RNUs ( max ) ] / 2 , where RFC s(max) (RFC s(max) = FC s /FC max ) is the relative frequency of citation of the species and is obtained by dividing the frequency citation of informant/s for a particular species (FC s ) by the number of informants citation of the species that has the maximum or highest frequency citation (FC max ). RNU s(max) , (RN s(max) = NU s /NU max ) is the relative number of the use categories and is obtained by dividing the number of use categories of a particular species (NU S ) by the number of use categories of the species with the highest use categories (NU max ). Values closest to 1 indicate that the medicinal plants are most frequently cited as useful in different use categories ( Tardío and Pardo-De-Santayana, 2008 ). ICF was used to evaluate the consensus or homogeneity of the ethnobotanical information from the participating informants using the following formula: ICF = ( Nur − Nt ) / ( Nur − 1 ) , where N ur is the number of use reports for each disease category and N t is the number of species used in that category ( Heinrich et al., 1998 ). FL was used to assess the percentage of the most preferred medicinal plant for a particular disease category using the following formula: FL = ( Np / N )  x 100 , where N p is the number of informants who cited or mentioned the use of a medicinal plant for a particular disease category and N is the total number of informants who cited that plant for any other use or purpose ( Friedman et al., 1986 ). A high value indicates that a medicinal plant has the highest use report and the most preferred species within a particular disease category. There were 16 different use or disease categories adapted and modified from the ICD-11 International Classification of Diseases 11th Revision of the World Health Organization ( World Health Organization, 2021 ), which is used in this ethnopharmacological documentation.

Medicinal Plants Characteristics

The present study documented a total of 131 medicinal plant species distributed in 121 genera and 57 families. The family Fabaceae was best represented with 13 species, followed by Lamiaceae with nine species and Poaceae with eight species ( Figure 2 ). Fabaceae are used to treat 28 diseases in 13 different use or disease categories, Lamiaceae in 24 diseases in ten disease categories, and Poaceae in 21 diseases in 12 disease categories.

FIGURE 2 . Family of medicinal plants with a high number of genera and species.

The medicinal plants recorded possess different growth forms such as herbs (43%), trees (31%), shrubs (16%), and climbers (10%) ( Figure 3 ). The plants were collected within the vicinity of the barangay mostly cultivated in the informant’s home gardens or backyards that serve as ornamentals and vegetables and used for medicinal purposes; some were cultivated as crops in the farmland; some were grown on the riverbanks and forest; others do grow as weeds pervasively around the community. Of all the 131 medicinal plants listed, 91 species were collected as cultivated plants and 40 species were collected in the wild. Out of 127 plants identified up to the species level, 78 species are not native (introduced, naturalized, cultivated) in the Philippines and 49 species are native. Three species ( Areca catechu L., Musa textilis Née, and Mussaenda philippica A. Rich.) of the native plants are considered endemic and their occurrence is widespread in the country. Information about the plant growth habit, collection sites, and geographical distribution and endemicity are found in = Supplementary Table S1 .

FIGURE 3 . Medicinal plant growth habit.

The medicinal plant details are summarized in Supplementary Table S2 . The scientific, local, and family names are also listed along with the plant part used, disease or purpose, quantity, mode of preparation, the form of administration, adverse or side effects, use value, relative frequency citation, and relative importance index.

Plant Part Used and Mode of Preparation and Administration

Sixteen different medicinal plant parts were used to address 94 diseases and health-related conditions documented in this study. The most frequently used plant parts for the preparation of the remedy were leaf (51%), followed by bark (8%), fruit (6%), and rhizome (6%) ( Figure 4 ). Root, stem, whole plant, flower, seed, bulb, shoot, sap, and aerial root were also used but less frequently. The least utilized plant parts were tuber, petiole, and tendril. There were ten different ways to prepare the medicinal plants and the most common forms were decoction (35%), followed by crushing or pounding (23%) and direct application (20%) ( Figure 5 ). Eat/chew/drink, heat/roast, soak in water, and grate/slice were also practiced. The least forms of preparation were cooking, processing into vinegar or oil, and burning for smoke or ash. The plant parts used and the mode of preparation of the medicinal plants depend on the ailments to be addressed and to whom they will be administered. Occasionally, some of the preparations include animal parts and products such as blood, egg, beeswax ( kabulay ), slaked lime ( apog ), minerals like salt, and chemicals like kerosene but in minute amounts. Sugar or breastmilk was also added to reduce or mask the bitterness of plant extracts to be taken orally by infants and children.

FIGURE 4 . Medicinal plant parts used.

FIGURE 5 . Medicinal plant preparation.

More than half of the medicinal plant preparations (52%) recorded were administered externally or topically by applying plant parts directly on the body, rubbing plant extracts, bathing, and burning for smoke and ash. The rest were taken orally (48%) by drinking decoction, eating, chewing, drinking extracts or liquids and used as a mouthwash.

Quantity and Dosage

The quantity of the medicinal plants used is influenced by the guided cultural and religious beliefs of the Panay Bukidnon and should be prepared or administered in odd numbers (3, 5, or 7). For example, in treating headaches, three different medicinal plants such as Pseuderanthemum carruthersii (Seem.) Guillaumin (3, 5, or 7 leaves depending on the leaf size), Curcuma longa L. (7 thinly sliced rhizomes), and Zingiber officinale Roscoe (7 thinly sliced rhizomes) were applied on the forehead. The frequency of the administration was dependent on the disease to be treated. For decoction, it was often administered by drinking a full glass to be taken twice or thrice a day or as a replacement for water intake. The detailed quantity and frequency of administration of medicinal plants are shown in Supplementary Table S2 .

Use Value and Relative Frequency of Citation

The use value was used to evaluate the relative importance of the medicinal plants: high values indicate high use report, while relative frequency citation determined the usefulness of the plant by high FC or being mentioned by all the informants.

The top three medicinal plants with the highest use value were Curcuma longa L. (0.79), Blumea balsamifera (L.) DC. (0.64), and Artemisia vulgaris L. (0.59) ( Table 2 ). C. longa is used to treat 13 diseases in nine disease categories and recorded a high use report in suppressing fever, headache, and sinda. It is usually prepared with two or four medicinal plants. The preparation and mode of administration for headache and fever were the same and with few modifications for sinda . C. longa is also used for muscle pain, stomachache, bloated stomach, tooth decay, typhus, typhoid fever, memory loss, cancer, cuts/wounds, and tetanus. It is cultivated in the informant’s home gardens for medicinal purposes.

TABLE 2 . Top ten medicinal plants with the highest UV, RFC, and RI values.

B. balsamifera was used to treat nine conditions or purposes under eight different disease categories and is widely known to cure cough, used in postpartum care and recovery, and relieved headache. It is also used for muscle pain, bloated stomach/gas pain, goiter, urinary tract infection (UTI), vomiting blood, and inaswang . It was collected growing in the farmland, but some informants also cultivated it in their backyards.

A. vulgaris was used to treat seven ailments in six disease categories and is the best-known therapy for cough, fever, headache, and body pains. It is also used for the remedy of chest pain, fracture, and hearing problems. It is grown in the home gardens as medicinal plants for future use. Seven medicinal plants were recorded with only one use report and FC for each species: Cheilocostus speciosus (J.Koenig) C.D.Specht , Luffa aegyptiaca Mill., Syzygium cumini (L.) Skeels , Lygodium circinnatum (Burm. f.) Sw . , Solanum melongena L ., Nauclea orientalis (L.) L ., and Leea guineensis G. Don, which garnered the lowest value for UV (0.01) and RFC (0.01).

Medicinal plants with the highest RFC were Artemisia vulgaris (0.57), followed by Curcuma longa (0.47) and Blumea balsamifera (0.44) ( Table 2 ). Out of the 75 informants who participated in the survey, A. vulgaris had the highest informant citation or FC.

Relative Importance Index

The RI was used to assess the relative importance of the medicinal plants by use or disease categories. A high value indicates that a particular medicinal plant species is most frequently cited as useful with a high number of use categories or having multiple uses. The top three plants with the highest RI values were Annona muricata L. (0.88), C. longa (0.87), and B. balsamifera (0.80) ( Table 2 ). A. muricata is used in 11 different use or disease categories: diseases of the genitourinary system; neoplasms; diseases of the circulatory system and blood or blood-forming organs; endocrine, nutritional and metabolic diseases; diseases and symptoms or signs involving the respiratory system; diseases and symptoms or signs involving the nervous system; diseases and symptoms or signs involving the digestive system or abdomen; infectious and parasitic diseases; diseases and symptoms or signs involving the skin; diseases and symptoms or signs of the musculoskeletal system or connective tissue; and other cultural uses. It is used to address 13 diseases or purposes and recorded the high use report in treating UTI, cancer, and hypertension by drinking the leaf decoction or soaking the young leaves in warm water and drink or by just eating a medium sliced fruit three times a day. A. muricata is also used for the remedy of high uric acid, pneumonia, dizziness, intestinal cleansing, kidney trouble, itchy throat, amoebiasis, lump, arthritis, and doklong . C. longa was used in nine categories: injury, poisoning and certain other consequences of external causes; neoplasms; diseases and symptoms or signs involving the nervous system; general symptoms and signs; diseases and symptoms or signs involving the digestive system or abdomen; infectious and parasitic diseases; diseases and symptoms or signs of the musculoskeletal system or connective tissue; mental or behavioral symptoms, signs, or clinical findings; other cultural uses. B. balsamifera is used in eight disease categories: diseases and symptoms or signs involving the digestive system or abdomen; endocrine, nutritional, and metabolic diseases; diseases of the genitourinary system; diseases and symptoms or signs of the musculoskeletal system or connective tissue; diseases and symptoms or signs involving the nervous system; diseases and symptoms or signs involving the respiratory system; pregnancy, childbirth, and the puerperium; other cultural uses. The top ten medicinal plants with the highest use value, relative frequency citation, and relative importance index are shown in Table 2 .

Informant Consensus Factor

There were 91 diseases and purposes in 16 different use or disease categories recorded in this study ( Table 3 ). ICF was used to evaluate the consensus in the medicinal plant information among the informants. High ICF values indicate one or few medicinal plants mentioned by a high number of informants within a particular disease category, and low values indicate that more species are being used and the informants differ in their preference on which plant to use. The highest ICF value (0.80) was in the diseases and symptoms or signs involving the respiratory system and in injury, poisoning, and certain other consequences of external causes. The diseases and symptoms or signs involving the respiratory system were cough, pneumonia, rhinorrhea, itchy throat, chest pain, and tonsillitis. B. balsamifera had the highest use report within the category and was frequently used plant for treating cough by consuming the young leaves or by drinking leaf or root decoction or by rubbing leaf extract on the head of the afflicted ones. A high proportion of informants mentioned and agreed upon the use of B. balsamifera in treating cough within the category. Injuries, poisoning, and certain other consequences of external causes recorded, such as animal bite, bruise, burn, caterpillar dermatitis, circumcision, cuts and wounds, fracture, and splinter, were the reported purposes or medical uses. Chromolaena odorata (L.) R.M.King & H. Rob . had the highest use report within the category and was the most preferred medicinal plant used to treat cuts/wounds by applying crushed leaves on the affected area. The next highest value was in the diseases and symptoms or signs involving the nervous system (0.73) with headache, migraine, and dizziness as the reported medical condition. Pseuderanthemum carruthersii had the highest use report and was widely used for treating headaches by applying leaves on the forehead alone or with C. longa and Z. officinale . The lowest ICF value was recorded in mental disorder (0.00) with memory loss as the reported condition and Curcuma longa was used for the treatment.

Fidelity Level

The FL was used to determine the relative importance of a medicinal plant within each category. Medicinal plants with the highest FL values were Chromolaena odorata (100%), Bambusa spinosa Roxb. (93%), and Pseuderanthemum carruthersii (93%) ( Table 3 ). C. odorata is exclusively used to treat cuts and wounds and can be seen growing invasively along the paths and roadsides in the community. B. spinosa recorded the highest use report for postpartum care and recovery under the pregnancy, childbirth, and puerperium category. It is preferably used and highly suggested by many informants for postpartum care and recovery therapy. Decoction of at least three up to ten different medicinal plants was used for drinking (1–2 glasses), body steaming, and bathing to be performed nine days after a mother gave birth. B. spinosa has also been used to treat cancer, UTI, and kidney stones but with only one citation recorded for each ailment P. carruthersii has the highest use report and is the most preferred medicinal plant for relieving headaches under the diseases and symptoms or signs involving the nervous system. The lowest FL value was recorded for C. longa in treating memory loss under the mental disorder category with only one informant mentioned for its curative effect.

TABLE 3 . Use or disease category, reported disease or uses, ICF, and FL of the most cited species.

Comparing Different Indices

Table 2 shows the top 10 medicinal plants with the highest UV, RFC, and RI values. High UV and RFC values indicate the high number of use reports and frequency citations (FC) from the informants, while high RI values consider the multiplicity of uses or the high number of uses in different disease categories. This implies that medicinal plants with high UV, RFC, and RI values are the most important and valued medicinal plants in the community. There are a few considerable differences in species ranking yielded by the three indices set out in Table 2 . The ranks of the first three species ( C. longa, Blumea balsamifera, and Artemisia vulgaris ) are nearly the same in all indices except in RI where Annona muricata had the highest value but ranked 4th in UV and only 9th in RFC. C. longa, B. balsamifera, and A. vulgaris had the highest use reports and FC from the informants and only next to A. muricata in terms of multiple uses in different disease categories. A. muricata had the highest number of uses or purposes in different disease categories (11 disease categories); however, its use reports and FC are not quite as high as those of the first three species mentioned above. A. muricata is the most frequently used medicinal plant in a wide range of diseases (13 diseases). Another noticeable difference is the inclusion of Moringa oleifera Lam. and Carica papaya L. in the RI index, which are not shown in the top ten species with high UV and RFC values. M. oleifera ranks 12th in UV and 13th in RFC, while C. papaya ranks 17th in UV and 14th in RFC (values are not shown in Table 2 but available in Supplementary Table S2 ). Their UV and RFC values are not quite as high, but they have multiple uses in different disease categories. Low UV, RFC, and RI values indicate a low number of use reports, FC, and have one or few uses in disease categories. For example, Andrographis paniculata (Burm.f.) has low UV (0.04), RFC (0.03), and RI (0.07) values, indicates low use report (2) and FC (2 informants), and is only used in one disease category (diseases and symptoms or signs involving the digestive system or abdomen). This implies that A. paniculata is a less important and less preferred medicinal plant species in the Panay Bukidnon community. On the other hand, Table 3 shows the use or disease categories and ICF and FL values. High ICF values are considered the most culturally relevant medicinal plants and the agreement of its use within a disease category in the community, while FL highlights the most preferred species for a particular disease. Medicinal plants with the high ICF values were Blumea balsamifera (0.80), Chromolaena odorata (0.80), and Pseuderanthemum carruthersii (0.73) and these species are highly agreed upon by most informants for the therapy of diseases in their respective disease categories. Medicinal plants with high FL values were C. odorata (100%), P. carruthersii (93%), and Bambusa spinosa (93%) and these are the most preferred species to a particular disease in each disease category. Though B. spinosa is not included in the top medicinal plants with high UV, RFC, and RI values, its curative effect for postpartum care and recovery is preferred by a high proportion of informants. Medicinal plants with high UV, RFC, RI, ICF, and FL values are the most culturally important, relevant, preferred, and agreed on species in the Panay Bukidnon communities.

Cultural Important Medicinal Plants

Indigenous peoples are strongly tied with their spiritual beliefs and practices. Interestingly, up to date, the Panay Bukidnon still believe that some of the illnesses and diseases are caused by spirits, supernatural beings, and sorcery. Some diseases were mentioned that were caused by aswang (witch), hiwit (sorcery), sinda (charm of spirits) and some health conditions like doklong and kolebra with more complicated and sometimes unexplained symptoms. Sinda is a condition with symptoms like dizziness and fever caused by spirits or supernatural beings, while kolebra has symptoms like chills, stomachache, nausea, shortness of breath, and paleness. Doklong is somewhat similar to “relapse” and sometimes accompanied by other symptoms like headache, muscle pain, and weakness. For inaswang , five medicinal plants were recorded for the therapy and a cultivar of Alocasia is frequently used by applying the heated leaf to the stomach area. For the treatment of hiwit , a species of Amomum is used by rubbing the stem extract on the body or by crushing the stem with the inner bark of Pipturus arborescens (Link) C.B. Rob. and taking the extract orally. Curcuma longa is the most used medicinal plant used to cure sinda by rubbing the rhizome’s extract on the head or applying the sliced rhizome along with other plants on the forehead. Jatropha curcas L. is frequently used as a remedy for kolebra by drinking the extract of the inner bark and for doklong , drinking the leaf decoction of Citrus maxima (Burm.) Merr. alone or with other medicinal plants is the most preferred.

Medicinal Plants Used to Strengthen Immunity Against Infection and for Potential COVID-19 Therapy

With the current situation of the novel coronavirus disease (COVID-19) in the country and the resurgences of the infection waves, communities in the far-flung areas tend to explore different medical plants as an alternative for potential therapy while waiting for the vaccine. There were ten medicinal plants mentioned by the council of elders that they used to boost their immunity against COVID-19 infection ( Table 4 ). If someone is suspected of having a COVID-19 infection or exhibits symptoms related to COVID-19, they use the available medicinal plants ( Table 2 ) available to alleviate their condition. Medicinal plants such as Curcuma longa, Zingiber officinale, Capsicum annuum L., and Peperomia pellucida (L.) Kunth are traditionally used by the Panay Bukidnon to treat fever, headache, cough, and body pains which were also the symptoms of COVID-19 and influenza. They also believed that chewing betel quid which is composed of Areca catechu L., Piper betle L., Nicotiana tabacum L. , and slaked lime ( apog ) can help them fight the infection and help them feel substantially better.

TABLE 4 . Medicinal plants used to strengthen immunity against infection.

Comparative Review of the Medicinal Plants With Other Ethnobotanical Studies

The anthropological study conducted in the Panay Bukidnon communities in the Province of Capiz in the 1950s recorded a total of 54 medicinal plant species and 21 of which are cited in this current ethnobotanical study. An additional 109 taxa were documented to the medicinal flora used by the Panay Bukidnon in Panay Island from this present study.

To identify the new medicinal plants and plant use, a comprehensive comparison was performed with 22 ethnobotanical studies published from 2011 up to the present and with one online database. Only the scientific names and their synonyms were used for the comparative review; local names were not considered because they are arbitrary within different cultures and dialects. Of the 127 medicinal plants identified up to the species level, three species ( Eleutherine palmifolia (L.) Merr., Hibiscus acetosella Welw. ex Hiern, and Oxalis triangularis A.St.-Hil.) show some novel medicinal uses that were not documented in other existing ethnobotanical studies conducted in the country. These medicinal plant species are not native to the Philippines. E. palmifolia is used for the therapy of rashes and headaches. Its red bulb is the preferred plant part for the treatment. It is usually used as an ornamental plant grown in the home gardens and community center. H. acetosella is used to cure cuts/wounds, boils, anemia, hypertension, diabetes, rhinorrhea, and cough. Filipinos also used this medicinal plant as a vegetable and normally use it to “sour” the dishes. With its deep red-purple foliage, it is also served as an ornamental plant. O. triangularis is used to treat cuts/wounds by the Panay Bukidnon and serves as a hanging ornamental plant for its striking deep maroon trifoliate leaves. Forty-seven medicinal plants were recorded to have an additional therapeutic use or purpose not mentioned in the other previous ethnobotanical studies, while 80 species have the same medicinal values as mentioned in the existing literature. Some of the additional uses or purposes of the medicinal plants that are rarely listed in other studies are angular cheilitis, breast engorgement, and promoting teething in toddlers. The detailed information about the comparative review of the medicinal plants and the additional plant uses is shown in Table 5 .

TABLE 5 . Comparative presence-absence matrix of the medicinal plants used by the Panay Bukidnon with other ethnobotanical studies.

The documentation of 131 medicinal plant species used in the indigenous health care practices showed the extensive usage of Panay Bukidnon ethnobotanical knowledge and indicative importance for their rich cultural heritage. The families of Fabaceae, Lamiaceae, and Poaceae were represented with a high number of medicinal plant species. Fabaceae as the most preferred medicinal plant family used by the Panay Bukidnon is parallel to the other folkloric studies conducted in Western Visayas ( Madulid et al., 1989 ; Tantiado 2012 ; Ong and Kim, 2014 ; Cordero and Alejandro, 2021 ) and other indigenous communities in the country ( Ragragio et al., 2013 ; Obico and Ragrario, 2014 ; Tangtengco et al., 2018 ; Pablo, 2019 ). Fabaceae is highly used by the Panay Bukidnon to treat infectious and parasitic diseases and diseases and symptoms or signs involving the digestive system or abdomen. The family constitutes phytochemicals that have antibacterial, antifungal, antioxidant, and insecticidal activities ( Wanda et al., 2015 ).

The use of leaves as the most preferred medicinal plant part to address medical conditions is comparable to other ethnobotanical surveys conducted throughout the archipelago ( Balangcod and Balangcod, 2011 ; Olowa et al., 2012 ; Abe and Ohtani, 2013 ; Gruyal et al., 2014 ; Ong and Kim, 2014 ; Raterta et al., 2014 ; Balangcod and Balangcod, 2015 ; Pizon et al., 2016 ; Odchimar et al., 2017 ; Baddu and Ouano, 2018 ; Tantengco et al., 2018 ; Agapin, 2019 ; Pablo, 2019 ; Cordero et al., 2020 ; Dapar et al., 2020 ; Belgica et al., 2021 ; Cordero and Alejandro, 2021 ; Madjos and Ramos, 2021 ; Montero and Geducos, 2021 ; Nuñeza et al., 2021 ). As a tropical country, leaves are always available for most plant species at all seasons and are readily accessible in case of emergencies. The collection of leaves is more sustainable than gathering other plant parts such as barks and roots that can cause damaging effects and even mortality to a plant if harvested in large quantities. Leaves contain the highest secondary metabolites with an antimicrobial effect ( Chanda and Kaneria, 2011 ), antioxidant property, antibiotic activity, and antidiabetic potential compared with other plant parts ( Jain et al., 2019 ).

Decoction is the most common form of preparation and preferably to be taken orally and occasionally used for body steaming, bathing, and washing. It is also an evident form of preparation in other indigenous communities in the country ( Balangcod and Balangcod, 2015 ; Pizon et al., 2016 ; Odchimar et al., 2017 ; Baddu and Ouano, 2018 ; Tantengco et al., 2018 ; Cordero et al., 2020 ; Cordero and Alejandro, 2021 ; Madjos and Ramos, 2021 ; Nuñeza et al., 2021 ). Decoction is done with the use of one medicinal plant species or in a combination of two or more. The Panay Bukidnon are culturally used to combine three, five, or seven (colloquially known as pito-pito ) different medicinal plants for higher efficacy. Each plant constitutes phytochemical compounds and is sometimes present in small quantities and inadequate to achieve desirable therapeutic effects. To yield better results and effectiveness, the combination of different medicinal plants demonstrates the synergistic effects. Some bioactive chemicals work significantly when combined with other plants rather than used singly ( Parasuraman et al., 2014 ).

Curcuma longa recorded the highest use value and is used as therapy for headache, fever, body pain, stomachache, bloated stomach, tooth decay, typhus, typhoid fever, anti-tetanus, memory loss, cancer, and sinda . The rhizome’s extract is usually used for the treatment. It is also used by other indigenous groups in the country for diarrhea, abdominal pain, flatulence, arthritis, and hypertension by the Higaonon tribe in Iligan City ( Olowa et al., 2012 ); arthritis, cough, and cuts and wounds by the Ivatan tribe in Batan Island ( Abe and Ohtani, 2013 ); fever, burn, dizziness, and abdominal pain by the Ati tribe in Guimaras Island ( Ong and Kim, 2014 ); arthritis by the Subanen tribe in Zamboanga del Sur ( Pizon et al., 2016 ); flatulence, headache, numbness, rheumatism, stomachache, and vomiting by the Aetas tribe in Bataan ( Pablo, 2019 ); cancer by the Manobo tribe in Bukidnon ( Pucot et al., 2019 ); skin eruptions and gastric pain by the Ati tribe in Aklan ( Cordero et al., 2020 ); ten different diseases by the Manobo tribe in Agusan del Sur ( Dapar et al., 2020 ); myoma, hepatitis, relapse, sore eyes, and stye by the eight ethnolinguistic groups in Zamboanga Peninsula ( Madjos and Ramos, 2021 ); bruise and boils by the Mamanwa tribe in Surigao del Norte and Agusan del Norte ( Nuñeza et al., 2021 ). In India, the use of C. longa dates back to 4,000 years ago not only as a culinary spice but also for religious and medicinal importance. It contains bioactive compounds that have antioxidant, antimutagenic, antimicrobial, antimutagenic, antimicrobial, antifungal, anticancer, and other countless medicinal uses ( Prasad and Aggarwal, 2011 ).

Artemisia vulgaris has the highest relative frequency citation. It is a cosmopolitan weed and is available nearly everywhere. It thus does not surprise that it is commonly used for cough, fever, headache, body pains, chest pain, fracture, and hearing problems. Other ethnobotanical surveys mentioned its efficacy against cough and scabies by the Kalanguya tribe in Ifugao ( Balangcod and Balangcod, 2011 ); stomachache ( Olowa et al., 2012 ); sore eyes, ear infection, and cough by the Ayta tribes in Pampanga ( Ragragio et al., 2013 ); cough with phlegm, fever, abdominal pain, body pains, and headache ( Ong and Kim, 2014 ); colds by the Talaandig tribe in Bukidnon ( Odchimar et al., 2017 ); dysmenorrhea by the Y’Apayaos in Cagayan arthritis ( Baddu and Ouano, 2018 ); fever, sore throat, colds, cough, and phlegm Ayta in Bataan ( Tantengco et al., 2018 ); fever, headache, dizziness, stomachache, bloated stomach, and cough ( Cordero et al., 2020 ); 11 different folkloric uses ( Madjos and Ramos, 2021 ); cough and gas pain ( Cordero and Alejandro, 2021 ); fever, cough, and cough with phlegm ( Nuñeza et al., 2021 ). In medieval times, it was known as the “mother of herbs” due to its beneficial effects. Studies have been conducted worldwide for its antioxidant, bronchodilatory, hepatoprotective analgesic, antihypertensive, estrogenic, cytotoxic, antifungal and antibacterial, anti-inflammatory, anti-allergenic, antimalarial, and anthelmintic activities ( Ekiert et al., 2020 ). Artemisia, per se, is an extremely important plant genus, pharmacologically as well as economically. A. annua L. makes the most important example, famous for its many pharmacologically active substances but especially for Artemisin ( Tu, 2011 ), an effective remedy against malaria.

Annona muricata , an important, widely grown fruit tree, has the highest relative importance index value (0.88) and is used to treat 13 diseases in 11 different use or disease categories. It recorded the high use report for treating UTI, cancer, and hypertension by drinking the leaf decoction or eating just the ripe fruit. It is also used by the Panay Bukidnon for high uric level, pneumonia, dizziness, intestinal cleansing, kidney trouble, doklong , itchy throat, amoebiasis, lump, and arthritis. In traditional medicine across the country, it is also used for the treatment of diarrhea ( Olowa et al., 2012 ); dermatological diseases ( Tantiado, 2012 ); fever, insect repellent, headache, and stomachache ( Ragragio et al., 2013 ); tetanus ( Pizon et al., 2016 ); gastrointestinal cleansing and tumors ( Odchimar et al., 2017 ); fever and arthritis ( Baddu and Ouano, 2018 ); stomachache and dizziness ( Tantengco et al., 2018 ); diabetes, high blood, stomachache, UTI, and vertigo ( Pablo, 2019 ); cancer ( Agapin, 2019 ); 12 different diseases ( Dapar et al., 2020 ); kidney problems, urinary tract infection, goiter, and anthelmintic ( Cordero et al., 2020 ); at least 16 medical problems ( Madjos and Ramos, 2021 ); cuts and wounds, stomach ulcer, intestinal cleansing, UTI, cough, and cancer ( Cordero et al., 2020 ); cancer ( Montero and Geducos, 2021 ); cough, wound, asthma, and UTI ( Nuñeza et al., 2021 ); cancer, stomach acidity, hypertension, and cough ( Belgica et al., 2021 ). Phytochemical constituents investigated on A. muricata exhibited antiarthritic, anticancer, anticonvulsant, antidiabetic, anti-inflammatory, antioxidant, antihypertensive, antiparasitic, antiplasmodial, cytotoxic, gastroprotective, and wound healing activity ( Moghadamtousi et al., 2015 ; Coria-Téllez et al., 2018 ).

The highest ICF value is in the diseases of the respiratory system category and Blumea balsamifera is the most frequently used medicinal plant to treat cough. A high number of informants agreed on the effectiveness of B. balsamifera against the diseases on the respiratory system, particularly for treating cough in the community. However, this therapeutic claim must be seriously considered for further pharmacological investigations to determine its efficacy. B. balsamifera is one of the ten medicinal plants endorsed by the Philippine Department of Health (DOH) as part of basic healthcare and clinically proven to have diuretic and antiurolithiasis properties. It is manufactured in the country for national distribution and marketing by the National Drug Formulary ( World Health Organization, 1998 ). It also contains compounds (monoterpenes, diterpenes, sesquiterpenes) that have antitumor, antioxidant, antimicrobial and anti-inflammation, antiplasmodial, antityrosinase, wound healing, anti-obesity, disease and insect resistance, and hepatoprotective effects and radical scavenging activities ( Pang et al., 2014 ).

The medicinal plant with the highest FL was the Chromolaena odorata under the injury, poisoning, and certain other consequences of external causes category. All informants who cited C. odorata preferred to use it as first aid for cuts and wounds. This suggests that C. odorata might contain valuable bioactive compounds with pharmacological effects for cuts and wounds that must be proven scientifically. Several ethnobotanical studies also recorded the use of C. odorata for cuts and wounds in the country ( Olowa et al., 2012 ; Ong and Kim, 2014 ; Pizon et al., 2016 ; Odchimar et al., 2017 ; Tantengco et al., 2018 ; Cordero et al., 2020 ; Dapar et al., 2020 ; Belgica et al., 2021 ; Cordero and Alejandro 2021 ; Madjos and Ramos, 2021 ). The leaves of C. odorata are rich in flavonoids and have the highest concentration of allelochemicals. They have antimalarial, anti-inflammatory, antibacterial, analgesic, antipyretic, antioxidant, anticancer, and wound healing properties ( Vijayaraghavan et al., 2017 ).

Traditional medical practices in the indigenous groups in the Philippines are generally influenced by their cultural, spiritual, and religious beliefs of supernatural beings. Curcuma longa is the most preferred medicinal plant administered by the Panay Bukidnon to a sick person with conditions caused by unseen beings. In Hindu worship rights, C. longa has been used for offerings and magic ( Velayudhan et al., 2012 ).

Plant-based compounds have been in constant use since ancient times for any emerging disease. There were several bioactive compounds extracted from medicinal plants with promising antiviral properties against the novel coronavirus (COVID-19) ( Adhikari et al., 2020 ). In Thailand, 60 medicinal plant species were used to treat mild symptoms of COVID-19 ( Phumthum et al., 2021 ). In Nepal, there were also 60 medicinal plants used ( Khadka et al., 2021 ) and 23 plants in Morroco ( El Alami et al., 2020 ) for potential COVID-19 therapy and Zingiber officinale is one of the common species used. In Bangladesh, phytochemicals extracted from Calotropis gigantea exhibited positive inhibitory effects against the COVID-19 virus ( Dutta et al., 2021 ), as well as the alkaloids and terpenoids isolated from plants of African origin ( Gyebi et al., 2021 ). Curcumin from C. longa also showed promising effects against the virus ( Adhikari et al., 2020 ).

In the Philippines, the Department of Science and Technology (DOST) has been conducted clinical trials and explored the therapeutic effects of the virgin coconut oil (VCO), Euphorbia hirta (tawa-tawa), and Vitex trifolia (lagundi) for their potential efficacy against COVID-19 infection ( Arayata, 2021 ). In the recent updates published in the Global Media Arts (GMA) news articles, clinical trials for V. trifolia and E. hirta have been proven to decrease mild-to-moderate symptoms of COVID-19. Mild-to-moderate symptoms of 172 random COVID-19 patients disappeared within 3–5 days after taking a 1,950 mg capsule of E. hirta thrice a day for ten days as a food supplement. V. trifolia also showed a positive result in decreasing mild symptoms of COVID-19. Community trials of VCO as an adjuvant for mild symptoms of COVID-19 patients showed a positive result in decreasing the virus count by 60–90%. A clinical trial of VCO on mild and severe symptoms of COVID-19 conducted in Philippine General Hospital is still ongoing ( Global Media Arts News, 2021a ; Global Media Arts News, 2021b ).

V. trifolia , C. longa, Z. officinale, Capsicum annuum, E. hirta, and Peperomia pellucida were used by the Panay Bukidnon as an alternative medicine to strengthen their immunity and they have claimed that these species can alleviate the symptoms of the COVID-19 infection. They used these plants traditionally to treat fever, headache, cough, and body pains, which were also the common indications of COVID-19. Further pharmacological research and investigations are highly suggested for these medicinal plants to explore their potential uses and therapeutic effects against COVID-19 infection especially for Zingiber officinale, Capsicum annuum , and Peperomia pellucida species . The Panay Bukidnon also believed that chewing betel quid could give them the strength to fight the virus. Chewing betel quid has been a customary practice of Filipinos since the pre-Spanish colonial period throughout the Philippines. It is part of the social undertakings and ceremonies and is believed to increase stamina, good health, and longevity ( Valdes, 2004 ). In India, the practice of chewing betel dates back to around 75 AD and it is known for centuries for its therapeutic properties ( Toprani and Patel 2013 ). A review was conducted on the synergistic prophylaxis effects of Piper betle and gold ash can hypothetically limit and manage the COVID-19 infection ( Sharma and Malik, 2020 ).

For the comparative review performed on the medicinal plants with other ethnobotanical studies conducted in the country, three species ( Eleutherine palmifolia , Hibiscus acetosella , and Oxalis triangularis ) showed no record of medicinal value in the previous studies. E. palmifolia is used by the Dayaks in Indonesia to treat a variety of diseases such as diabetes, cancer, hypertension, stroke, and sexual disorders and as a galactagogue. Bioactive compounds from this species contain various pharmacological activities such as antibacterial, anti-inflammatory, anticancer, and antidiabetic ( Kamarudin et al., 2021 ). H. acetosella is used as therapy for anemia in Southern Uganda ( Ssegawa and Kasenene, 2007 ) and its phenolic compounds exhibit antioxidant and antibacterial properties ( Lyu et al., 2020 ). Limited literature is available for O. triangularis, but its medicinal uses include remedies for fever, UTI, mouth sores, cuts, rashes, and skin infections ( Arakelyan and Arakelyan, 2020 ). The comparison of the medicinal plants and their uses was performed with five ethnobotanical studies that were previously conducted in the rural and urban communities and villages ( Tantiado, 2012 ; Gruyal et al., 2014 ; Agapin, 2019 ; Belgica et al., 2021 ; Montero and Geducos, 2021 ), 17 studies conducted in the IP communities ( Balangcod and Balangcod, 2011 ; Olowa et al., 2012 ; Abe and Ohtani, 2013 ; Ragragio et al., 2013 ; Ong and Kim, 2014 ; Raterta et al., 2014 ; Balangcod and Balangcod, 2015 ; Pizon et al., 2016 ; Odchimar et al., 2017 ; Baddu and Ouano, 2018 ; Tantengco et al., 2018 ; Pablo, 2019 ; Cordero et al., 2020 ; Dapar et al., 2020 ; Paraguison et al., 2020 ; Cordero and Alejandro, 2021 ; Nuñeza et al., 2021 ) all over the country, and one online database: the Philippine Traditional Knowledge Digital Library on Health ( Philippine Traditional Knowledge Digital Library on Health, 2021 ). The PTKDL is an electronic library that documented 16,690 enumerations of medicinal plant preparations and 66 healing rituals and practices mentioned by 509 traditional healers in 43 different research sites in the country ( World Health Organization, 2019 ). The database ( https://www.tkdlph.com/ ) recorded about 1,200 medicinal plants used by the local and indigenous communities from different ethnobotanical studies, lexicographic and linguistic texts, and current researches conducted in selected indigenous communities nationwide.

The ethnobotanical use of many different plant species is an important predominating practice in the Philippines. It is an integral part of Filipino custom and tradition and has been culturally accepted for ages. The results of this ethnobotanical documentation of 131 medicinal plants used in addressing 91 diseases across 16 different disease categories portray the strong dependence of the Panay Bukidnon in the medicinal flora in their area. This could be attributed to the great distance of the study site to the town and the health centers or well-functioning hospitals. The most culturally relevant and important species recorded in this study in terms of UV, RFC, RI, ICF, and FL are Curcuma longa , Blumea balsamifera , Artemisia vulgaris, Annona muricata, and Chromolaena odorata, respectively. The efficacy and effectivity of the therapeutic claims of these species must be further pharmacologically investigated and validated. These species have been used for centuries by many people worldwide and have proven to cure a myriad of diseases. The comparative study of the medicinal plants with other ethnobotanical studies revealed some novel and additional therapeutic uses that are valuable to the immense body of traditional knowledge and practices in the country. The traditional knowledge and practices from indigenous peoples add more treatment opportunities for potential therapy of pre-existing and novel diseases. The indigenous knowledge on the medicinal plants used by the Panay Bukidnon is passed from one generation to the other mostly in oral forms with the influence of their religious and cultural beliefs. Furthermore, it is urgent to document the indigenous knowledge before it is forgotten because of environmental and social challenges such as species extinction, climate change, acculturation, modernization, availability and accessibility of prescribed medicines, and lack of interest of the younger generations. The results of this study also serve as a medium for preserving cultural heritage, ethnopharmacological bases for further drug research and discovery, and preserving biological diversity. The ethnobotanical study on the Panay Bukidnon communities in Panay Island is limited by the expensive and lengthy process of acquiring government permits and by the fact that some communities are infested by leftists (New People’s Army) that could risk the safety of researchers and there are no access roads in the upland areas. Lastly, it is strongly recommended to conduct further comprehensive surveys on other Panay Bukidnon communities in other provinces of the Panay Island and to conduct pharmacological studies and investigations on the important medicinal plants, especially the ones that have high ICF and FL values for potential drug development and formulation.

Data Availability Statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by The Graduate School–Ethics Review Committee, University of Santo Tomas. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CSC processed and acquired the necessary government permits, conducted the field works, and drafted the manuscript. All authors designed the study, GJDA and UM supervised, reviewed, and made the final revision of the manuscript.

The research had partial funding from the scholarship of the first author from the Commission on Higher Education K-12 Transition Program (CHED K-12) and the Digital Cooperation Fellowship from the Alexander von Humboldt Foundation awarded to GJDA and UM.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors, and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors are forever grateful to the Panay Bukidnon IP leader, the council of elders, members, and Brgy. officials of Brgy. Caguisanan, Lamunao, Iloilo; DENR Region VI for the Wildlife Gratuitous Permit; NCIP Iloilo-Guimaras Service Center officers for facilitating the community meetings; NCIP Region VI/VII for the issuance of the Certification Precondition. Heartfelt gratitude is also given to the Ethics Review Committee of the University of Santo Tomas Graduate School, Danilo Tandang of the Philippine National Museum, and Michael Calaramo of the Herbarium of the Northwestern University Luzon. CSC would like to thank CHED K-12 for her scholarship. GJDA and UM acknowledge the Alexander von Humboldt Foundation for the Digital Cooperation Fellowship.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fphar.2021.790567/full#supplementary-material

Abe, R., and Ohtani, K. (2013). An Ethnobotanical Study of Medicinal Plants and Traditional Therapies on Batan Island, the Philippines. J. Ethnopharmacol. 145, 554–565. doi:10.1016/j.jep.2012.11.029

CrossRef Full Text | Google Scholar

Adhikari, B., Marasini, B. P., Rayamajhee, B., Bhattarai, B. R., Lamichhane, G., Khadayat, K., et al. (2020). Potential Roles of Medicinal Plants for the Treatment of Viral Diseases Focusing on COVID-19: A Review. Phytother. Res. 5, 1298–1312. doi:10.1002/ptr.6893

PubMed Abstract | CrossRef Full Text | Google Scholar

Agapin, J. S. F. (2019). Medicinal Plants Used by Traditional Healers in Pagadian City, Zamboanga del Sur, Philippines. Philipp. J. Sci. 149, 83–89. doi:10.2139/ssrn.3625332

Arakelyan, S. S., and Arakelyan, H. S. (2020). Beauty for Health – Oxalis Triangularis . Available at: https://www.researchgate.net/publication/340829095_Beauty_For_Health_-Oxalis_Triangularis (Accessed November 5, 2021).

Google Scholar

Arayata, M. C. (2021). PH Researchers Study Herbal Plants' Benefit in Fight vs. Covid-19 . Philippine News Agency . Available at: https://www.pna.gov.ph/articles/1104955 (Accessed September 03, 2021).

Baddu, V., and Ouano, N. (2018). Ethnobotanical Survey of Medicinal Plants Used by the Y’Apayaos of Sta. Praxedes in the Province of Cagayan, Philippines. Mindanao J. Sci. Technol. 16, 128–153.

Balangcod, T., and Balangcod, A. K. (2011). Ethnomedical Knowledge of Plants and Healthcare Practices Among the Kalanguya Tribe in Tinoc, Ifugao, Luzon, Philippines. Indian J. Tradit Knowl. 10, 227–238.

Balangcod, T., and Balangcod, A. K. (2015). Ethnomedicinal Plants in Bayabas, Sablan, Benguet Province, Luzon, Philippines. E J. Biol. 11, 63–73.

Belgica, T. H., Suba, M., and Alejandro, G. J. (2021). Quantitative Ethnobotanical Study of Medicinal flora Used by Local Inhabitants in Selected Barangay of Malinao, Albay, Philippines. Biodiversitas 22, 2711–2721. doi:10.13057/biodiv/d220720

Beyer, O. H. (1917). Population of the Philippine islands in 1916 (población de las islas Filipinas en 1916) prepared under the direction of, preparado bajo la dirección de H. Otley Beyer . Manila, Philippines: Philippine Education Co. Inc .

Chanda, S., and Kaneria, M. (2011). in Indian Nutraceutical Plant Leaves as a Potential Source of Natural Antimicrobial Agents in Science against Microbial Pathogens: Communicating Current Research and Technological Advances . Editor M. Vilas (Badajoz, Spain: Formatex Research Center ), 1251–1259.

Cordero, C., and Alejandro, G. J. D. (2021). Medicinal Plants Used by the Indigenous Ati Tribe in Tobias Fornier, Antique, Philippines. Biodiversitas 22, 521–536. doi:10.13057/biodiv/d220203

Cordero, C., Ligsay, A., and Alejandro, G. (2020). Ethnobotanical Documentation of Medicinal Plants Used by the Ati Tribe in Malay, Aklan, Philippines. J. Complement. Med. Res. 11, 170–198. doi:10.5455/jcmr.2020.11.01.20

Coria-Téllez, A. V., Montalvo-GónzalezYahia, E. E. M., and Obledo-Vázquez, E. N. (2018). Annona Muricata : A Comprehensive Review on its Traditional Medicinal Uses, Phytochemicals, Pharmacological Activities, Mechanisms of Action and Toxicity. Arab. J. Chem. 11, 662–691. doi:10.1016/j.arabjc.2016.01.004

Dapar, M. L. G., Alejandro, G. J. D., Meve, U., and Liede-Schumann, S. (2020). Quantitative ethnopharmacological documentation and molecular confirmation of medicinal plants used by the Manobo tribe of Agusan del Sur, Philippines. J. Ethnobiol. Ethnomed 16, 14. doi:10.1186/s13002-020-00363-7

Department of Environment and Natural Resources (2019). Regional Profile: Historical Background of the Region . DENR Region . Available at: https://r6.denr.gov.ph/index.php/about-us/regional-profile (Accessed September 02, 2021).

Dutta, M., Nezam, M., Chowdhury, S., Rakib, A., Paul, A., Sami, S. A., et al. (2021). Appraisals of the Bangladeshi Medicinal Plant Calotropis Gigantea Used by Folk Medicine Practitioners in the Management of COVID-19: A Biochemical and Computational Approach. Front. Mol. Biosci. 8, 625391. doi:10.3389/fmolb.2021.625391

Ealdama, E. (1938). The Monteses of Panay , 35. Manila, Philippines: Philippine Magazine .

Ekiert, H., Pajor, J., Klin, P., Rzepiela, A., Ślesak, H., and Szopa, A. (2020). Significance of Artemisia Vulgaris L. (Common Mugwort) in the History of Medicine and its Possible Contemporary Applications Substantiated by Phytochemical and Pharmacological Studies. Molecules 25, 4415. doi:10.3390/molecules25194415

El Alami, A., Fattah, A., and Chait, A. (2020). Medicinal Plants Used for the Prevention Purposes during the Covid-19 Pandemic in Morocco. J. Anal. Sci. Appl. Biotechnol. 2, 4–11. doi:10.48402/IMIST.PRSM/jasab-v2i1.21056

Friedman, J., Yaniv, Z., Dafni, A., and Palewitch, D. (1986). A Preliminary Classification of the Healing Potential of Medicinal Plants, Based on a Rational Analysis of an Ethnopharmacological Field Survey Among Bedouins in the Negev Desert, Israel. J. Ethnopharmacol. 16, 275–287. doi:10.1016/0378-8741(86)90094-2

German, M. A. (2010). (Re)searching Identity in the highlands of Central Panay . Quezon City, Philippines: Ugnayang Pang-Aghamtao, Inc. Vol. 19, 20–37.

Global Media Arts News (2021a). DOST Exec Bares Positive Results of Lagundi, Tawa-Tawa Trials. Available at: https://www.gmanetwork.com/news/scitech/science/807308/dost-exec-bares-positive-results-of-lagundi-tawa-tawa-trials/story/ (Accessed October 30, 2021).

Global Media Arts News (2021b). VCO Trials Show Big Drop in Virus Count of Mild COVID-19 Cases. Available at: https://www.gmanetwork.com/news/scitech/science/807310/vco-trials-show-big-drop-in-virus-count-in-mild-covid-19-cases/story/ (Accessed October 30, 2021).

Gowey, D. (2016). Palawod, Pa-Iraya: A Synthesis of Panay Bukidnon Inland Migration Models . Available at: https://www.academia.edu/29928804/Palawod_Pairaya_A_Synthesis_of_Panay_Bukidnon_Inland_Migration_Models (Accessed September 03, 2021).

Gruyal, G., del Rosario, R., and Palmes, N. (2014). Ethnomedicinal Plants Used by Residents in Northern Surigao del Sur,Philippines. Nat. Prod. Chem. Res. 2014 2, 1–5. doi:10.4172/2329-6836.1000140

Tantengco, O. A. G., Condes, M. L. C., Estadilla, H. H. T., and Ragragio, E. M. (2018). Ethnobotanical Survey of Medicinal Plants Used by Ayta Communities in Dinalupihan, Bataan, Philippines. Pharmacog. J. 10, 859–870. doi:10.5530/pj.2018.5.145

Gyebi, G. A., Ogunro, O. B., Adegunloye, A. P., Ogunyemi, O. M., and Afolabi, S. O. (2021). Potential Inhibitors of Coronavirus 3-chymotrypsin-like Protease (3CLpro): an In Silico Screening of Alkaloids and Terpenoids from African Medicinal Plants. J. Biomol. Struct. Dyn. 39, 1–13. doi:10.1080/07391102.2020.1764868

Heinrich, M., Ankli, A., Frei, B., Weimann, C., and Sticher, O. (1998). Medicinal Plants in Mexico: Healers' Consensus and Cultural Importance. Soc. Sci. Med. 47, 1859–1871. doi:10.1016/s0277-9536(98)00181-6

International Plant Names Index (2021). The Royal Botanic Gardens, Kew, Harvard University Herbaria & Libraries and Australian National Botanic Gardens . Available at: http://www.ipni.org (Accessed September 04, 2021).

Jain, C., Khatan, S., and Vijayvergia, R. (2019). Bioactivity of Secondary Metabolites of Various Plants: a Review. Int. J. Pharm. Sci. Res. 10, 494–504. doi:10.13040/IJPSR.0975-8232.10(2).494-04

Jocano, L. (1968). Sulud Society. A Study in the Kinship System and Social Organization of a Mountain People of Central Panay. Diliman . Quezon City: University of the Philippines Press .

Kamarudin, A. A., Sayuti, N. H., Saad, N., Razak, N. A. A., and Esa, N. M. (2021). Eleutherine Bulbosa (Mill.) Urb. Bulb: Review of the Pharmacological Activities and its Prospects for Application. Int. J. Mol. Sci. 22, 6747. doi:10.3390/ijms22136747

Khadka, D., Dhamala, M. K., Li, F., Aryal, P. C., Magar, P. R., Bhatta, S., et al. (2021). The Use of Medicinal Plants to Prevent COVID-19 in Nepal. Ijms 22, 26. doi:10.1186/s13002-021-00449-w

Lyu, J. I., Ryu, J., Jin, C. H., Kim, D. G., Kim, J. M., Seo, K. S., et al. (2020). Phenolic Compounds in Extracts of Hibiscus acetosella (Cranberry Hibiscus) and Their Antioxidant and Antibacterial Properties. Molecules 25 (18), 4190. doi:10.3390/molecules25184190

Madjos, G., and Ramos, K. (2021). Ethnobotany, Systematic Review and Field Mapping on Folkloric Medicinal Plants in the Zamboanga Peninsula, Mindanao, Philippines. J. Complement. Med. .Res. 12. doi:10.5455/jcmr.2021.12.01.05

Madulid, D. A., Gaerlan, F. J. M., Romero, E. M., and Agoo, E. M. G. (1989). Ethnopharmacological Study of the Ati Tribe in Nagpana, Barotac Viejo, Iloilo. Acta Manil 38, 25–40.

Magos, A. (2004). Balay Turun-An: An Experience in Implementing Indigenous Education in Central Panay , 13. Quezon City, Philippines: Ugnayang Pang-Aghamtao, Inc. , Vol. 19, 95–102.

Magos, A. (1999). Sea Episodes in the Sugidanon (Epic) and Boat-Buildng Tradition in Central Panay, Philippines. Danyag (UP Visayas Journal of the Social Sciences and the Humanities) 4, 5–29.

Moghadamtousi, S. Z., Fadaeinasab, M., Nikzad, S., Mohan, G., Ali, H. M., and Kadir, H. A. (2015). Annona Muricata (Annonaceae): A Review of its Traditional Uses, Isolated Acetogenins and Biological Activities. Int. J. Mol. Sci. 16, 15625–15658. doi:10.3390/ijms160715625

Montero, J. C., and Geducos, D. T. (2021). Ethnomedicinal plants used by the local folks in two selected villages of San Miguel and Surigao del Sur, villages of San Miguel, Surigao del Sur, Mindanao, Philippines. Int. J. Agric. Technol. 17, 193–212.

National Commission on Indigenous Peoples (2019). Community Population (Census) Province of Antique and Aklan . San Jose Buenavista, Antique: National Commission on Indigenous Peoples Antique/Aklan Community Service Center .

National Commission on Indigenous Peoples (2011). Indigenous Peoples MasterPlan (2012-2016) . Available at: https://www.ombudsman.gov.ph/UNDP4/wp-content/uploads/2013/02/Indigenous-Peoples-Master-Plan-2012-2016.pdf (Accessed August 21, 2021).

National Commission on Indigenous Peoples (2020). Region VI Statistical Report 2020 . Available at: https://www.ncipro67.com.ph/statistics-corner/ (Accessed September 01, 2021).

National Economic Development Agency (2017). Philippine Development Plan 2017-2022 . Available at: http://pdp.neda.gov.ph/ (Accessed August 02, 2021).

Nuneza, O., Rodriguez, B., and Nasiad, J. G. (2021). Ethnobotanical survey of medicinal plants used by the Mamanwa tribe of Surigao del Norte and Agusan del Norte, Mindanao, Philippines. Biodiversitas 22, 3284–3296. doi:10.13057/biodiv/d220634

Obico, J. J. A., and Ragrario, E. M. (2014). A Survey of Plants Used as Repellants against Hematophagous Insects by the Ayta People of Porac, Pampanga Province. Phil. Sci. Lett. 7, 179–186.

Odchimar, N. M., Nuñeza, O., Uy, M., and Senarath, W. T. P. S. (2017). Ethnobotany of Medicinal Plants Used by the Talaandig Tribe in Brgy. Lilingayon, Valencia City, Bukidnon, Philippines. Asian J. Biol. Life Sci. 6, 358–364.

Olowa, L., Torres, M. A., Aranico, E., and Demayo, C. (2012). Medicinal Plants Used by the Higaonon Tribe of Rogongon, Iligan City, Mindanao, Philippines. Adv. Environ. Biol. 6, 1442–1449. doi:10.3923/erj.2012.164.174

Ong, H. G., and Kim, Y.-D. (2015). Herbal Therapies and Social-Health Policies: Indigenous Ati Negrito Women's Dilemma and Reproductive Healthcare Transitions in the Philippines. Evidence-Based Complement. Altern. Med. 2015, 1–13. doi:10.1155/2015/491209

Ong, H. G., and Kim, Y. D. (2014). Quantitative Ethnobotanical Study of the Medicinal Plants Used by the Ati Negrito Indigenous Group in Guimaras Island, Philippines. J. Ethnopharmacol. 157, 228–242. doi:10.1016/j.jep.2014.09.015

Pablo, C. G. (2019). Botika Sa Kalikasan: Medicinal Plants Used by Aetas of Sitio Parapal Hermosa Bataan, Philippines. J. Soc. Health 2, 101–127.

Pang, Y., Wang, D., Fan, Z., Chen, X., Yu, F., Hu, X., et al. (2014). Blumea Balsamifera --a Phytochemical and Pharmacological Review. Molecules 19, 9453–9477. doi:10.3390/molecules19079453

Paraguison, L. D. R., Tandang, D. N., and Alejandro, G. J. D. (2021). Medicinal Plants Used by the Manobo Tribe of Prosperidad, Agusan Del Sur, Philippinesan Ethnobotanical Survey. Ajbls 9, 326–333. doi:10.5530/ajbls.2020.9.49

Parasuraman, S., Thing, G. S., and Dhanaraj, S. A. (2014). Polyherbal Formulation: Concept of Ayurveda. Pharmacogn. Rev. 8, 73–80. doi:10.4103/0973-7847.134229

Pelser, P. B., Barcelona, J. F., and Nickrent, D. L. (2011). Co’s Digital Flora of the Philippines . Available at: www.philippineplants.org (Accessed September 02, 2020).

Philippine Statistics Authority (2021). 2020 Census of Population and Housing (2020 CPH) Population Counts Declared Official by the President . Available at: https://psa.gov.ph/content/2020-census-population-and-housing-2020-cph-population-counts-declared-official-president (Accessed November 11, 2021).

Philippine Traditional Knowledge Digital Library on Health (2021). Philippine Plants and Natural Products Used Traditionally . Available at: https://www.tkdlph.com/index.php/ct-menu-item-3/ct-menu-item-7 (Accessed October 30, 2021).

Phillips, O., and Gentry, A. H. (1993). The Useful Plants of Tambopata, Peru: I. Statistical Hypotheses Tests with a New Quantitative Technique. Econ. Bot. 47, 15–32. doi:10.1007/bf02862203

Phumthum, M., Nguanchoo, V., and Balslev, H. (2021). Medicinal Plants Used for Treating Mild Covid-19 Symptoms Among Thai Karen and Hmong. Front. Pharmacol. 12, 699897. doi:10.3389/fphar.2021.699897

Pizon, J. R. L., Nuneza, O. M., Uy, M. M., and Senarath, W. T. P. S. K. (2016). Ethnobotany of Medicinal Plants Used by the Subanen Tribe of Lapuyan, Zamboanga del Sur. Bull. Env. Pharmacol. Life Sci. 5, 53–67.

Plants of the World Online (2021). Facilitated by the Royal Botanic Gardens, Kew . Available at: http://plantsoftheworldonline.org/ (Accessed September 03, 2021).

Prasad, S., and Aggarwal, B. B. (2011). “Turmeric, the Golden Spice: From Traditional Medicine to Modern Medicine,” in Herbal Medicine: Biomolecular and Clinical Aspects . Editors I. F. F. Benzie, and S. Wachtel-Galor (Boca Raton, FL: CRC Press/Taylor & Francis ).

Province of Iloilo (2015). About Iloilo . Available at: https://www.iloilo.gov.ph/about-iloilo (Accessed September 01, 2021).

Provincial Planning Development Office (2018). Iloilo Provincial Annual Profile . Available at: https://www.iloilo.gov.ph/iloilo-provincial-annual-profile (Accessed August 20, 2021).

Pucot, J. R., Manting, M. M. E., and Demayo, C. G. (2019). Ethnobotanical Plants Used by Selected Indigenous Peoples of Mindanao, the Philippines as Cancer Therapeutics. Pharmacophore 10, 61–69.

Ragragio, E., Zayas, C. N., and Obico, J. J. A. (2013). Useful Plants of Selected Ayta Communities from Porac, Pampanga, Twenty Years after the Eruption of Mt. Pinatubo. Philipp. J. Sci. 142, 169–181.

Raterta, R., de Guzman, G. Q., and Alejandro, G. J. D. (2014). Assessment, Inventory and Ethnobotanical Survey of Medicinal Plants in Batan and Sabtang Island (Batanes Group of Islands, Philippines). Int. J. Pure App. Biosci. 2, 147–154.

Sharma, S., and Malik, J. (2020). Synergistic Prophylaxis on COVID-19 by Nature Golden Heart ( Piper Betle ) & Swarna Bhasma. Asian J. Res. Dermat. Sci. 3, 21–27.

Smith, W. (1915). Notes on the Geology of Panay. From the Division of Mines . Manila, Philippines: Bureau of Science .

Ssegawa, P., and Kasenene, J. M. (2007). Medicinal Plant Diversity and Uses in the Sango bay Area, Southern Uganda. J. Ethnopharmacol 113 (3), 521–540. doi:10.1016/j.jep.2007.07.014

Talledo, T. (2004). Construction of Identity in Central Panay: A Critical Examination of the Ethnographic Subject in the Works of Jocano and Magos. Asian Stud. 40, 111–123.

Tantiado, R. (2012). Survey on Ethnopharmacology of Medicinal Plants in Iloilo, Philippines. Inter. J. Bio-sci. Bio-tech. 4, 11–26.

Tardío, J., and Pardo-De-Santayana, M. (2008). Cultural Importance Indices: a Comparative Analysis Based on the Useful Wild Plants of Southern Cantabria (Northern Spain)1. Econ. Bot. 62, 24–39. doi:10.1007/s12231-007-9004-5

Toprani, R., and Patel, D. (2013). Betel Leaf: Revisiting the Benefits of an Ancient Indian Herb. South. Asian J. Cancer 2, 140–141. doi:10.4103/2278-330X.114120

Tropicos (2021). Missouri Botanical Garden . Available at: https://tropicos.org (Accessed September 02, 2021).

Tu, Y. (2011). The Discovery of Artemisinin (Qinghaosu) and Gifts from Chinese Medicine. Nat. Med. 17, 1217–1220. doi:10.1038/nm.2471

United Nations Development Programme (2019). 10 Things to Know about Indigenous Peoples . Available at: https://stories.undp.org/10-things-we-all-should-know-about-indigenous-people (Accessed August 06, 2021).

Valdes, C. O. (2004). Betel Chewing in the Philippines. Arts of Asia 34, 104–115.

Velayudhan, K. C., Dikshit, N., and Nizar, M. A. (2012). Ethnobotany of Turmeric ( Curcuma Longa L.). Indian J. Tradit. Knowl. 11, 607–614.

Vijayaraghavan, K., Rajkumar, J., Bukhari, S. N., Al-Sayed, B., and Seyed, M. A. (2017). Chromolaena Odorata : A Neglected weed with a Wide Spectrum of Pharmacological Activities (Review). Mol. Med. Rep. 15, 1007–1016. doi:10.3892/mmr.2017.6133

Wanda, J. M., Gamo, F., and Njamen, D. (2015). “Medicinal Plants of the Family of Fabaceae Used to Treat Various Ailments in Fabaceae,” in Classification, Nutrient Composition and Health Benefits Series . Editor W. Garza (NY: Nova Science Publishers, Inc. ).

World Flora Online (2021). World Flora Online . Available at: http://www.worldfloraonline.org/ (Accessed September 02, 2021).

World Health Organization (2021). ICD-11 International Classification of Diseases 11th Revision . Available at: https://icd.who.int/en (Accessed September 03, 2021).

World Health Organization (2019). WHO Global Report on Traditional and Complementary Medicine . Available at: https://www.who.int/traditionalcomplementary-integrative medicine/Who Global Report On TraditionalAndComplementaryMedicine2019.pdf?ua=1 (Accessed October 28, 2021).

World Health Organization (1998). Working Group on Herbal Medicines . Manila: WHO Regional Office for the Western Pacific .

Keywords: ethnobotany, ethnomedicine, Panay Bukidnon, Panay Island, Philippines

Citation: Cordero CS, Meve U and Alejandro GJD (2022) Ethnobotanical Documentation of Medicinal Plants Used by the Indigenous Panay Bukidnon in Lambunao, Iloilo, Philippines. Front. Pharmacol. 12:790567. doi: 10.3389/fphar.2021.790567

Received: 06 October 2021; Accepted: 18 November 2021; Published: 10 January 2022.

Reviewed by:

Copyright © 2022 Cordero, Meve and Alejandro. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Cecilia Salugta Cordero, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• DOI: 10.5195/ijms.2021.849
• Corpus ID: 237250502

Folk Medicine in the Philippines: A Phenomenological Study of Health-Seeking Individuals

• Nadine Angela Rondilla , I. C. Rocha , +6 authors Carina Viktoria Javier
• Published 2021
• Medicine, Sociology

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Folk Medicine in the Philippines: A Phenomenological Study of Health-Seeking Individuals

• Nadine Angela O. Rondilla School of Medicine, Centro Escolar University, Manila, Philippines
• Ian Christopher N. Rocha School of Medicine, Centro Escolar University, Manila, Philippines https://orcid.org/0000-0002-8775-6876
• Shannon Jean R. Roque School of Medicine, Centro Escolar University, Manila, Philippines
• Ricardo Martin S. Lu School of Medicine, Centro Escolar University, Manila, Philippines
• Nica Lois B. Apolinar School of Medicine, Centro Escolar University, Manila, Philippines
• Alyssa A. Solaiman-Balt School of Medicine, Centro Escolar University, Manila, Philippines
• Theorell Joshua J. Abion School of Medicine, Centro Escolar University, Manila, Philippines
• Pauline Bianca P. Banatin School of Medicine, Centro Escolar University, Manila, Philippines
• Carina Viktoria M. Javier School of Medicine, Centro Escolar University, Manila, Philippines

Background: Folk medicine refers to traditional healing practices anchored on cultural beliefs of body physiology and health preservation. Reflective of indigenous heritage, it fosters a better understanding of health and disease, healthcare systems, and biocultural adaptation. In the Philippines, Quiapo is a well-known site for folk medicine services, cultural diversity, religious practices, and economic activities.

Methods: This study utilized a phenomenological approach to comprehend the lived experiences of health-seeking individuals and the meaning behind their acquisition of folk medicine products. Using convenience sampling, seven participants acquiring folk medicine products in Quiapo on the day of data collection were approached and interviewed on separate instances. The collected data subsequently underwent thematic analysis.

Results: Analysis revealed three emergent themes: health-seeking behavior, sources of knowledge, and folk medicine utilization. Health-seeking behavior was linked with the participants’ purpose of going to Quiapo, reasons for utilizing folk medicine, experiences in using folk medicine, and beliefs associated with the product bought. Sources of knowledge tackled the participants’ sources of information about Quiapo and its products. Folk medicine utilization relates to the type of product bought, its perceived medicinal use, and its history of usage.

Conclusion: Folk medicine is perceived to be effective alleviating health concerns. The acquisition of such products is attributed to satisfaction from prior experience, distrust in the current healthcare system, family tradition, and intention to supplement existing medical treatment. This study provides health professionals a better understanding of patients who patronize folk medicine, subsequently aiding them in providing a holistic approach to treatment.

Author Biographies

Nadine angela o. rondilla, school of medicine, centro escolar university, manila, philippines.

Nadine Angela O. Rondilla is a graduate of Bachelor of Science in Biology from the University of Santo Tomas. She is currently studying Doctor of Medicine at Centro Escolar University.

Ian Christopher N. Rocha, School of Medicine, Centro Escolar University, Manila, Philippines

Ian Christopher N. Rocha is a registered nurse and licensed professional teacher. He obtained his Master of Health Social Science degree from De La Salle University, his Master in Business Administration degree from National College of Business and Arts, and his Bachelor of Science in Nursing and Associate in Health Science Education degrees from Far Eastern University. He is currently studying Doctor of Medicine at Centro Escolar University.

Shannon Jean R. Roque, School of Medicine, Centro Escolar University, Manila, Philippines

Shannon Jean R. Roque is a graduate of Bachelor of Science in Biology from the Pamantasan ng Lungsod ng Maynila (University of the City of Manila). She is currently studying Doctor of Medicine at Centro Escolar University.

Ricardo Martin S. Lu, School of Medicine, Centro Escolar University, Manila, Philippines

Ricardo Martin S. Lu is a graduate of Bachelor of Science in Biology from the University of Santo Tomas. He is currently studying Doctor of Medicine at Centro Escolar University.

Nica Lois B. Apolinar, School of Medicine, Centro Escolar University, Manila, Philippines

Nica Lois B. Apolinar is a registered medical technologist. She took her Bachelor of Science in Medical Technology degree from Centro Escolar University. She is currently studying Doctor of Medicine at the same university.

Alyssa A. Solaiman-Balt, School of Medicine, Centro Escolar University, Manila, Philippines

Alyssa A. Solaiman-Balt is a registered pharmacist. She earned her Bachelor of Science in Pharmacy degree from the University of San Carlos. She is currently studying Doctor of Medicine at Centro Escolar University.

Theorell Joshua J. Abion, School of Medicine, Centro Escolar University, Manila, Philippines

Theorell Joshua J. Abion is a graduate of Bachelor of Science in Biochemistry from the University of Santo Tomas. He is currently studying Doctor of Medicine at Centro Escolar University.

Pauline Bianca P. Banatin, School of Medicine, Centro Escolar University, Manila, Philippines

Pauline Bianca P. Banatin is a graduate of Bachelor of Science in Biology from De La Salle University. She is currently studying Doctor of Medicine at Centro Escolar University.

Carina Viktoria M. Javier, School of Medicine, Centro Escolar University, Manila, Philippines

Carina Viktoria M. Javier is a graduate of Bachelor of Science in Psychology degree from Trinity University of Asia. She is currently studying Doctor of Medicine at Centro Escolar University.

Abion TJ, Apolinar NL, Atutubo MJ, Banatin PB, Javier CV, Lu RM, Rocha IC, Rondilla NA, Roque SJ, Solaiman-Balt A. Experiences of health-seeking individuals acquiring folk medicine services from Quiapo. Proceedings of the 17th National Health Research Forum for Action; 2018 Sep 19-20; Mandaluyong City, Philippines. Manila: Department of Health; 2018. p. 127-8.

Bhasin V. Medical anthropology: a review. Stud Ethnomed. 2007;1(1):1-20.

Society for Medical Anthropology. What is medical anthropology? United States: Society for Medical Anthropology; 2017. Cited Oct, 2020. Available from: http://www.medanthro.net/about/about-medical-anthropology/

Wangkheirakpam S. Traditional and folk medicine as a target for drug discovery. In: Mandal SC, Mandal V, Konishi T, editors. Natural products and drug discovery: an integrated approach. Elsevier; 2018. p. 29-56.

Fokunang CN, Ndikum V, Tabi OY, Jiofack RB, Ngameni B, Guedje NM, et al. Traditional medicine: past, present and future research and development prospects and integration in the National Health System of Cameroon. Afr J Tradit Complement Altern Med. 2011;8(3):284-95.

Gritto MJ, Nanadagopalan V, Doss A. Ethnobotanical survey of medicinal plants used by traditional healers in Shobanapuram village of Pachamalai Hill, Tamilnadu. Adv Appl Sci Res. 2015;6(3):157-164.

Panter-Brick C, Eggerman M. The field of medical anthropology in social science and medicine. Soc Sci Med. 2018 Jan;196:223-39.

Tan ML. Revisiting usog, pasma, kulam. Quezon City: University of the Philippines Press; 2010.

Rebuya NR, Lasarte, ES, Amador, MMA. Medical pluralism, traditional healing practices, and the Partido albularyo: challenges in inclusion. Open J Soc Sci. 2020;8:72-79.

Zialcita FN. Quiapo: heart of Manila. Quezon City: Ateneo de Manila University Press; 2006.

Abdullah F, Corrado J, Detros K, Galima A, Germo AG, Olaya D, Orinion G, Posadas K, Vidal L. Organized chaos: a cultural analysis of Quiapo [research project]. University of the Philippines; 2013.

Flores RL, Legario RA, Malagotnot DBM, Peregrin K, Sato RA, Secoya ER. Ethnomedicinal study of plants sold in Quiapo, Manila, Philippines. Scholars Acad J Biosci. 2016;4(4A):359-365.

Romero P. Mixing science and faith, herbal medicine markets offer-cures and jobs [Internet]. The Rockefeller Foundation; 2013. Cited Oct, 2020. Available from: https://nextcity.org/informalcity/entry/mixing-science-and-faith-herbal-medicine-markets-offer-cures-and-jobs .

World Health Organization. Traditional, complementary, and integrative medicine [Internet]. Geneva: World Health Organization; 2020 [cited 2021 Feb]. Available from: https://www.who.int/traditional-complementary-integrative-medicine/about/en/ .

Cerio CT. Albularyo folk healing: cultural beliefs on healthcare management in Partido District, Camarines Sur, Philippines. J Southeast Asian Stud. 2020 Jun;25(1):210-237.

Petrovska BB. Historical review of medicinal plants' usage. Pharmacogn Rev. 2012 Jan;6(11):1-5.

Nanjunda D. Factors affecting health seeking behavior and medical pluralism among rural populations: implications for health care professionals. Sri Ramachandra J Med. 2014;7:1.

Ekor M. The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety. Front Pharmacol. 2014 Jan 10;4:177.

Montepio SN. Folk medicine in the Filipino American experience. Amerasia J. 1986;13(1):151-162.

Dayrit MM, Lagrada LP, Picazo OF, Pons MC, Villaverde MC. The Philippines health system review [Internet]. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018. Cited Feb, 2021. Available from: https://apps.who.int/iris/handle/10665/274579 .

Ulep VGT, Dela Cruz NAO. Analysis of out-of-pocket expenditures in the Philippines. Philipp J Dev. 2013;40(1-2d):93-123.

Tobe M, Stickley A, Del Rosario RB Jr, Shibuya K. Out-of-pocket medical expenses for inpatient care among beneficiaries of the National Health Insurance Program in the Philippines. Health Policy Plan. 2013 Aug;28(5):536-48.

Tumanan-Mendoza BA, Mendoza VL, Bermudez-Delos Santos AAA, Punzalan FER, Pestano NS, Natividad RB, et al. Economic burden of hospitalisation for congestive heart failure among adults in the Philippines. Heart Asia. 2018 Oct 10;10(2):e011039.

Udayanga S. Lay reflections of health experiences and Sinhalese medicine in Sri Lanka. Asian Anthropol. 2018 Nov;17(4):276-292.

Berdon JS, Ragosta EL, Inocian RB, Manalag CA, Lozano EB. Unveiling Cebuano traditional healing practices. Asia Pac J Multidiscip Res. 2016;4(1):51-59.

Robles W. (Un)lucky charms: amulet vendors of Quiapo church. Quezon City: Central Book Supply; 2009.

Tan ML. Anting-anting. Philippine Daily Inquirer. Last updated: Nov 11, 2015, cited Feb, 2021. Available from: https://opinion.inquirer.net/90210/anting-anting .

Joven AE. Review of the book traditional medicine in the colonial Philippines, 16th to the 19th century. Philipp Stud. 2020;68(1):130-133.

Abad PJ, Tan ML, Baluyot MM, Villa AQ, Talapian GL, Reyes ME, et al. Cultural beliefs on disease causation in the Philippines: challenge and implications in genetic counseling. J Community Genet. 2014 Oct;5(4):399-407.

Rocha ICN, Roque SJR, Tanyag LG, Reyes KA, Sigui MAMM. Effect of Citrofortunella microcarpa (calamansi) peelings on whole blood coagulation using blood samples from albino mice. J Complement Altern Med Res. 2020 Dec;12(1):51-56.

Tan ML. True or false. Philippine Daily Inquirer. Last updated: Jun 6, 2018, Cited Feb, 2021. Available from: https://opinion.inquirer.net/113721/true-or-false .

Tan ML. Nationalism and medicine. Philippine Daily Inquirer [Internet]. Last updated: Jun 13, 2018, cited Feb, 2021. Available from: https://opinion.inquirer.net/113892/nationalism-and-medicine .

Sivertsen K, Lukic M, Kristoffersen AE. Gender specific association between the use of complementary and alternative medicine (CAM) and alcohol consumption and injuries caused by drinking in the sixth Tromso study. BMC Complement Altern Med. 2018 Aug 13;18(1):239.

Kristoffersen AE, Broderstad AR, Musial F, Stub T. Prevalence, and health- and sociodemographic associations for visits to traditional and complementary medical providers in the seventh survey of the Tromso study. BMC Complement Altern Med. 2019 Nov 11;19(1):305.

Luketina-Sunjka M, Rancic N, Mihailovic N, Jakovljevic M. The Impact of the Socio-Demographic Characteristics of Complementary and Alternative Medicine Users in Serbia on OTC Drug Consumption. Front Public Health. 2019 Oct 24;7:303.

Rivera JO, Loya AM, Ceballos R. Use of herbal medicines and implications for conventional drug therapy medical sciences. Altern Integ Med. 2013 Jul;2(6).

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Folk Medicine in the Philippines: A Phenomenological Study of Health-Seeking Individuals

2021, International Journal of Medical Students

Background: Folk medicine refers to traditional healing practices anchored on cultural beliefs of body physiology and health preservation. Reflective of indigenous heritage, it fosters a better understanding of health and disease, healthcare systems, and biocultural adaptation. In the Philippines, Quiapo is a well-known site for folk medicine services, cultural diversity, religious practices, and economic activities. Methods: This study utilized a phenomenological approach to comprehend the lived experiences of health-seeking individuals and the meaning behind their acquisition of folk medicine products. Using convenience sampling, seven participants acquiring folk medicine products in Quiapo on the day of data collection were approached and interviewed on separate instances. The collected data subsequently underwent thematic analysis. Results: Analysis revealed three emergent themes: health-seeking behavior, sources of knowledge, and folk medicine utilization. Health-seeking behavi...

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Patient satisfaction with telemedicine in the Philippines during the COVID-19 pandemic: a mixed methods study

Alicia victoria g. noceda.

1 School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines

Lianne Margot M. Acierto

Morvenn chaimek c. bertiz, david emmanuel h. dionisio, chelsea beatrice l. laurito, girrard alphonse t. sanchez, arianna maever loreche.

2 National Clinical Trials and Translation Center, National Institutes of Health, University of the Philippines Manila, Manila, Philippines

Associated Data

The quantitative dataset generated and/or analyzed during the current study is available from the corresponding author on reasonable request. The dataset generated during individual interviews are not publicly available due to the information provided to the participants when obtaining their informed consent, stating that all attempts would be made to maintain confidentiality.

The capacity to deliver essential health services has been negatively impacted by the COVID-19 pandemic, particularly due to lockdown restrictions. Telemedicine provides a safe, efficient, and effective alternative that addresses the needs of patients and the health system. However, there remain implementation challenges and barriers to patient adoption in resource-limited settings as in the Philippines. This mixed methods study aimed to describe patient perspectives and experiences with telemedicine services, and explore the factors that influence telemedicine use and satisfaction.

An online survey consisting of items adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Adult Visit Survey 4.0 (beta) and the Telehealth Usability Questionnaire (TUQ) was completed by 200 participants aged 18 to 65 years residing in the Philippines. A subsample of 16 participants was interviewed to provide further insights on their experiences. We used descriptive statistics to analyze survey data and thematically analyzed data from interviews guided by the principles of grounded theory.

Participants were generally satisfied with telemedicine, and found it to be an efficient and convenient means of receiving healthcare. About 3 in 5 perceived telemedicine as affordable, with some finding telemedicine costs to be high and comparable to in-person consultations. Our results suggest that participants preferred telemedicine services, especially in cases where they feel that their condition is not urgent and does not need extensive physical examination. Safety against COVID-19, privacy, accessibility, and availability of multiple communication platforms contributed to patient satisfaction with telemedicine. Negative perceptions of patients on quality of care and service related to their telemedicine provider, inherent limitations of telemedicine in the diagnosis and management of patients, perceived high costs especially for mental health conditions, and poor connectivity and other technological issues were barriers to telemedicine use and satisfaction.

Telemedicine is viewed as a safe, efficient, and affordable alternative to receiving care. Expectations of patients on costs and outcomes need to be managed by providers to increase satisfaction. Continued adoption of telemedicine will require improvements in technology infrastructure and technical support for patients, training and performance evaluation of providers to ensure quality of care and service, better patient communication to meet patient needs, and integration of telemedicine services in remote areas that have limited access to medical services. Telemedicine, to realize its full potential, should be centered in health equity – addressing patient barriers and needs, reducing health disparities across population groups and settings, and providing quality services to all.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-023-09127-x.

Telemedicine involves the use of technology in the diagnosis, treatment, monitoring, and management of patients [ 1 ], including video teleconferencing, remote patient monitoring, mobile health applications, and more traditional methods of communication such as text, email, voice and video calls [ 2 ]. It is a safe, efficient, and affordable alternative to in-person healthcare services, which benefits both the patient and health system. Patients are able to access high-quality healthcare for non-urgent conditions without visiting a health facility [ 2 – 4 ], thereby saving resources and reducing unnecessary burden on the health system [ 1 ]. It has also been shown to be effective in improving health outcomes and lowering risks of hospitalization and readmission [ 5 – 7 ].

The COVID-19 pandemic has negatively impacted the capacity of health systems to deliver essential services, especially among low-and-middle income countries such as the Philippines [ 8 , 9 ]. As cases increased and lockdown restrictions were imposed in the country, hospital admissions and procedures declined for non-COVID-19 and 12 high-burden diseases [ 10 ]. To respond to this public health crisis, the use of telemedicine has rapidly expanded to respond to the needs of different population groups, health conditions, and settings including urban areas [ 11 ].

Despite the benefits of telemedicine, challenges related to the patient (e.g., costs, access), health provider and system (e.g., financial and time constraints), and external factors such as poor connectivity pose problems to its wide-scale implementation [ 6 , 8 , 12 ]. Barriers to patient adoption, in particular, need to be addressed to encourage continued use. Studies on factors influencing telemedicine use and satisfaction have provided recommendations on how to improve the design and delivery of quality telemedicine services [ 13 , 14 ]. To date however, only three local studies have documented patient perspectives and experiences with telemedicine services during the pandemic and all reported good levels of satisfaction [ 15 – 17 ]. Factors negatively influencing telemedicine use and satisfaction were not explored due to the quantitative nature of the studies conducted, and data were only collected from Filipinos residing in Luzon – one of the three main island groups in the country – potentially missing out on experiences from other regions and more rural settings.

With the transition of the Philippine health system to Universal Health Care (UHC) [ 18 , 19 ], telemedicine adoption will be critical in achieving the UHC goal of providing healthcare to all by overcoming geographical barriers and delivering care to even the most disadvantaged communities [ 20 ]. Our study builds on existing evidence by using a mixed methods approach to give further context on factors influencing patient adoption of telemedicine throughout the country. By better understanding patient experience with telemedicine including barriers and satisfaction, this study may provide insights into opportunities for integrating telemedicine into routine care and improving telemedicine services for widespread adoption even beyond the pandemic.

Study design

This study used an explanatory mixed methods design consisting of an online survey and in-depth interviews. The qualitative component was guided by grounded theory to study concrete realities of participants and experiences using telemedicine services to render a conceptual understanding of patient satisfaction through an inductive, iterative, and interactive method [ 21 ].

Study participants

Participants were individuals aged 18 to 65 who reside in the Philippines and received telemedicine services during the COVID-19 pandemic.

Sampling and study size

Convenience sampling was used given the logistical constraints to conduct field data collection during the pandemic. For the online survey, participants were invited through personal and professional networks, telemedicine providers, Facebook, and Instagram. A subsample of the survey participants was invited for an in-depth interview. We selected them based on age, sex, location, and survey answers relating to their telemedicine experience and satisfaction to allow maximum variation sampling, which aims to capture as many population contexts as possible. The chosen respondents were individually contacted through text or email using information they provided in the survey. A total of 200 participants answered the online survey and 16 of them were interviewed.

Instruments and measures

The online survey questionnaire consisted of items on key socio-demographic characteristics and health-related expenditures, and questions from two validated instruments: 15 questions from Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Adult Visit Survey 4.0 (beta) and 11 questions from Telehealth Usability Questionnaire (TUQ) [ 22 , 23 ]. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ) with the purpose of advancing our scientific understanding of patient experience with healthcare. TUQ was designed to be a comprehensive questionnaire that covers all usability factors, including usefulness, ease of use, effectiveness, reliability, and satisfaction. The TUQ has acceptable construct validity and internal consistency [ 24 – 26 ]. Telemedicine usability and levels of patient satisfaction were measured for six components (convenience, communication, patient-physician relationship, cost, access, overall satisfaction) using a 5-point Likert scale to rate responses (1: strongly disagree; 2: disagree; 3: neutral; 4: agree; 5: strongly agree), with higher scores reflecting higher usability and satisfaction. Participants were asked how they found out about telemedicine: advertising/paid promotions/endorsements, news, personal research, recommendations by friends or a health professional, social media, or through other means. Participants were also asked on the telemedicine platforms used: SMS (text message), email, video call, voice call, general messaging applications (e.g., Facebook Messenger, Viber), telemedicine-specific platforms (e.g., KonsultaMD, SeeYouDoc, Aide, ClinicKo, Kitika, Medgate, SeriousMD), and others not in the options. Comparisons of the quality of services delivered through telemedicine and in-person were also measured using a 5-point Likert scale of agreement to the following statements: ‘Telemedicine services are the same as in-person consultations” and “Telemedicine services are better than in-person consultations”. A more in-depth response was obtained in the interviews, probing on their telemedicine use and experience, reasons for preferring or not preferring telemedicine over face-to-face, and the factors influencing their telemedicine use and satisfaction. The interview guide was developed and pre-tested following the general themes of the CAHPS and TUQ in English (Additional file 1 ) and Filipino.

Data collection procedures

We collected data through an online survey and online interviews from July to November 2021. We used Google Forms for the online survey, while Zoom and Google Meet were used for the interviews. We pre-tested the questionnaire and interview guide in English and Filipino among 15 participants who were similar in characteristics to our study population. The pre-test was conducted online in the same manner as the full-scale survey, and assessed for clarity, organization, and content. The survey and interview guide were revised based on the comments during the pre-testing phase.

All 200 survey participants were asked if they were interested in participating in the interview. To verify that they had used telemedicine services, we included a screening question at the start of the survey to ask about their last telemedicine consultation. For interview participants, we asked them to briefly narrate why and how they used telemedicine. We were unable to confirm through telemedicine providers and managers because of data privacy policies and measures. Among those who consented, we invited participants for an interview through their preferred video call platform (i.e., Zoom, Google Meet). Each interview lasted anywhere from 30 to 120 min. Each interview participant was given approximately USD 3 (USD 1 = PhP 52 as of 11 May 2022) worth of token for participation. Interviews were conducted by AVGN, LMMA, MCCB, DEHD, CBLL, and GATS until data saturation was reached [ 27 ]. In our study, we reached data saturation with the 16th participant who no longer provided new data, and where no new emerging themes were observed. Each participant was provided an information sheet and consent form, and time to ask questions prior the start of the interview. The reasons for studying their telemedicine use and satisfaction, and the general background of the research team were also shared with the participants. All participants consented to the interview being recorded.

Data analysis

Quantitative analysis.

We analyzed our quantitative data using descriptive statistics: percentage for categorical variables, and median for continuous variables using SPSS Statistics version 25.0 [ 28 ]. We described participants according to their age in years, sex (male or female), setting of residence (urban or rural), residence by island group (Luzon, Visayas, Mindanao), educational attainment (secondary or lower, college, post-graduate), employment status (full-time employment, part-time employment, unemployed, student, retired), monthly household income, monthly household health expenditure, monthly individual health expenditure, membership to any health insurance (yes, no), and overall health rating measured as a 5-point Likert scale. Levels of patient satisfaction were measured by computing the frequency and percentage for each item. This analysis is consistent with a study by Ackerman [ 29 ] that used TUQ to assess patients’ utilization of and satisfaction with telemental healthcare in the perinatal period. For comparisons between telemedicine services and in-person consultations, we computed the frequency and percentage for both questions with respect to those who answered ‘agree’ and ‘strongly agree’. We classified those who disagreed or strongly disagreed that telemedicine is better than in-person under the theme, “Telemedicine services are inferior to in-person visits”.

Qualitative analysis

All interviews were audio-recorded, transcribed verbatim, and translated from Filipino to English. Field notes were made in the course of the qualitative data collection. The researchers are native and fluent speakers of the two languages. Each participant was assigned a unique code to maintain anonymity. The codes or participant IDs presented in this paper are not known to anyone (i.e., providers or patients themselves) outside the research team. Inductive analysis was used to identify emergent themes and patterns from the qualitative data focusing on experiences and satisfaction with telemedicine services, guided by the principles of grounded theory [ 30 ]. Transcripts of the interviews were read to identify themes and two research members independently coded the interviews (AVGN, LMMA, MCCB, DEHD, CBLL, GATS) in Microsoft Excel. Each interview was initially coded according to general themes: facilitators or barriers to telemedicine use and satisfaction, which made our preliminary codebook. This codebook was applied to the transcripts and further refined. Once data saturation was reached, we identified emergent themes, which were iteratively reviewed and later finalized (AVGN, LMMA, MCCB, DEHD, CBLL, GATS, AML). Any disagreements were resolved through a consensus. The quotes presented in this paper are either in the original English or translated from Filipino. We report our qualitative findings following the consolidated criteria for reporting qualitative research (COREQ) guideline (Additional file 2 ).

Reflexivity

The senior author (AML) has a background in health systems research, health policy, and epidemiology, and has published COVID-19 papers in the Philippine context. The lead and contributing authors (AVGN, LMMA, MCCB, DEHD, CBLL, GATS) have a background in medicine, with males and females well represented in the research team. All authors acknowledge that their perceptions and experiences on health service delivery before and during the pandemic may influence the way data were interpreted. Drawing on the grounded theory approach allowed us to reflect on the richness of experiences by our participants. To ensure we were co-constructing and presenting accurate information, we used coding language that was reflective of the participants’. Finally, we triangulated our qualitative data with findings from the the survey.

Participant characteristics

The median age of the 200 individuals who participated in our survey was 31.50 years (IQR 23.5–46.0 years). More than half of our study population were female (64.0%) and college graduates (65.0%). A total of 62 participants worked full-time (31.0%) and 162 resided in Luzon (81.0%). The median monthly household income of participants was USD 577, which is considered part of the lower middle-income class in the Philippines [ 31 ]. The median monthly household health expenditure was USD 69 and the median monthly individual health expenditure was USD 38. Only half availed of any health insurance (51.5%). The median overall health rating of participants was 4 out of 5 (Table  1 ).

Characteristics of survey respondents ( n  = 200)

a May not total to 100% because of missing data

The median age in years of the 16 interview participants was 29. More than half (62.5%) were female. Thirteen (81.25%) participants were from Luzon, two (12.5%) were from Visayas, and one (6.25%) was from Mindanao. More than half (68.75%) of the participants availed of health insurance. Only seven (43.75%) participants disclosed their monthly household income with a median of USD 577.

Overall telemedicine usability and satisfaction

Across all statements, most participants agreed that they were satisfied with telemedicine services in terms of convenience, communication, patient-physician relationship, cost, and access. Of these reasons, convenience was identified by majority of the participants (91.0%) to positively influence their telemedicine use and satisfaction, saving them time from traveling to a hospital or specialist clinic. On the other hand, 3 in 5 perceived telemedicine to be affordable. A number of participants provided lower ratings to communication, patient-physician relationship, and access items in the TUQ. Only 116 survey participants (58.0%) strongly agreed that they would use telemedicine services again (Fig.  1 ).

Telehealth Usability Questionnaire (TUQ) ratings for telemedicine services in the Philippines during the COVID-19 pandemic ( n  = 200)

Comparisons between telemedicine and in-person consultations

Telemedicine services are the same as in-person consultations.

A total of 68 survey participants agreed (34.0%) that the service provided through telemedicine was the same as in-person consultations. This is supported by our qualitative findings that just like face-to-face consultations, telemedicine allows patients to access services provided by physicians, express their medical concerns, and have their concerns addressed. This perception of adequacy of care provided via telemedicine promotes its use:

“[In a way,] telemedicine is the same [as face-to-face consultation] because I still get to talk to a doctor. You get to voice out your problems or your medical history, and then get a prescription or diagnosis.” (E131, 20–24 years old, female)

Telemedicine services are better than in-person consultations

A total of 72 survey participants (36.0%) perceived telemedicine services to be better than in-person consultations. One participant who used KonsultaMD for a skin condition mentioned convenience and experiencing better quality of service:

“[Telemedicine is] just so much more efficient and convenient, and I feel like the doctors are not in a rush to get to the next patient, and they really try to [serve] you better over telehealth as compared to face-to-face consultations.” (E3, 20–24 years old, female)

Telemedicine services are inferior to in-person consultations

A total of 60 survey participants (30.0%) perceived telemedicine services to be inferior to in-person consultations. Interview participants elaborated and expressed that telemedicine is lacking in multiple functions of care including laboratory tests and diagnostics, physical assessment, and rapport-building. Their preference for telemedicine or in-person visit depended on the health condition. A participant with an atypical presentation of her illness who needed multiple laboratory tests for her diagnosis: “I would never use telehealth consultation again for other matters besides follow-up care.” (E69, 20–24 years old, female). She explained that the telemedicine consultation was not useful because she still needed to do an in-person consultation to have her concerns addressed. She also mentioned that whether or not she did telemedicine or an in-person consultation, she still had to be at the hospital for laboratory results.

Several respondents noted that some diseases cannot be assessed through telemedicine due to the necessity for certain equipment or physical assessment, leading to the preference for face-to-face consultations:

“For those illnesses that cannot be diagnosed by video call, like those that need additional equipment to check, then it’s better to do it face-to-face.” (E133, 25–29 years old, female) “I used to have skin asthma. So for me, it’s really necessary to go and see a dermatologist so that he/she can physically see what rashes I have.” (E93, 40–44 years old, female)

Factors influencing telemedicine use and satisfaction

Facilitators, safety of telemedicine during the pandemic.

All 16 interviewees cited COVID-19-related reasons for their telemedicine consultations. Many participants used telemedicine because of the possibility of being exposed to the virus on the way or at the place of face-to-face consultation itself:

“Telemedicine has less exposure [to the coronavirus], less travel time and it’s also related to my mental health wherein I really don’t want to leave the house.” (E128, 25–29 years old, female) “With the pandemic, of course you’d choose to not expose yourself further. If you’re already sick, you don’t want to expose yourself to an additional kind of virus that’s more deadly.” (E133, 25–29 years old, female)

Telemedicine offers options that maintain privacy

A number of interviewees preferred telemedicine because privacy could be maintained. Being able to be discuss their chief complaints and answer questions in history taking pertaining to their private areas were some of the reasons they chose telemedicine:

“Telemedicine is convenient for me. You’re still one-on-one with the doctor. For example, either I’m in the living room or in my bedroom. Pre-pandemic – in the clinic, sometimes there are other doctors who share a cubicle. Especially when the doctor is asking questions regarding your private area, sometimes you are ashamed to mention it because others might hear.” (E97, 35–39 years old, female).

“In my case, I couldn’t go out [because] it’s a sexual concern.” (E131, 20–24 years old, female).

Telemedicine is affordable due to overall reduced costs

Around 128 survey participants (64.0%) identified low cost of telemedicine services as a facilitator. Interviewees supported this and mentioned being able to save on transportation costs and doctor’s fees:

“For me, I was able to save with telemedicine. I’m not sure if it depends on the doctor’s fee, but so far it seems that the doctor’s fee is cheap and only costs around USD 7–11 per consultation.” (E97, 35–39 years old, female)

Telemedicine is convenient due to reduced time and travel requirements

Most of the survey participants (91% ) identified convenience as a facilitator to telemedicine use and satisfaction for the following reasons: decrease in waiting time which additionally removes the necessity to file a leave of absence to go to the doctor, the absence of traffic, and the elimination of niceties when going outside such as taking a bath and dressing up:

You don’t have to get dressed, and drive or take a Grab.” (E131, 20–24 years old, female) “There are more chances that the video chat will definitely save a lot more time. There’s no travel time, there’s no waiting time.” (E79, 25–29 years old, male) “With telemedicine – generally at least in my experience, the waiting time is reduced so I think in that regard it’s nice.” (E74, 20–24 years old, female)

Telemedicine is easily accessible and readily available

Another facilitator to telemedicine use and satisfaction was accessibility of services, which was identified by 160 survey participants (80.0%). The interviewees explained that telemedicine services were available at any time and did not require them to see their doctor physically:

“Access [was one of the reasons why I chose to use telemedicine] because you just wait in the house and/or the doctor’s availability.” (E56, 50–54 years old, male) “I like telemedicine because when you need it and you’re far from your doctor, you can just call, and describe and maybe send pictures or information. You can still get your medicine and advice from the doctor.” (E22, 40–44 years old, female)

Telemedicine offers more avenues of communication

Telemedicine offers more avenues for communication as its scope includes text-based messaging, voice calls, and video calls across different platforms. In the interviews, several platforms were identified including KonsultaMD, SeriousMD, and Aide. Messenger and Viber were noted by some participants to be convenient applications for communication because they can reach out to their provider anytime. Hospital hotlines and school medical services were also platforms mentioned by interviewees. This was perceived as a benefit of telemedicine in itself:

“If you are out of the WiFi zone, it is hard to connect with video call. You have the option to email, text, or call.” (E11, 55–59 years old, female).

Survey respondents identified the use of one or more of the following: SMS, general messaging applications, email, video call, voice call, telemedicine-specific platforms, and others (i.e., dedicated hotlines). About half have used messaging applications (50.0%) and video call (45.5%) for telemedicine. Email (11.5%) is least used for telemedicine (Table  2 ).

Applications and platforms of telemedicine ( n  = 200)

a N does not total to 200 since each participant was permitted to select all methods of telemedicine they have used

Limited to absent prior patient-physician relationship

Of the 200 survey participants, 162 or 81.0% had an existing medical record with their telemedicine provider. For some, this limited to no previous physician-patient relationship contributed to dissatisfaction with telemedicine services:

“That’s also the weakness of that telemedicine platform [redacted]. It’s because you’re queueing for doctors, for GP [general practitioner] doctors, right? What happens is that you don’t get to choose. Whoever is available, that’s who your provider will be.” (E69, 20–24 years old, female)

Perceived lack of experience and ability to provide quality service among telemedicine providers

Related to the absence or lack of prior-physician relationship, depending on the telemedicine service and platform used, some interview participants were unable to choose a physician whom they preferred and perceived to be able to meet their needs:

“For emergency cases, it’s mostly resident doctors who would answer [the telemedicine hotline], not really a doctor [consultant/attending]. I experienced that in [redacted hospital 1], they weren’t sure if they should ask their superior, or rather the department head of dermatology, how my case should be managed. This means they couldn’t make decisions on the spot about what should be done to the patient, unlike in [redacted hospital 2], decision making is automatic because it’s really a doctor [consultant/attending] answering.” (E15, 30–34 years old, male)

Inherent limitations of telemedicine

Almost 3 in 10 of our survey participants disagreed, or were neutral, on telemedicine being an acceptable way to receive healthcare services. Interviewees expressed concerns on quality of services provided through telemedicine due to its limitations, especially for conditions that require diagnostic tests and physical check-ups. Doctors ask several questions and seek validation from patients. There is also perceived poorer quality of care because patients feel that they are not being checked thoroughly by the doctor:

“I don’t think the consultation can provide enough accuracy compared to an in-person consultation for the prescribing doctor. I don’t think an over-the-phone conversation can truly give a telemedicine provider an accurate evaluation of myself.” (E89, 25–29 years old, male) “It’s really different when the doctor looks at you, puts his stethoscope on you, and conducts physical assessment. Unlike in the past, the doctors will immediately check the part of your body that is painful.” (E71, 50–54 years old, male)

Perceived high costs that are comparable to in-person consultations

The cost of telemedicine was perceived as a barrier to the use and satisfaction of telemedicine services with some participants expecting that telemedicine costs would be lower. As one interviewee remarked: “I really expected it [telemedicine] to be cheaper than an in-person consultation. If I’m going to pay the same price, then I’ll choose to go to a health facility.” (E82, 15–19 years old, male).

In the survey, the cost of telemedicine ranged from USD 0 to USD 192 with a median of USD 7.5. Telemedicine consultations for mental health conditions were in the higher range. Nearly half (42.5%) of the survey participants had consultations for free with some relying on promotions to avail telemedicine. There were also participants who perceived the price of telemedicine to be expensive and inaccessible for other population groups: “I was just thinking in general, how would Filipinos –from all demographics, all social classes – how would they find it? So I said it [the cost] might be a barrier for some.” (E131, 20–24 years old, female).

Poor network connectivity resulting to ineffective communication

Ineffective communication as a result of poor network connectivity was identified as a barrier by five (2.5%) survey participants. One interview participant noted: “Even if you’re connected and you’re talking, sometimes the telemedicine provider doesn’t hear what you’re saying, or vice versa. They hear you, but they don’t understand because of poor call quality [due to poor connectivity].” (E84, 50–54 years old, male). Of the 200 survey participants, one disagreed and 25 were neutral when asked if they were able to communicate with their provider clearly. Others also mentioned that their satisfaction with telemedicine depends on how smoothly the telemedicine consultation goes, which in turn is significantly influenced by internet connectivity, the platform’s data usage, and the gadgets used for the consultation: “If we’re in the middle of a serious discussion, then suddenly it [the internet connection] will be cut off? It’s awkward and embarrassing, especially if I don’t know the doctor.” (E93, 40–44 years old, female).

Inaccessibility of required technology interferes with telemedicine use and satisfaction

Participants identified access to technology required for the consultation to be an important consideration, and cited inaccessibility as a contributing factor to its disuse and dissatisfaction: “People don’t have mobile load. Some don’t have good cameras for their phones or gadgets, or some don’t have it. I think that’s the disadvantage of using telemedicine.“ (E21, 40–44 years old, female).

Our study showed that Filipino patients are generally satisfied with the services provided through telemedicine applications and platforms. This is consistent with previous studies that report high levels of patient satisfaction [ 32 – 34 ]. Telemedicine was perceived to be similar to in-person consultations in that the participants were able to obtain medical advice and have their health concerns addressed regardless of the mode of delivery. Some perceived it to be better primarily because of convenience and accessibility. However, the inherent limitations of telemedicine restrict its utility, especially for health conditions that require physical assessments and laboratory tests.

We found that telemedicine use and satisfaction are positively influenced by a number of factors including safety during the pandemic, privacy, affordability, convenience and accessibility, and availability of more avenues of communication. Safety was a major concern that prompted participants to use telemedicine. Telemedicine enables patients to avoid situations that would expose them to SARS-CoV-2, the causative agent of COVID-19, such as traveling and staying for long periods in high-risk environments. These safety concerns, together with lockdown restrictions, resulted to significant declines in hospital admissions for non-urgent procedures [ 10 ]. As a result, digital health solutions and telemedicine have been introduced to respond to health concerns while reducing the risks to the patient and the burden to the health system [ 34 ]. Participants also mentioned that telemedicine allowed them to maintain privacy, which is not always possible for in-person consultations. The benefits of anonymity are especially important with regards to sensitive and potentially stigmatizing health issues such as mental or sexual health conditions [ 29 ]. Because telemedicine removes the need to travel, participants also viewed it as more affordable, accessible, and convenient. This was noted by participants as an enabling factor to use telemedicine, especially since a third of our participants are full-time employees and a quarter are students. Traveling for healthcare purposes could mean missing work or school [ 35 ], and telemedicine therefore gives them greater ability to manage their time around consultations. Additionally, the variety of communication modes and platforms available contributed to patient use and satisfaction [ 36 ]. This enables patients and providers to communicate through other avenues when technical difficulties arise.

Barriers to telemedicine use and satisfaction included: perceived poor quality of care and service due to limited or absent prior physician-patient relationship and inability to choose preferred providers, inherent limitations of telemedicine, perceived high costs that are comparable to in-person consultations, and poor internet connectivity and other technological barriers (e.g., gadget availability and specification). Lack of trust in the physician can leave the patient dissatisfied with the service provided, which can affect adherence to doctor’s advice or prescribed treatment plan [ 37 ]. Established relationships are an important factor in telemedicine use, as patients are less willing to use telemedicine to see a provider that they do not know [ 38 , 39 ]. Telemedicine was perceived as an efficient and effective alternative to in-person consultations, but not for all health conditions especially those requiring physical assessments and diagnostics. Other studies have reported similar findings [ 40 – 42 ], with providers having to determine when a telemedicine is most useful vis-à-vis a face-to-face visit, considering their risks and benefits, and the needs of the patient. Innovative solutions such as automated logic flows (bots) for referrals and scheduling, tools such as video otoscopes and electronic stethoscopes for examination, and artificial intelligence technologies can be explored [ 1 ]. Studies comparing these modes of healthcare delivery and traditional face-to-face method need to be carried out to ensure effective, accurate, and quality care is provided. While some participants in our study and in other published literature noted cost as a factor contributing to patient satisfaction [ 5 , 34 , 43 ], we also found it to be a reason for dissatisfaction among our participants. This may be due to the significant proportion of participants in our sample who were not employed with almost a half not enrolled in any health insurance plan. The Implementing Rules and Regulations (IRR) of the Universal Health Care (UHC) Act stipulates that the Philippine Health Insurance Corporation or PhilHealth shall use its contracts to incentivize the integration and use of telemedicine [ 18 ]. The PhilHealth “ Konsultasyong Sulit at Tama ” (or Konsulta ) package is a comprehensive outpatient benefit that integrates telemedicine to ensure access to services [ 44 ]. According to a PhilHealth circular released in 2021 [ 45 ], home isolation services including telemedicine will be incentivized as long as Konsulta providers have accomplished all necessary documents. In addition, several health maintenance organizations in the Philippines reimburse telemedicine consultations or provide these services for free among insured patients, which lessens financial burden [ 46 – 48 ]. While medical insurance and benefit packages allow access and utilization of healthcare services at lower costs [ 49 ], the rollout of the Konsulta package has been significantly delayed and therefore, patients need to pay out-of-pocket to avail of services including telemedicine. Some of our participants availed promotions to get free telemedicine consultations, however this may not be sustainable for both provider and patient. Poor network connectivity and technological barriers resulting to ineffective communication also decreased levels of patient satisfaction, which is consistent with published findings [ 50 ]. These barriers are especially significant in the Philippines, where service delivery and resources are inequitably distributed and affected by the pandemic [ 9 , 19 ] – further compounded by the limited access to the Internet and technology in remote areas. As a result, telemedicine is not widely adopted in these communities. These technological issues and other barriers identified by the study need to be addressed to provide services to patients where physicians are few, and where long-distance care is most needed [ 35 ].

Limitations

A number of limitations need to be considered when interpreting our findings. First, the results of the study are influenced by the social context and implications of the COVID-19 pandemic during the time the study was conducted. Because of this, scores provided by the participants are not indicative of telemedicine alone, but rather, indicative of patient satisfaction when using telemedicine in the context of the COVID-19 pandemic. Patient telemedicine satisfaction studies also generally report high ratings reflective of their experiences with healthcare and service delivery [ 50 ]. However, we addressed this issue by including a measure on preference between telemedicine and face-to-face consultation [ 50 ]. A considerable proportion of participants reported the same level of satisfaction for both modes of service delivery, while a few interview participants reported less satisfaction for telemedicine. This confirms in part that telemedicine satisfaction is high in our study because of their experience with telemedicine itself, and not only because of the general care they receive from the health system. Second, our use of convenience sampling for the descriptive quantitative study and online data collection methods potentially excluded participants from low-resource and remote communities who may have other experiences and where the impact of barriers may be more profound. This limits the generalizability of our findings to those who share similar characteristics with the study participants. While we attempted to interview participants with different backgrounds and experiences to address this issue, majority of those who were willing and consented were still mainly from urban areas. However, we were still able to capture issues of cost and technology, which are also barriers to use and satisfaction among individuals from rural and lower-resource communities. Third, we asked their general experience and satisfaction to telemedicine regardless of platforms used. We are therefore unable to disentangle the effect of specific telemedicine platforms on satisfaction and use. Despite these limitations, our study provides a rich source of data, contributing to the evidence that telemedicine can be integrated into routine care during and beyond the pandemic while offering insights into use and satisfaction through the lens of patients in a low-and-middle income country.

This study showed that Filipino patients are generally satisfied with telemedicine services provided during the COVID-19 pandemic. Telemedicine use and satisfaction are influenced by factors related to the individual (e.g., cost, perceived safety, convenience), health provider and system (e.g., perceived competence of providers, physician-patient relationship), and external factors such as connectivity and technological demands. Our findings also suggest that participants have varying reasons for perceiving telemedicine to be equal, inferior, or better than in-person consultations. Telemedicine was viewed as safe, efficient, and effective especially when barriers are removed, but only for health conditions that do not require physical examination and laboratory tests. Expectations of patients on the costs, as well as the conditions that can be addressed through telemedicine, need to be managed and discussed by providers to increase satisfaction. Continued adoption of telemedicine will require improvements in technology and better patient communication to meet their needs. Our study points to the following recommendations: (a) Integration of telemedicine services in geographically remote areas that lack access to medical services to advance the UHC agenda of providing quality healthcare to all; (b) Strengthening of infrastructure to allow the use of devices and Internet for telemedicine with little to no interruption; (c) Training and performance evaluation of telehealth providers to ensure quality telemedicine services; (d) Patient communication on telemedicine and its limitations; (e) Patient support for those with technological difficulties; and (f) Future research to include stakeholder perspectives and patient experiences from remote and low-resource communities.

Acknowledgements

We want to thank all the participants for sharing their experiences. We also acknowledge the faculty and mentors at Ateneo School of Medicine and Public Health who provided feedback throughout the research process, and Dr. Lourdes Sumpaico-Tanchanco and Kriselle Abcede for the administrative guidance and support.

Authors’ contributions

All authors were involved in the design of the study. AVGN, LMMA, MCCB, DEHD, CBLL, and GATS conducted the survey and individual interviews, performed the analyses, and drafted the manuscript in consultation with AML. All authors were involved in the interpretation of findings. All authors read and approved the final manuscript.

The authors received financial support for this research from the Ateneo Center of Research and Innovation (ACRI). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Availability of data and materials

Declarations.

The study has been performed in accordance with the Declaration of Helsinki and was approved by the Ateneo University Research Ethics Committee (SMPH 2021 Group 15). Only those who consented to participate accomplished the online survey. Digital written informed consent was obtained from all interview participants.

Not applicable.

We have read the journal’s policy and the authors of this manuscript have the following competing interests: AML received funding from the International Initiative for Impact Evaluation, Inc. (3ie) to propose a study on programs designed by the Philippine Health Insurance Corporation. The views expressed in this article are not necessarily those of 3ie or their members. AVGN, LMMA, MCCB, DEHD, CBLL, and GATS declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

List of Researches

Formulation of Anti-Hypertensive Standardized Herbal Extracts for Pre-Clinical and Clinical Development (2016, On-going study of Toralba, Bulatao, & Larcia)

Formulation of Standardized Herbal Alpha-Glucosidase Inhibiting Extracts for Pre-Clinical and Clinical Development (2016, On-going study of Balotro, Yu, & Quibin)

Formulation of Xanthine Oxidase Inhibition Activity of the Formulated Tablet from the Ethanolic Extracts of Selected Medicinal Plants for Gout (2016, On-going study of Palacpac & Ladignon)

Modification of a Pharmaceutical Analytical Chemistry Laboratory Course Design to Improve Student Performance (2016, Toralba, Larcia, & Orejola)

Effect of the Expanded Senior Citizens Act of 2010 (Republic Act of 9994) on Drug Accessibility among Elderly (2016, Salenga, Loquias, Sarol)

Determination of the Angiogenic Effect of Ficus pseudopalma Blanco (Niyog-niyogan) Leaf Fractions on the Chorioallantoic Membrane of 10-Day Old Anna luzonica (Duck) Eggs (2015, Santiago, et al.)

Fractionation of the Antibacterial Components of Citrus aurantifolia Swingle (Fam. Rutaceae) Fruit Extracts (2015, Padilla, Avestruz, Gutierrez, & Toralba)

Academic Entrepreneurial Intention of Researchers of the University of the Philippines Manila – National Institutes of Health (2014, Balotro & Nevado)

Conceptual Design of Community-Based Herbal Manufacturing and Testing Laboratory in a Primary Health Care Setting (2014, Casauay)

Extraction and Purification of Pectin from the Fruit Peel Wastes of Selected Philippine Fruits (2014, Loquias)

Formulation of Standardized Plant Extracts as Supplements for Diabetes Mellitus (2014, Toralba, Orejola, & Ladignon)

In Vitro Pediculicidal Efficacy and Acute Dermal Irritation Tests of Coconut Oil Lotion and Cream Shampoo from Makabuhay Extract (2014, Balotro, Sagun, Balita, & Salud-Gnilo)

Junior Faculty Mentoring Relationships and Its Effectiveness in the College of Pharmacy in Metro Manila (2014, Gutierrez)

Evaluation of Community Pharmacy Internship Programme in the Philippines (2013, Carrido, Lorenzo, Macaldo, & Loquias)

Screening for the Anti-Angiogenic Activity of Selected Philippine Medicinal Plants using Chorioallantoic Membrane Assay (2013, Camposano, Dela Torre, Laxamana, Larcia, Loquias)

Peel Wastes of Ananas comosus , Sandoricum koetjape , Citrus nobilis as Lead and Cadmium Biosorbent in Manila Tap Water (2013)

Lead, Cadmium and Chromium in Selected Local Cigarettes Available in the Philippines (2013)

Comparison of Lead Absorption Ability of Bougainvillea ( Bougainvillea spectabilis L.) Leaves in Two Cities in Metro Manila, Philippines (2013)

The Roles of Pharmacists in Relation to Medical Doctors, Nurses, and BHWs in Preventing Dengue (2013)

Heavy Metal Concentrations in Canned Fruits of Litchi chinensis , Prunus persica , and Ananas comosus Marketed in the Philippines (2013)

Assessment and Filling of Gaps of the Anti-Dengue Program in the Philippines (2013)

Chemical Analysis and Culture Characterization of Water Kefir (2013)

Comparative Stability Study of Innovator and Generic Cefuroxime Sodium Powder for Injection Using High Performance Liquid Chromatography (2013)

Thin Layer Chromatography Methods in the Characterization and Stability Analyses of the Aqueous and Dichloromethane Extracts of Lagerstroemia speciosa L. (Fam. Lythraceae) Leaves (2013)

Identification and Segregation of Chemical Wastes of Unknown Composition Generated and Implementation of Proper Chemical Waste Disposal by the College of Pharmacy University of the Philippines Manila (2011)

A Simple and Direct Titrimetric Assay of Acetaminophen in Tablets Using Cerium (IV) Sulfate (2010)

Comparative TLC Analysis of the Constituents of Four Commercially-Available Blumea balsamifera Preparations (2009)

Comparison of the Spectrophotometric and Titrimetric Methods for the Quantitative Analysis of Sulfa Drugs using Diazotization and Coupling Reactions with Phenol (2009)

Bioactive Metabolites from Sponge-derived Fungi (2007)

First Person: Moving from fear to hope after war on drugs in the Philippines

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People who use drugs in the Philippines are being treated less as criminals and more as patients who need medical help and other interventions, as authorities there look to update the country’s former controversial policies.

Thousands of people across the Southeast Asian country were reportedly killed during the so-called war on drugs which was promoted by the last Filipino administration.

But now a more compassionate and less punitive approach is being taken from the local level up.

UN News’ Daniel Dickinson travelled to Antipolo - close to the capital Manlia - to meet Michael John Maestro, a registered nurse who works on drug-abuse prevention and treatment at the Antipolo City Anti-Drug Abuse Office and whose work has been supported by the UN Office on Drugs and Crime ( UNODC ).

“One young man, who I will call Carlo, who abused meth amphetamine was referred to our office. He was having psychotic episodes in December last year and January this year and was being threatening towards his mother.

He also tried to choke a child. His family realized they needed to keep him and other people in the community safe, so they kept him locked in his room. He only had his dog Butchokoy for company.

I realized that his abuse of drugs was due to mental health issues as he was showing symptoms of schizophrenia, which could have been chemically- induced by the meth amphetamine.

He was prescribed anti-psychotic drugs six weeks ago and the change since I last saw him is incredible. He has not experienced any more psychotic episodes, his mood is more positive and he is able to move around his neighbourhood, even to play basketball with other young people.

Crime and punishment

During the war on drugs he might have been targeted and thrown in jail and perhaps even killed. That period was characterized by fear and punishment and people who use drugs were considered evil and a menace to society.

It was clear to me that Carlo needed compassion and understanding and not punishment. He is a normal person, he just has different medical needs. Drug addiction is a chronic disorder. It is both a medical and mental health condition, which requires treatment and that is now the new approach taken here in Antipolo and by health authorities across the country.

This change in policy and our compassion towards people who use drugs has resulted in more people seeking treatment for their condition at the Antipolo City Anti-Drug Abuse Office. Last year, 30 people voluntarily sought treatment in our office, but already during the first five months of 2024 we have seen 36 patients.

Reducing stigma

By showing respect and empathy, we can continue to help to reduce the stigma that still exists around people who take drugs. This change will take time, but I think through my experience of talking about drugs at schools and community centres that people are ready to listen.

With the help of UNODC , I am using a tool-kit of questionnaires which identify the needs of patients and inform treatment plans. The tool-kit tracks all sorts of economic, health and social data and from the information we gather, we can refer the patient to the appropriate city agency to treat and support him or her.

The tool-kit approach is unique and we are carrying out an impact study with the hope that if the results are positive, we can expand it to other municipalities in the Philippines.

I’m very passionate about my job. I look at people and see that they need help, my role is to take care. The love and passion I feel towards the people who step into my office and the positive change in their life that I can contribute to through a compassionate approach gives me the motivation to do this job.”

• First Person
• philippines
• drugs and crime

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• 2024 Trafficking in Persons Report

A PDF accessible version will be posted as soon as the ongoing accessibility and accommodation updates are concluded. Your patience is appreciated.

If you have questions about the 2024 Trafficking in Persons Report, please email  [email protected] .

• Message From the Secretary of State

Dear Reader:

Human trafficking is a stain on the conscience of our society.  It fuels crime, corruption, and violence.  It distorts our economies and harms our workers. And it violates the fundamental right of all people to be free.

Around the globe, an estimated 27 million people are exploited for labor, services, and commercial sex.  Through force, fraud, and coercion, they are made to toil in fields and factories, in restaurants and residences.  Traffickers prey on some of the world’s most marginalized and vulnerable individuals – profiting from their plight.

The State Department’s annual Trafficking in Persons Report provides the world’s most comprehensive assessment of this abhorrent practice, as well as efforts by governments and stakeholders around the globe to combat it.  By measuring progress in 188 countries – including the United States – we are advancing President Biden’s commitment to prevent trafficking, prosecute perpetrators, and protect survivors.

Even as this resource covers long-standing forms and methods of trafficking, it also examines the growing role of technology in both facilitating exploitation and countering it.

Digital tools have amplified the reach, scale, and speed of trafficking. Perpetrators use dating apps and online ads to recruit victims.  They use online platforms to sell illicit sexual content.  They leverage encrypted messaging and digital currencies to evade detection.

At the same time, technology is also one of our most powerful tools to combat this enduring scourge.  Mobile phones, social media platforms, and artificial intelligence make it possible for advocates and law enforcement to raise greater awareness about the rights of workers and migrants, locate victims and perpetrators of online sexual exploitation, and analyze large amounts of data to detect emerging human trafficking trends.

As technology makes it easier for traffickers to operate across geographies and jurisdictions, those of us committed to rooting out this horrendous crime – in government, businesses, civil society – can and must work together and coordinate our efforts.

I am grateful to everyone who contributed to this report, especially the State Department’s Human Trafficking Expert Consultant Network, who helps ensure our findings and recommendations are informed by those with lived experience of human trafficking.

I also want to recognize our TIP Report Heroes who have been essential partners in this work.  For the past 20 years, the Department of State has honored more than 170 such champions of human dignity and decency from over 90 countries – survivors, government leaders, law enforcement officials, lawyers, social workers.  Many of them have put their own safety at risk to support victims and share their stories.

The courage and persistence of survivors and advocates like these humble and inspire us all as we continue working to build a safer and more just world.

Antony Blinken

• Message From the Ambassador-at-Large

Innovation drives successful anti-trafficking work.  As criminals continually adapt to take advantage of new vulnerabilities and opportunities to exploit others, we must persistently keep pace with a rapidly evolving trafficking landscape.  This year’s introduction examines the role of digital technology, which has had a profound impact on trafficking methods and trends in recent years.  Traffickers use online platforms to recruit, groom, defraud, coerce, and exploit victims, taking advantage of the potential for anonymity offered by online spaces.  At the same time, when harnessed effectively, digital technology can strengthen our anti-trafficking response, providing opportunities for stakeholders to strengthen prevention efforts, protect victims, and partner with survivors and other stakeholders to combat the crime.

In our fight against human trafficking, we must constantly strive to connect and unite through innovation, including optimization of our use of digital technology.  Traffickers take advantage of the ever-shifting nature of the internet to exploit others; it is imperative that we too embrace technology to counter this trend.   Digital technology has given us new ways to prevent trafficking, protect victims, prosecute bad actors, and forge global partnerships to combat this crime.  This year’s report highlights a range of successful and promising innovations that set us on that path.  Developing partnerships and empowering communities most affected by human trafficking are key to combating this crime.  This report examines, for example, how current efforts to prevent and address forced labor are buoyed by strategic partnerships with workers, including worker-led approaches to advancing labor rights and standards.

The internet can provide spaces to share information, for example to train and educate youth regarding online safety, empower workers to know and protect their rights, and educate vulnerable populations to recognize indicators of exploitation.  Digital tools can provide human trafficking victims with streamlined access to services such as hotlines, peer support and therapy, and other resources for technical training and financial literacy to help survivors navigate the exit and recovery stages of human trafficking.  Technological advances can increase the speed and accuracy of data collection, an area that when harnessed effectively can aid in the identification of trafficking patterns and trends.  Stakeholders can use technology to strengthen communication and information-sharing tools that incorporate workers’ voices, increase transparency and accountability in supply chains, and streamline collaboration and data-sharing among stakeholders.

This year’s introduction also covers a topic of personal importance to me as a former prosecutor.   Utilizing strategic investigative processes can effectively shift the burden of proof away from a reliance on victim testimony, which can endanger and retraumatize victims, and onto the prosecuting authority to both strengthen criminal justice procedures and better facilitate the safety and long-term well-being of victims and survivors.  Strengthening partnerships with survivors and innovating for greater inclusion of historically marginalized communities such as those with disabilities, are crucial to the anti-trafficking movement.  Survivors must continue to be consulted early and often in the development and implementation of anti-trafficking work.  Their firsthand knowledge of the ways in which traffickers are utilizing technology for exploitation is critical to ensure effective prevention, protection, and prosecution efforts.

Governments have a responsibility to guide and leverage efforts, including the use of digital technology, to protect the rights and safety of their citizens; however, governments cannot do this alone.  Collaboration and partnerships among stakeholders – governments, tech companies, NGOs, survivor communities, and financial institutions – are more important than ever to creating a safer world without human trafficking.  A fierce commitment to innovation has the power to renew and strengthen the deep connections that bind together all of us working to end human trafficking.  The United States is proud to work alongside our partners at home and overseas as we document and disseminate efforts to end this terrible crime while also recognizing the heroes whose work around the globe brings hope to victims, empowerment to marginalized communities, and motivation to continue our collective efforts.

• Human Trafficking Defined

The Trafficking Victims Protection Act of 2000, as amended (TVPA), defines “severe forms of trafficking in persons” as:

• sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or
• the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

A victim need not be physically transported from one location to another for the crime to fall within this definition.

Exploring the Role and Impacts of Digital Technology on Human Trafficking

In today’s rapidly evolving world, technology is often a double-edged sword.   While technology has provided innovative solutions to preventing and addressing human trafficking, it has also prompted complex ethical questions and created new opportunities for criminals, including human traffickers, to be increasingly sophisticated in exploiting individuals for profit.   Traffickers use technology to recruit, control, market and exploit vulnerable individuals while also evading detection.   Traffickers do this, for example, by using the Internet to advertise and sell children online for sex, advertise false jobs on social media platforms that are actually human trafficking schemes, transfer cryptocurrency to other traffickers, and perpetuate online scam operations.   At the same time, anti-trafficking stakeholders are using technological innovations to prevent human trafficking, protect victims, and prosecute traffickers.   The 2024 Trafficking in Persons Report (TIP Report) introduction explores the challenges associated with digital technology in the fight against human trafficking and highlights how it can be used effectively by the anti-trafficking community.

Defining “Digital Technology”

Digital technology refers to an ever-expanding set of electronic systems and resources that facilitate learning, communication, entertainment, and more.   Examples include hardware, such as computers, smartphones and mobile devices, and robotics; software, including mobile applications, geolocation, online games, financial databases, web-based and cloud-based systems, and artificial intelligence (AI); and other online services, such as websites, video streaming, blogs, and social media.   For the purposes of this report, digital technologies are explored through their use by traffickers as well as by key anti-trafficking stakeholders and beneficiaries.

The Intersection between Digital Technology and Human Trafficking

One way digital technology and human trafficking can intersect occurs when traffickers use online platforms to exploit victims.   While not a novel phenomenon, renewed attention was brought to the issue because many people shifted their daily activities online at the height of the COVID-19 pandemic.   Reports from several countries demonstrated drastic increases in online commercial sexual exploitation and sex trafficking, including online sexual exploitation of children (OSEC), and demand for and distribution of child sexual abuse material (CSAM).   Traffickers have continued to advance schemes to exploit individuals using digital tools to groom, deceive, control, and exploit victims.   Some of these schemes lure individuals hundreds of miles away, including across borders, while others do not require them to leave their homes.  Increasingly, victims and survivors of human trafficking have shared that they first connected with their traffickers online.   While traffickers continue to refine and advance their use of digital technologies, governments and other anti-trafficking stakeholders must do the same to combat human trafficking.

How Traffickers Use Technology to Facilitate Trafficking

Human traffickers use a wide range of tactics to manipulate and exploit victims—using technology at every stage of their criminal activities, from the initial planning and execution of the scheme to the way in which they coerce, monitor, and maintain individuals to further their exploitative purpose and increase their profits.

Traffickers use the Internet to facilitate the identification and grooming of potential victims.   Traffickers often target and victimize individuals in vulnerable situations such as those experiencing conflict, natural disasters, poverty, challenging home lives, systemic oppression, or a combination of hardships.   The UN Office on Drugs and Crime (UNODC) identified “hunting” and “fishing” as two common strategies perpetrators use to deceive and recruit victims.   According to UNODC, online platforms help traffickers search proactively and anonymously for a specific type of individual who they believe is particularly susceptible to further their scheme (the hunting process), or passively attract potential victims by posting online and waiting for a response (the fishing process).   Perpetrators may use social media, online advertisements, websites, dating apps, and gaming platforms – or fraudulent or deceptive duplications of such tools – to hide their true identity through fake accounts and profiles while interacting with potential victims.   Once potential victims are identified and contact is established, communication through the Internet serves as a powerful tool to deceive individuals with false promises of education, employment, housing, or romantic relationships only to lure them into labor and sex trafficking situations.   For example, a trafficker may create an online business website, perhaps posing as a talent recruiter, on which they often include realistic photos to gain a victim’s trust and make them believe the opportunity is authentic and will help advance their career or improve their life.   In these cases, traffickers trick the victim into believing they can legitimately earn income not only for themselves, but for their families as well.   As trust is established, the trafficker manipulates and traps the individual in an exploitative situation through force, fraud, or coercion.   Tactics such as threatening physical abuse or harm to an individual, their reputation, future employment, financial prospects, or their loved ones, are used by traffickers to foster fear.   The internet can also serve as a platform to escalate the exploitative scheme further, including via sextortion.

The Federal Bureau of Investigation (FBI) defines sextortion as a serious crime that occurs when a perpetrator threatens to distribute private and sensitive material if the victim does not provide images of a sexual nature, sexual favors, or money.   The perpetrator, who often poses as a love interest, entices individuals to send sensitive images, which the victim believes are being shared privately, but the perpetrator then uses the images to control and coerce their victims to produce more images, perform sexual favors, or give money in cases involving sex trafficking or forced labor.   In addition to blackmailing the victims for large sums of money, traffickers may also use the content to generate additional revenue by selling the sensitive material on illicit platforms.

Additionally, traffickers can use the Internet to facilitate forced criminality, an increasingly common mechanism involving traffickers coercing their victims to engage in or support criminal activities ranging from working as part of online scam operations to commercial sex.   In online scam operations, traffickers largely recruit victims through deceitful job listings online, confine them in gated compounds, and force them to engage in online criminal activity under threat of serious harm.   Online scam operations include illegal online gambling, cryptocurrency investment schemes, and romance scams, all of which involve the victim of trafficking forming relationships with individuals in order to defraud them of significant sums.   Some traffickers compel victims to continue to work by threatening that if they seek help, they will be prosecuted for the unlawful acts committed as a direct result of being trafficked; while others are simply unaware that they are trafficking victims.

In sum, traffickers use digital tools like the Internet to amplify the reach, scale, and speed of their trafficking operations.   While the methods and means may have evolved with technological developments, the exploitation at the heart of trafficking persists, underscoring the urgent need for comprehensive and innovative approaches to investigate and combat this crime.

Challenges and Risks Technology Presents for the Anti-trafficking Community

Digital technology has broadened the scope and scale of operations for traffickers as it allows the flexibility to target and exploit victims across the world while remaining hidden and more difficult to trace.   Traffickers adapt their schemes to take advantage of the obscurity available with new online tools, such as hiding behind anonymization tools or software, and benefiting from loose regulations of online platforms.   These challenges make it increasingly difficult for law enforcement and anti-trafficking stakeholders to identify and implement coordinated solutions fast enough to effectively combat technology-facilitated human trafficking.  Constant evolution in digital technology and the ways in which it is being used also makes it difficult to concentrate efforts or decipher trafficking indicators on a given platform, because law enforcement agencies must continuously adapt their tactics, develop technical expertise, and collaborate with technology companies to effectively combat trafficking.   Additionally, NGOs and service providers with data relevant to the field may struggle with how to effectively share information while considering data ownership and ensuring privacy is being maintained and protected.

Cross-Sector Coordination Challenges  

Traffickers have widened their reach by communicating with and recruiting victims globally, which has created a need for greater global coordination among anti-trafficking stakeholders and technology experts.   These stakeholders face several challenges to coordinating a global response, including navigating diverse legal frameworks to address technology-facilitated human trafficking that transcends borders.   It is often difficult to determine which jurisdiction has authority to investigate and prosecute perpetrators and coordinate international investigation efforts involving multiple countries.   Even when the jurisdiction is established, the necessary evidence gathering and coordination often results in lengthier processes, causing further strain on law enforcement agencies.   Traffickers also take advantage of and operate with impunity due to gaps, inadequacies, or loopholes in laws and regulations to address technology-facilitated trafficking and associated activities.

The lack of sufficient funding for research and training on traffickers’ exploitation of digital tools can leave the anti-trafficking field responding reactively rather than proactively.   Capacity and resources are particularly acute challenges for law enforcement in regions with limited access to advanced technology.  Several technology-based anti-trafficking tools exist for data mining; however, many regions are unable to take advantage of these resources due to a lack of technological infrastructure and digital literacy.   Victims may also find themselves isolated and unable to easily seek help in geographical areas with limited technological capabilities, and poor internet connectivity or coverage may affect their ability to receive information and services from anti-trafficking NGOs in a timely manner.

Data Privacy, Protection, and Access

Data protection, data analysis, and data sharing are crucial methods of using digital technologies to prevent, identify, and reduce instances of human trafficking, but practitioners must consider potential negative effects on the safety and well-being of victims and survivors.   Collecting and sharing data on human trafficking cases, including victims’ personally identifiable information (PII) can be essential for law enforcement and victim support efforts, but could raise serious data privacy concerns for victims and survivors should their information be inadvertently released to the public through data breaches, which has become a common issue with digital technology in general.   NGOs and technology companies often use data mining techniques to support law enforcement in investigating offenses but may lack appropriate security protocols to properly safeguard the data and protect victims’ PII from bad actors.   Different standards for ensuring data privacy and protections across countries and concerns around national security hinder effective information sharing between governments.   Frameworks for data collection, storage, and sharing of personal data are often different, complicating international cooperation.   Governments should consider strengthening digital literacy and infrastructure, where possible, to improve data security standards and procedures, while listening to the recommendations from anti-trafficking stakeholders, including those with lived experiences of trafficking, to assess the best mechanisms for gathering, analyzing, and sharing data related to victims and survivors.    

Encryption & Anonymity

Encryption systems are one way to safeguard data in digital interactions including in web browsing, messaging apps, and financial transactions.   Such systems prevent third parties from accessing data by turning readable data into a scrambled code that can only be recovered by the receiver’s system, ensuring that only authorized parties can access the original data.   Anonymizing technology provides a high level of privacy and obscures the connection between an individual’s online activity and their real identity.   Encryption systems found in many online platforms are designed to protect the privacy and security of all online users; however, these systems and anonymizing technologies such as virtual private networks (VPNs), can also offer protection to bad actors, allowing them to avoid detection and accountability.

As with any crime, heightened anonymity may pose a major challenge for law enforcement and anti-trafficking stakeholders in identifying traffickers and their co-conspirators, whether it is the creator of a fraudulent social media account or author of an online advertisement scam.   Traffickers increasingly benefit from and rely on the protection that digital tools offer as it amplifies an offender’s ability to anonymize themselves through the entire transactional process – from the recruitment and the solicitation to the management of the transactions and relationships to the payment.  Virtual currency has even enabled a distance between those making and receiving payments and the movement of the money.  Traffickers may also hide their IP addresses and encrypt their communications, such as emails, chat messages, and file transfers.   Together this allows greater physical separation between the offender and the offense, impacting the crime itself and law enforcement’s ability to intercede.

Media or Misinformation

The proliferation of social media and online forums have increased the potential for false narratives and misinformation about human trafficking to circulate online and skew public perceptions of the crime.   Even accurate reporting on human trafficking cases and issues may unintentionally minimize the wide range of potential trafficking experiences.   Unfortunately, the most sensationalized and misleading stories tend to attract the most attention and mispresent what human trafficking is while also shifting focus away from more prevalent forms of trafficking and from marginalized populations whose exploitation may not receive the same coverage.   Such reports may also create a singular or limited perception within communities of what human trafficking looks like, perpetuating stereotypes and interfering with prevention efforts or victims’ ability to self-identify.

The Promise of Technology in Monitoring and Combating Human Trafficking

Technology also plays an important role in investigating and countering human trafficking.   Digital technology, including mobile applications, social media campaigns, and online hubs, can be used to further share information, resources, and training on human trafficking.   It can also be used to improve access to online support services for victims, survivors, and vulnerable populations.   Organizations are using data analytic tools to help identify current trends in fraudulent recruitment, map complex supply chains for links to forced labor, and detect emerging human trafficking schemes.   These tools help support information sharing used to bolster identification, investigation, and prosecution efforts by providing means to integrate and analyze data from multiple sources.

Enhancing Education and Outreach Efforts

Digital technology and literacy expand the reach of prevention efforts to raise awareness and educate the public on human trafficking globally.   Given the increase in online activity among children, governments and parents should even further prioritize education around online safety for children and youth, and could take advantage of online tools to inform children of the risks related to the internet.   Fortunately, there are already a number of beneficial training tools for young people using social media and mobile applications, as well as for parents and guardians, that help support early interventions to prevent technology-facilitated trafficking of youth.   One example of how technology is being used for public awareness is through online campaigns including the Can You See Me? campaign administered by A21, a global anti-trafficking organization in the United States, aimed at informing the general public on how to spot signs of human trafficking and where to report it.

Technology is also being used to improve awareness and outreach efforts to support worker engagement and empowerment.   Commonly used messaging apps and social media platforms, as well as specially designed worker engagement and empowerment platforms, are used to educate workers on their labor rights, including the right to organize; access legal and social services; and connect with legitimate employers and jobs.   Some tools also offer responsible employment training for managers, provide secure grievance mechanisms for workers, aggregate worker survey responses, and provide feedback opportunities, allowing workers to share information about their recruitment and work experiences.   One promising example comes from Polaris, an NGO based in the United States.   Through its Nonechka project, Polaris collaborated with technology partner Ulula on a platform that allows farmworkers in Mexico and now in the United States to share their experiences, including information on risky recruitment and employment processes.   This information also helps Polaris formulate prevention strategies, as well as inform workers about their rights, wages, and working conditions and how to access general services locally including emergency, transitional, or long-term services.

Victim Services

Digital technology tools can aid victims during the exit and recovery phases of a human trafficking experience.   Technology can play a pivotal role in victim identification, employing various methods and platforms for finding victims online and allowing for self-reporting exploitation.   For example, the Canadian NGO Center for Child Protection (C3P) operates Project Arachnid , a web crawler that searches for known CSAM.   When such material is detected, C3P sends a notice to the provider asking that the material be removed. The NGO Thorn also has an AI-powered tool that detects CSAM and tools that aid law enforcement in child sex trafficking investigations.   While digital investigative techniques, including those that make use of AI, can assist in trafficking detection, investigation, and successful prosecutions, basic communication tools such as messaging apps, SMS and text, and phone channels also offer lower-tech and straightforward avenues for victims to communicate with service providers in real time.   Successful tools to advance victim services include those that facilitate and increase access to victim resource hotlines, virtual peer community spaces, and financial inclusion resources.   There are also online tools to bolster training and technical assistance for professionals who wish to support victims and survivors during the aftermath of victimization and to navigate the criminal justice system.   Most of these tools are mobile applications and leverage web- and cloud-based solutions for victim services.   The GraceCity App, for example, developed by anti-trafficking advocates in Sacramento, California, is a mobile application that offers victims and survivors details on the community resources in their area.   The app can canvass thousands of first responders and provide users with useful resources including nearby NGOs, medical professionals, social workers, and therapists.   Technologically enhanced interventions can be instrumental in overcoming challenges to victim identification, outreach, and intervention, providing real-time communication channels that are accessible, secure, and more efficient in providing immediate assistance tailored to the individual’s situation and unique needs.

Data Collection and Sharing Efforts

As mentioned earlier, data collection, data analysis, and data sharing are crucial components of using digital technologies to prevent, identify, and reduce instances of human trafficking.   Anti-trafficking stakeholders have created tools and established new initiatives to improve their data collection and sharing to support investigation and prosecution efforts.   For example, social media and communication platforms are rich sources of information for law enforcement investigations, but combing through large-scale datasets can be time consuming and labor intensive.   A diverse group of stakeholders, including governments, international organizations, civil society organizations, private sector businesses, and information technology professionals developed technology tools to assist in anti-trafficking efforts.   These tools help anti-trafficking stakeholders collect and analyze vast amounts of qualitative and quantitative data through techniques such as data mining, machine learning, and natural language processing.   These digital tools not only enhance the utility and speed of traditional data collection methods used for case management and investigative purposes, but also make it easier for anti-trafficking actors to analyze the data to share real-time insights that better equip the field to address and combat trafficking.   Despite this potential, reports show that NGOs have traditionally underutilized such tools due to lack of knowledge, access, expertise, and funding, and more information is needed to better understand barriers to use.    

Anti-trafficking applications can help investigators perform pattern analyses from big-data searches encompassing structured and unstructured data from sources including social media.   These analyses allow investigators to understand traffickers’ online activities as well as their most frequently used platforms and profiles used to target and mislead victims.  For example, the Counter Trafficking Data Collaborative (CTDC), developed by the International Organization for Migration, brings together anti-trafficking organizations from around the world to make human trafficking data publicly available in a central, accessible online platform.   The goal of CTDC is to break down information sharing barriers and equip the anti-trafficking community with reliable data. CTDC offers primary, individual-level data scrubbed of personally identifiable information on victims of human trafficking that can be used to track human trafficking trends globally.

From identifying trafficking patterns to increasing accountability within supply chains to prevent forced labor, the multifaceted nature of data collection and sharing requires multidisciplinary partnerships for the benefits of data-related solutions to fully materialize.   Data collection and sharing among several anti-trafficking stakeholders is key to effectively developing anti-trafficking policies, identifying victims, prosecuting the perpetrators, and mapping where and how traffickers and transnational criminal networks operate.   Collaboration on data collection and sharing should particularly be encouraged between sectors and stakeholders equipped with capabilities to collect data and gather intelligence and insights.   Such stakeholders should include NGOs, survivor-led organizations, individuals with lived experience of human trafficking, and intelligence or investigative agencies.   The Traffik Analysis Hub is another example of a global solution that supports joint analysis of large AI-generated data sets, providing partners with the ability to pool data assets to generate new insights into patterns and hotspots of trafficking incidents.   Information from the Traffik Analysis Hub, which was developed with the support of IBM, is also shared with law enforcement so actions can be taken to disrupt trafficking operations.   The ability to use large quantities of data and data analytics also helps to minimize the use of individual victim information and victim testimony to support trafficking prosecutions.

However, the collection and analysis of large data sets present several significant risks and challenges including privacy and data security concerns, misuse of data, and bias and inaccuracies that could result from reliance on large data collections.   To mitigate these risks, it is crucial to implement data protection measures to ensure ethical data collection practices and protect individual’s right to privacy.

• Lessons Learned and Looking Ahead

The Role of Government

Governments have the responsibility to regulate the use of technology, including in anti-trafficking efforts, such as disincentivizing the abuse of online resources for trafficking.   Efforts to legislate and regulate tech companies to better prevent and address human trafficking will have broader impacts in areas such as privacy, security, and innovation, so careful consideration with a wide range of stakeholders will be needed.

Right now, government approaches to addressing emerging issues in the digital era continue to be fragmented, in part due to the scale and speed at which digital technology evolves.   Inconsistent policies make it difficult to combat tech-facilitated crimes due to their transnational and multi-jurisdictional elements.   Some governments are recognizing the importance of regulating digital platforms to protect and further national security, economic development, and human rights priorities and many have begun developing policies around the production, deployment, and use of digital technologies.   Collaboration and coordination at the international and national level will make it harder for perpetrators to continue their illicit activities.

Globally, government investment in digital technologies for anti-trafficking efforts remains low, despite significant potential.   Private sector and civil society stakeholders, including those with lived experience, will be critical to identifying additional government-funded research and development necessary to channel the positive aspects of technology and protect those who use it.   An OSCE and Tech Against Trafficking analysis found that out of 305 technology tools readily available to combat human trafficking, only 9 percent were developed through government investments.   Consideration should also be given as to how best to develop and share existing tech tools in regions of the world that lack such tools.    

The Role of Law Enforcement

Law enforcement agencies are tasked with combating technology-facilitated human trafficking by monitoring online platforms, investigating suspicious activity, and prosecuting perpetrators.   Law enforcement agencies can continuously look for new ways to proactively investigate trafficking cases by harnessing technological innovations to collect evidentiary material.   For proactive investigations, agencies can focus on increasing internal capacity to integrate data analytics and artificial intelligence tools into casework, as well as collaborate and coordinate with NGOs and technology companies in tool development, training, and information sharing – with due regard to privacy safeguards.

Law enforcement agencies have found ways to leverage technology to help identify, track, and monitor illicit activity by following its digital footprint.   A digital footprint could include online activity, from websites visited to social media posts published, and can help paint a clearer picture of a trafficker’s identity, location, and criminal activity.   Such publicly available digital evidence is often helpful in building a trafficking case.

Examples of law enforcement leveraging online data to support criminal investigations include:

• In September 2023, The Netherlands, supported by EUROPOL, coordinated a 3-day investigation targeting online criminal activities that enable human trafficking.   Law enforcement from 26 countries alongside representatives from European Labor Authority, European Police College (CEPOL), INTERPOL, OSCE, and International Justice Mission, focused on identifying online platforms and social media to recruit victims for sexual and labor exploitation.   This led to identifying 11 suspected human traffickers and 45 potential victims.
• In 2023, Operation Synergia led by INTERPOL, targeted human trafficking rings linked to cyber scam centers.   Partnering with a leading creator of cybersecurity technology, Group-IB’s Threat Intelligence and High-Tech Crime Investigation teams collected and shared information with INTERPOL and other law enforcement agencies to locate over 2,400 IP addresses associated with cybercrime, leading to the removal of the servers.   Over 60 law enforcement agencies from 50 countries participated in the search and seizure of 1,300 malicious servers and electronic devices, shutting down 70 percent of identified cybercrime command servers while the remaining 30 percent are under investigation.

Law enforcement agencies must be better resourced to combat technology-facilitated human trafficking or use technology for human trafficking investigations.   This can be achieved through greater investment in staff, training, and software.   Law enforcement officers must be trained on monitoring and evaluating online platforms and developing technical knowledge.   Law enforcement agencies can deepen their capabilities by establishing cybercrime units tasked with data analysis and decryption technology.   Cooperation protocols with NGO and private sector partners will further data sharing and the design and deployment of new tools that are victim-centric and trauma- and survivor-informed.   Multilateral knowledge exchange should also be considered when developing technology tools to prevent traffickers from exploiting the gaps in capacity and legislation between law enforcement agencies.   Governments should also focus on implementation of the UN Convention against Transnational Organized Crime and its Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children to address legislation gaps.   Lastly, law enforcement agencies with access to victims’ personal data must have protection standards in place on the collection and storage of such personal data.

The Role of the Financial Sector

The financial sector also plays a vital role in combating human trafficking.   According to the International Labour Organization, human trafficking is responsible for an estimated $236 billion in illicit profits annually.   All forms of currency, including both traditional and digital assets (e.g. cryptocurrency), can be laundered, requiring a multidimensional approach involving legislative measures, collaboration between justice and financial sectors, technological innovations, and ethical considerations to detect their use in criminal enterprises.   The financial sector’s role extends beyond upholding regulatory frameworks, often guided by promising practices in the area of corporate responsibility.  As illicit proceeds from human trafficking can intersect with formal financial systems at any stage of a human trafficking crime, it is essential that financial institutions proactively manage the risk of technology-facilitated human trafficking and train staff on the financial indicators and techniques used by human traffickers to launder money.   Coordination in this area should also include financial institutions working with law enforcement, technology companies, and survivors to inform their efforts, including on the development of training programs to enhance the ability of frontline staff and other industry professionals to detect transactions connected to human trafficking, how and when to intervene, and how to determine when a third party is benefitting from the exploitation of another.

Globally, the Financial Action Task Force (FATF) is the standard-setting body for anti-money laundering and countering the financing of terrorism and weapons proliferation.   More than 200 countries have agreed to implement FATF recommendations, which provide guidance for member countries to identify, assess, and understand money laundering and illicit finance risks and to mitigate those risks.   Since 2019, the FATF has included guidance on how to assess and mitigate risks associated with digital assets and digital asset service providers, including recommendations on how member jurisdictions should regulate cryptocurrency transactions.   Countries are encouraged to adapt FATF recommendations to their specific context to establish or enhance efforts to tackle illicit financial transactions.

Following digital financial transactions human traffickers leave behind can identify broader criminal networks and make it more difficult to profit from human trafficking.   For this reason, responsible innovation in technology and proactive partnerships between governments, financial institutions, law enforcement, and civil society experts, including those with lived experiences are an important part of identifying illicit financial activity associated with human trafficking and safeguarding financial systems against human trafficking, money laundering, terrorist financing, and other serious financial crimes.

The Role of NGOs

NGOs are one of the primary users and drivers of the development of anti-trafficking technological tools, algorithms, and programs and use digital technology to provide survivors easier access to resources and support services such as online counseling and helplines.   NGOs are also well-positioned to build strong partnerships with and bridge the gap between technology companies, governments, survivors, and community organizations to enhance the creation and broaden the use of essential anti-trafficking application services.   NGOs can use these relationships to advocate for and consult on the creation of standardized response frameworks, data privacy for victims when using anti-trafficking technology tools, and solutions to other emerging concerns around technology.    

A result of a partnership between NGOs and international organizations (IOs) to advance work under the UN’s Global Compact on Decent Work in Global Supply Chains, the Interactive Map for Businesses of Anti-Human Trafficking Organizations was developed to be a user-friendly repository database that tracks global and local initiatives and organizations that businesses can partner with on anti-trafficking efforts.   The map provides NGOs an opportunity to optimize coordination, research, awareness, and prevention efforts through the ability to identify specific industry initiatives to combat human trafficking via a filter tool that organizes data based on industry, geography, or issue, among others.

The Role of the Technology Industry

The technology industry, while providing many benefits can also inadvertently create environments that facilitate trafficking and other crimes, including by creating a space that facilitates unsupervised access to children.  Many companies acknowledge that the popularity and simplicity of user-friendly application services contribute to unsafe environments by providing traffickers with easy access to communicate, advertise, and coordinate illicit activity. Some technology companies have taken steps to address these challenges, but ongoing efforts are needed to enhance security measures, improve content moderation, and collaborate with law enforcement to prevent technology from being used by bad actors for illicit activities. Technology can play several roles to include using data and algorithm tools to detect human trafficking patterns, identify suspicious and illicit activity, and report such activity to law enforcement.   Technology companies play a pivotal role in protecting victims and vulnerable individuals from being exploited through the use of their online platforms and must be part of the solution to combat human trafficking.

Some technology companies are increasingly investing in better language models and machine learning to allow computers to learn from and make predictions based on data trends.   These tools are a useful resource as they may provide law enforcement agencies with powerful tools to more efficiently target illicit activity and possible cases for investigation, but they are not required.   Language models can detect, translate, and categorize key words used by traffickers to identify trafficking communication patterns.   It can be used to aid international investigations and target traffickers since they often recruit individuals in different countries primarily communicating through technology and internet platforms in the victims’ native language.   Alongside language models, other machine learning tools have the ability to cross reference various data sets, such as combining law enforcement data and transit trends, to help stakeholders formulate specific algorithms that can trace traffickers’ patterns.   These tools can enhance collaboration between law enforcement agencies and other stakeholders, as well as quickly close the gap for countries that may not have established effective tools to track or investigate human trafficking.   As developers continue to build and enhance anti-trafficking applications for protection, prevention, or prosecution functions, they must be designed to tackle the unique challenges and scenarios that arise in the context of human trafficking.

Regardless of the progress provided by technology tools, it is crucial that anti-trafficking stakeholders be cautious of becoming overly reliant on using AI and facial recognition technology to identify victims of human trafficking and the traffickers.   These tools should enhance, not replace, existing methods.   Developers, policymakers, and anti-trafficking leaders seeking to improve anti-trafficking efforts with AI and facial recognition tools should prioritize establishing data privacy rights and ensuring individuals’ information is protected throughout data-sharing processes.

Taking Action: Considerations for Anti-Trafficking Stakeholders

Harnessing technology to advance the shared goal of governments, law enforcement actors, technology companies, and civil society to eliminate human trafficking will require proactive efforts by all actors to resolve the complex, often contradictory byproducts of technological progress.   Governments can adopt policies and legislation that recognize human traffickers’ use of technology and incentivize the positive use of technology tools to investigate and counter human trafficking, and must coordinate implementation of these policies through collaboration with the technology sector, the financial sector, anti-trafficking NGOs, and lived experience experts who can help build capacity to monitor online spaces, train staff, develop technology tools, and cultivate technical expertise.   Law enforcement entities can use technology to conduct data analytics on traffickers, their connections, and their modus operandi to inform human trafficking investigations and related money laundering activities, bolster the identification of victims online, and enhance safety nets.   Governments can also strengthen data security from unauthorized access to better protect victims and investigations and find technology-based solutions that further privacy, safety, and trust.   Multilateral forums offer important venues for governments to share best practices and develop new policies and standards that uphold current international frameworks but are also tailored to regional and local trafficking situations and existing technological capabilities.

NGOs can advocate for policies and tech solutions that empower vulnerable individuals, strengthen access to services, advance digital learning, and further privacy protections.   Local communities, NGOs, and those with lived experience know current trafficking trends and how technology is being used to facilitate crimes, and thus can recommend ways to enhance trauma-informed and victim-centric tech solutions and ways to get tech tools in the hands of those who most need them.   The technology sector should work to ensure their online platforms are being used for legitimate purposes and ensure privacy and safety for users.   The technology sector can also invest in new technologies that include detecting and countering child sexual abuse material, livestreaming trafficking offenses, and fraudulent cyber scams or job offers among other crimes occurring on their platforms.   Governments, anti-trafficking NGOs, companies, and innovators can also employ routine audits of technology tools as digital technologies evolve to limit negative consequences and better guarantee efficient, sustainable means to address human trafficking.

Collaborative efforts allow all relevant parties to inform and promote best practices for the responsible and safe use of technology by a variety of actors, including individuals vulnerable to technology-facilitated trafficking.   The challenge is immense, but political will, resource investments, innovation, and partnerships will help prevent traffickers’ use of technology for exploitation, and instead amplify and scale the best applications that assist all anti-trafficking stakeholders in meeting our obligations to combat the newest continuously evolving aspects of this pernicious crime.

• Understanding Human Trafficking

“Trafficking in persons” and “human trafficking” are umbrella terms—often used interchangeably—to refer to a crime whereby traffickers exploit and profit at the expense of adults or children by compelling them to perform labor or engage in commercial sex.  When a person younger than 18 is used to perform a commercial sex act, it is a crime regardless of whether there is any force, fraud, or coercion involved.

The United States recognizes two primary forms of trafficking in persons:  forced labor and sex trafficking.  The basic meaning of these forms of human trafficking and some unique characteristics of each are set forth below, followed by several key principles and concepts that relate to all forms of human trafficking.

More than 180 nations have ratified or acceded to the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons (the UN TIP Protocol), which defines trafficking in persons and contains obligations to prevent and combat the crime.

The United States’ TVPA and the UN TIP Protocol contain similar definitions of human trafficking.  The elements of both definitions can be described using a three-element framework focused on the trafficker’s 1) acts; 2) means; and 3) purpose.  All three elements are essential to form a human trafficking violation.

Forced Labor

Forced Labor, sometimes also referred to as labor trafficking, encompasses the range of activities involved when a person uses force, fraud, or coercion to exploit the labor or services of another person.

The  “acts”  element of forced labor is met when the trafficker recruits, harbors, transports, provides, or obtains a person for labor or services.

The  “means”  element of forced labor includes a trafficker’s use of force, fraud, or coercion.  The coercive scheme can include threats of force, debt manipulation, withholding of pay, confiscation of identity documents, psychological coercion, reputational harm, manipulation of the use of addictive substances, threats to other people, or other forms of coercion.

The  “purpose”  element focuses on the perpetrator’s goal to exploit a person’s labor or services.  There is no limit on the location or type of industry.  Traffickers can commit this crime in any sector or setting, whether legal or illicit, including but not limited to agricultural fields, factories, restaurants, hotels, massage parlors, retail stores, fishing vessels, mines, private homes, or drug trafficking operations.

All three elements are essential to constitute the crime of forced labor.

There are certain types of forced labor that are frequently distinguished for emphasis or because they are widespread:

Domestic Servitude

“Domestic servitude” is a form of forced labor in which the trafficker requires a victim to perform work in a private residence.  Such circumstances create unique vulnerabilities.   Domestic workers are often isolated and may work alone in a house.  Their employer often controls their access to food, transportation, and housing.  What happens in a private residence is hidden from the world – including from law enforcement and labor inspectors – resulting in barriers to victim identification.  Foreign domestic workers are particularly vulnerable to abuse due to language and cultural barriers, as well as a lack of community ties.  Some perpetrators use these types of conditions as part of their coercive schemes to compel the labor of domestic workers with little risk of detection.

Forced Child Labor

The term “forced child labor” describes forced labor schemes in which traffickers compel children to work.  Traffickers often target children because they are more vulnerable.  Although some children may legally engage in certain forms of work, forcing or coercing children to work remains illegal.  Forms of slavery or slavery-like practices – including the sale of children, forced or compulsory child labor, and debt bondage and serfdom of children – continue to exist, despite legal prohibitions and widespread condemnation.  Some indicators of forced labor of a child include situations in which the child appears to be in the custody of a non-family member and the child’s work financially benefits someone outside the child’s family; or the denial of food, rest, or schooling to a child who is working.

Sex Trafficking

Sex trafficking encompasses the range of activities involved when a trafficker uses force, fraud, or coercion to compel another person to engage in a commercial sex act or causes a child to engage in a commercial sex act.

The crime of sex trafficking is also understood through the “acts,” “means,” and “purpose” framework.  All three elements are required to establish a sex trafficking crime (except in the case of child sex trafficking where the means are irrelevant).

The  “acts”  element of sex trafficking is met when a trafficker recruits, harbors, transports, provides, obtains, patronizes, or solicits another person to engage in commercial sex.

The  “means”  element of sex trafficking occurs when a trafficker uses force, fraud, or coercion.  Coercion in the case of sex trafficking includes the broad array of means included in the forced labor definition.  These can include threats of serious harm, psychological harm, reputational harm, threats to others, and debt manipulation.

The  “purpose”  element is a commercial sex act.  Sex trafficking can take place in private homes, massage parlors, hotels, or brothels, among other locations, as well as on the internet.

Child Sex Trafficking

In cases where an individual engages in any of the specified “acts” with a child (under the age of 18), the means element is irrelevant regardless of whether evidence of force, fraud, or coercion exists.  The use of children in commercial sex is prohibited by law in the United States and most countries around the world.

Key Principles and Concepts

These key principles and concepts relate to all forms of trafficking in persons, including forced labor and sex trafficking.

Human trafficking can take place even if the victim initially consented to providing labor, services, or commercial sex acts.  The analysis is primarily focused on the trafficker’s conduct and not that of the victim.  A trafficker can target a victim after a victim applies for a job or migrates to earn a living.  The trafficker’s exploitative scheme is what matters, not a victim’s prior consent or ability to meaningfully consent thereafter.  Likewise, in a sex trafficking case, an adult victim’s initial willingness to engage in commercial sex acts is not relevant where a perpetrator subsequently uses force, fraud, or coercion to exploit the victim and cause them to continue engaging in the same acts.  In the case of child sex trafficking, the consent of the victim is never relevant as a child cannot legally consent to commercial sex.

Neither U.S. law nor international law requires that a trafficker or victim move across a border for a human trafficking offense to take place.  Trafficking in persons is a crime of exploitation and coercion, and not movement.  Traffickers can use schemes that take victims hundreds of miles away from their homes or exploit them in the same neighborhoods where they were born.

Debt Bondage

“Debt bondage” is focused on human trafficking crimes in which the trafficker’s primary means of coercion is debt manipulation.  U.S. law prohibits perpetrators from using debts as part of their scheme, plan, or pattern to compel a person to work or engage in commercial sex.  Traffickers target some individuals with an initial debt assumed willingly as a condition of future employment, while in certain countries traffickers tell individuals they “inherited” the debt from relatives.  Traffickers can also manipulate debts after the economic relationship begins by withholding earnings or forcing the victim to assume debts for expenses like food, housing, or transportation.  They can also manipulate debts a victim owes to other people.  When traffickers use debts as a means to compel labor or commercial sex, they have committed a crime.

The Non-Punishment Principle 

A victim-centered and trauma-informed approach is key to successful anti-trafficking efforts.  A central tenet of such an approach is that victims of trafficking should not be inappropriately penalized solely for unlawful acts they committed as a direct result of being trafficked.  Effective implementation of the “non-punishment principle,” as it is increasingly referred to, not only requires recognizing and embracing the principle in regional and national laws, but also increasing proactive victim identification.

State-Sponsored Human Trafficking

While the TVPA and UN TIP Protocol call on governments to proactively address trafficking crimes, some governments are part of the problem, directly compelling their citizens into sexual slavery or forced labor schemes.  From forced labor in local or national public work projects, military operations, and economically important sectors, or as part of government-funded projects or missions abroad, officials use their power to exploit their nationals.  To extract this work, governments coerce by threatening the withdrawal of public benefits, withholding salaries, failing to adhere to limits on national service, manipulating the lack of legal status of stateless individuals and members of minority groups, threatening to punish family members, or conditioning services or freedom of movement on labor or sex.  In 2019, Congress amended the TVPA to acknowledge that governments can also act as traffickers, referring specifically to a “government policy or pattern” of human trafficking, trafficking in government-funded programs, forced labor in government-affiliated medical services or other sectors, sexual slavery in government camps, or the employment or recruitment of child soldiers.

Unlawful Recruitment or Use of Child Soldiers

Another manifestation of human trafficking occurs when government forces or any non-state armed group unlawfully recruits or uses children – through force, fraud, or coercion – as soldiers or for labor or services in conflict situations.  Children are also used as sex slaves.  Sexual slavery, as referred to here, occurs when armed groups force or coerce children to “marry” or be raped by commanders or combatants.  Both male and female children are often sexually abused or exploited by members of armed groups and suffer the same types of devastating physical and psychological consequences associated with sex trafficking.

Accountability in Supply Chains

Forced labor is well documented in the private economy, particularly in agriculture, fishing, manufacturing, construction, and domestic work; but no sector is immune.  Sex trafficking occurs in several industries as well.  Most well-known is the hospitality industry, but the crime also occurs in connection with extractive industries where activities are often remote and lack meaningful government presence.  Governments should hold all entities, including businesses, accountable for human trafficking.  In some countries, the law provides for corporate accountability in both the civil and criminal justice systems.  U.S. law provides such liability for any legal person, including a business that benefits financially from its involvement in a human trafficking scheme, provided that the business knew or should have known of the scheme.

Topics of Special Interest

• Trafficking in Persons for the Purpose of Organ Removal

Trafficking in persons for the purpose of organ removal is one of the least reported and least understood forms of trafficking – but one that experts believe may be growing.  Like sex trafficking and labor trafficking, it is ultimately a crime that exploits human beings for economic profit.  Trafficking in persons for the purpose of organ removal is “a form of trafficking in which an individual is exploited for their organ, including by coercion, deception and abuse of a position of vulnerability.”  The crime is sometimes confused with organ trafficking; however, organ trafficking refers more broadly to the illicit trade or exchange of organs for financial or other material gain.  In organ trafficking, the focus is on the organ itself; conversely, with trafficking in persons for the purpose of organ removal, the focus is on the individual.  The key global anti-trafficking instrument, the Palermo Protocol, defines exploitation to include at a minimum “the removal of organs,” alongside sexual exploitation, forced labor, and slavery or slavery-like practices.

Often, in cases of trafficking in persons for the purpose of organ removal, would-be donors are tricked into organ donation.  Common deceptions include being told human beings have three kidneys or that kidneys regenerate after being removed, or being falsely told they will experience no negative side effects from a kidney removal (in fact, kidney donors may face serious lifelong medical challenges and be unable to work).  Although kidneys are the most common organ involved, other organs and tissues, such as livers, corneas, or skin, are also sought, although notably the Palermo Protocol’s definition covers only exploitation for the removal of organs, not of tissues or cells.  Victims may not be paid at all, or they may receive some payment; importantly, an individual can still be a victim of trafficking in persons or other human rights abuses even if they received some form of payment.

The 2022 UNODC Global Report on Trafficking in Persons noted trafficking in persons for the purpose of organ removal constituted only 0.2 percent of detected victims of trafficking compared to the much higher numbers for sex trafficking and forced labor.  UNODC has warned “existing barriers to reporting suggest that the full scale of this phenomenon is not yet known.”  The report also noted an uptick in cases (from 25 in 2017 to 40 in 2018), though the overall numbers are small.  Between 2008 and 2022, UNODC reported 700 victims of trafficking in persons for the purpose of organ removal while noting “the scale of the problem is likely to be much larger.”

Trafficking in persons for the purpose of organ removal is difficult to detect for several reasons.  Data-collection efforts are scarce, and some instances of trafficking in persons for the purpose of organ removal may be mistakenly classified or prosecuted as organ trafficking.  Moreover, unlike sex trafficking and labor trafficking, which can take place over months or years, trafficking in persons for the purpose of organ removal usually involves a brief, often one-time, interaction.  Like other forms of trafficking, transactions have increasingly shifted online and become more sophisticated, facilitating the emergence of smaller networks, and even independent brokers and suppliers, which may be more difficult to track.

Both the 2020 and 2022 UNODC Global Report on Trafficking in Persons and a 2021 INTERPOL report suggest North Africa and the Middle East have the highest share of detected victims, in part due to the prevalence of large vulnerable communities, limited access to medical care, and corruption.  The media and some NGOs have also reported instances of trafficking in persons for the purpose of organ removal for ritual purposes.  However, instances of trafficking in persons for the purpose of organ removal can occur worldwide.  In a case recently prosecuted in the United Kingdom, the victim was recruited in Nigeria and brought to London, where the organ removal was to take place (see inset box for additional information).  In another case reported by the BBC in late 2023, revealing the connection between organ trafficking and trafficking in persons for the purpose of organ removal, Pakistani police arrested eight members of an organ-trafficking ring that “lure[d] vulnerable patients from hospitals” and conducted transplants “often without the patient knowing;” several people died from these procedures.

The government of the People’s Republic of China, in particular, has been accused of systematically forcibly removing organs from political prisoners.  For example, a group of UN human rights experts noted in 2021:

Forced organ harvesting in China appears to be targeting specific ethnic, linguistic, or religious minorities held in detention, often without being explained the reasons for arrest or given arrest warrants, at different locations.  We are deeply concerned by reports of discriminatory treatment of the prisoners or detainees based on their ethnicity and religion or belief.

(Note:  forced organ harvesting is not a term defined in the Palermo Protocol, but the phrase is commonly used to describe trafficking in persons for the purpose of organ removal.)

While there is a need for additional studies and reporting to thoroughly assess the geographic and numeric scope of trafficking in persons for the purpose of organ removal, stakeholders are taking steps to attempt to address the issue.  A number of regional instruments, including the Council of Europe Convention against Trafficking in Human Organs, the Council of Europe Convention on Action against Trafficking in Human Beings, and the ASEAN Convention against Trafficking in Persons, Especially Women and Children, recognize organ removal as a form of trafficking-related exploitation.

Experts have also proposed ideas to increase the supply of legally donated organs, with the intention of making trafficking in persons for the purpose of organ removal and organ trafficking less lucrative.  These ideas include transitioning deceased organ donation from an opt-in to an opt-out system; implementing paired exchanges matching donors and patients; creating awareness campaigns targeted at potential donors, including addressing barriers to altruistic organ donation and providing guidance on how to prevent trafficking in persons for the purpose of organ removal; building the capacity of law enforcement to detect and investigate these cases; and improving transparency and reporting around transplantation.

Twenty-one-year-old “Daniel” (not his real name) scraped out a living selling mobile-phone accessories at an outdoor street market in Lagos, Nigeria, but he thought his luck took a turn when he was offered a “life-changing opportunity” to work in the United Kingdom.   The people he believed were his employers instructed him to take a blood test, which he thought was required to secure a visa.   The people he had been working with put him on a flight and confiscated his passport.   Within days of arriving in London, Daniel was taken to the Royal Free Hospital, where doctors discussed the risks of the upcoming “operation” – something Daniel knew nothing about.   Seeing his confusion, the doctors sent Daniel away – but did not notify authorities.   Later, Daniel overheard a conversation among those who had brought Daniel to the UK speaking about sending him back to Nigeria to remove his kidney.   Scared, Daniel escaped, sleeping on the streets for several days until walking into a police station and telling his story.   Daniel’s bravery eventually led to the UK’s first prosecution of – and convictions for – human trafficking for the purpose of organ removal.   A prominent Nigerian politician and his wife who had arranged the trafficking scheme to provide their daughter with a kidney transplant, as well as a Nigerian doctor, were convicted in 2023.

This story was published by the BBC, Organ Harvesting:   Trafficked for His Kidney and Now Forced into Hiding , June 26, 2023 ( https://www.bbc.com/news/65960515 ); for additional details, see the Crown Prosecution Service, Updated with Sentence: Senior Nigerian Politician Jailed Over Illegal UK Organ-Harvesting Plot , May 5, 2023 ( https://www.cps.gov.uk/cps/news/updated-sentence-senior-nigerian-politician-jailed-over-illegal-uk-organ-harvesting-plot ).

• Connecting the Dots:  Preventing Forced Labor by Empowering Workers

Forced labor, a form of human trafficking, is universally condemned yet prevalent in nearly every industry globally.  The International Labour Organization (ILO) reports forced labor has grown in recent years – with no region of the world or private sector industry spared – and the majority of forced labor takes place in the private economy, meaning forced labor is connected to global supply chains.  These facts demand a re-examination of current efforts to prevent and address forced labor, including the need to elevate the voice and agency of workers and place them at the center of prevention efforts through strategic partnerships.  In addition, particular focus should be placed on vulnerable populations, such as migrant workers.  ILO research shows the rates of forced labor among migrant workers are higher if migration is irregular or poorly governed, or where recruitment practices are unfair or unethical.

Although prosecuting specific traffickers and assisting individual victims are critical for governments combating forced labor, successful interventions to prevent forced labor require a range of stakeholders willing to visualize and address broader systemic issues centered on worker’s labor rights, including those of migrant workers, as well as supply chain power imbalances.  For governments, this may require additional resources and oversight of workplaces, especially in key sectors where forced labor is often present; better monitoring of the labor recruitment industry; increased outreach to and protections for migrant workers; and improved screening measures by well-trained officials targeting populations at greater risk of exploitation.  For the private sector, it will mean proactively supporting workers and their ability to advocate for themselves, setting clear expectations of suppliers, and rooting out practices that create environments ripe for exploitation.

Worker-led Approaches to Prevent Forced Labor 

Over time, policymakers, academics, and other stakeholders have expanded their thinking to encompass worker-led approaches to address the vulnerabilities of workers and prevent forced labor.  Such approaches include advancing labor rights and standards – including freedom of association, collective bargaining, and the remediation of labor rights abuses – as well as worker-driven approaches that include migrants.  Research has demonstrated workers are most vulnerable to forced labor if they do not know their rights, are excluded from labor protection laws, and lack access to grievance mechanisms.  Workers in the informal sector and women and girls, who often face gender-based violence and harassment in the workplace, can be particularly vulnerable.  One of the most effective ways to prevent worker exploitation is to guarantee workers’ full rights to freedom of association and collective bargaining.  Independent and democratic labor unions, led by workers, are best able to represent workers’ collective interests at multiple levels, including at the national, subnational, regional, and international levels.  Collaborating with local workers, regional international organizations, and global union federations, these unions can reach the most vulnerable workers, organize across a labor sector, and advocate for key policy changes, including responsible migration management.  As a result, they are well positioned to engage powerful transnational companies to address forced labor in their supply chains.

According to ILO’s Director of the Bureau for Workers’ Activities, there have been positive developments over time with unions reaching outside of their traditional base to include the unionization of self-employed workers.  Many unions have also expanded to include more informal economy, migrant, and domestic workers, which is key as many of these workers are governed by a variety of working arrangements, including fixed-term and temporary contracts.

This diversification of representation is important as unions allow workers to negotiate for better working conditions, influence the laws and policies that impact them, and remediate labor rights abuses.  Unions play a pivotal role in securing legislated labor protections and rights, such as legally entitled wages and benefits, occupational safety and health protections, overtime pay, and medical leave.  Union-led efforts help raise the wages for the lowest paid and least skilled workers and lead to fewer hours of unpaid overtime work.  Unions play crucial roles in identifying labor rights abuses and enforcing rights on the job.  One of the most effective ways to prevent the exploitation of migrant workers is by guaranteeing their right to join unions in destination countries.  The multiplier impact is notable, as industries with strong union representation tend to have lower levels of labor rights abuse, the worst forms of child labor, and forced labor.

Where there is an absence of unions, there at least should be effective, secure mechanisms for worker communication and grievances.   Governments should strongly encourage employers to provide mechanisms so workers can advocate for their rights, discuss workplace issues of concern and interest, and communicate grievances, even if that takes place outside a formal union mechanism.  Such mechanisms are essential to preventing forced labor, as they position workers, including migrant workers, to better protect themselves against coercion, deception, discrimination, and other forms of exploitation.

Promising Practices in Improving Labor Conditions 

Several examples stand out as raising labor conditions for workers.  

Dindigul Agreement, India

Indian women and the Dalit-worker led union Tamil Nadu Textile and Common Labor Union (TTCU) signed in April 2022 a historic agreement with clothing and textile manufacturers and major fashion companies to end gender-based violence and harassment at factories in the southern state of Tamil Nadu.  This enforceable brand agreement resulted in multinational companies committing to support a worker- or union-led program at certain factories or worksites.  An assessment a year later by the multi-stakeholder oversight committee found that the workers are now effectively able to detect, remediate, and prevent gender-based violence and harassment.  In addition, the TTCU has conducted peer education training of more than 2,000 workers and management, held more than 30 meetings with management to resolve grievances, and recruited 58 workers as monitors to help remediate gender-based violence and harassment throughout the factory units.

Freedom of Association for Garment Workers, Honduras 

In the decade that has followed Honduran workers signing an agreement with major brand Fruit of the Loom, close to 50 percent of all Honduran garment workers are now employed at a factory where an independent union represents the workforce.  As a result of this signed collective bargaining agreement, workers have won increased wages and benefits and witnessed a reduction in verbal harassment and gender-based violence.

While unionization rates vary considerably across the globe, the ILO notes other encouraging examples.  In Uzbekistan, trade unions have organized seasonal workers and facilitated dual affiliation to different unions in other countries.  In Moldova, unions have begun to establish agreements with unions in destination countries so that migrants have protection when working abroad .  In Benin, Botswana, and Mauritius, trade unions have set up Joint Trade Union Councils, which have drawn up joint declarations, charters, and protocols on the modalities of working together in national social dialogue fora.  In Lithuania and Ukraine, unions have established structures of cross-border collaboration to improve the recruitment and representation of truck drivers in both countries.  

Overall, research has also shown that unionization has spillover effects that extend beyond union workers.  Competition means workers at nonunionized firms also often see increased wages and improved workplace safety norms.  Union members improve communities through heightened civic engagement and increased voter rates.  Unions can also boost business’ productivity by giving experienced workers more input into decisions that design better, more cost-effective workplace procedures.

Milestones, Momentum, and Motivation   

Over the last several years, government and private sector attention has become focused on resilient supply chains, and there are increasing supply chain transparency and due diligence policies, regulations, and laws globally.  In addition, various initiatives have been developed to raise the importance of workers’ agency.  It is notable that flower-sector leader Bloomia’s entire cut-flower supply chain, which encompasses farms in the United States, Chile, and South Africa, will now be certified for human rights protections by the Fair Food Program, pioneers in the worker-driven social responsibility model with its partnerships among retailers, growers, and workers.  Combined, the Partnership for Workers‘ Rights, launched by the United States and Brazil at the 2023 UN General Assembly; the Multilateral Partnership for Worker Organizing, Empowerment, and Rights (M-POWER), which is part of the U.S. Presidential Initiative for Democratic Renewal; and the 2023 U.S. Presidential Memorandum on Advancing Worker Empowerment, Rights, and High Labor Standards present a unique opportunity to proactively advance worker empowerment in the short and long term while simultaneously preventing labor rights violations and abuses, especially forced labor.  The independent UN Special Rapporteur on Contemporary Forms of Slavery made a key theme for 2024 the role of trade unions and worker organizations in preventing contemporary forms of slavery.

The timing is ideal for all stakeholders committed to preventing forced labor to fully embrace the importance of supporting, elevating, and improving labor standards, bringing workers’ voices to the policy formulation and decision-making table, and working to help the public and private sector enforce rules against unfair labor practices.  Governments should take every step to use a whole-of-government approach to advance worker rights and address gaps in labor rights protection and compliance, including for migrant workers; the private sector should see free and fair unions as critical partners in competing in the global economy while protecting workers; and other civil society  stakeholders should ensure that workers’ voices are incorporated early and often, especially when their equities are at stake.

• Human Trafficking in Cuba’s Labor Export Program

Each year, the Cuban government sends tens of thousands of workers around the globe under multi-year cooperation agreements negotiated with receiving countries.  While medical missions remain the most prevalent, the Cuban government also profited from other similarly coercive labor export programs, including those involving teachers, artists, athletes and coaches, engineers, forestry technicians, and nearly 7,000 merchant mariners worldwide.    According to a report published by the Cuban government, by the end of 2023, there were more than 22,000 government-affiliated Cuban workers in over 53 countries, and medical professionals composed 75 percent of its exported workforce.  The COVID-19 pandemic increased the need for medical workers in many places around the world, and the Cuban government used the opportunity to expand its reach by increasing the number of its medical personnel abroad through the Henry Reeve Brigades, which Cuba first initiated in 2005 to respond to natural disasters and epidemics.  Experts estimate the Cuban government collects $6 billion to $8 billion annually from its export of services, which includes the medical missions.  The labor export program remains the largest foreign revenue source for the Cuban government.

There are serious concerns with Cuba’s recruitment and retention practices surrounding the labor export program.  While the conditions of each international labor mission vary from country to country, the Cuban government subjects all government-affiliated workers to the same coercive laws.  Cuba has a government policy or pattern to profit from forced labor in the labor export program, which includes foreign medical missions.  The Cuban government labels workers who leave the program without completing it as “deserters,” a category that under Cuban immigration law deems them as “undesirable.”  The government bans workers labeled as “deserters” and “undesirables” from returning to Cuba for eight years, preventing them from visiting their families in Cuba.  It categorizes Cuban nationals who do not return to the country within 24 months as having “emigrated.”  Individuals who emigrate lose all their citizen protections, rights under Cuban law, and any property they left behind.  These government policies and legal provisions, taken together, coerce workers and punish those seeking to exercise freedom of movement.  According to credible sources, by 2021, the Cuban government had sanctioned 40,000 professionals under these provisions, and by 2022, there were approximately 5,000 children forcibly separated from their parents due to the government’s policies surrounding the program.

Complaints filed with the International Criminal Court and the UN indicate most workers did not volunteer for the program, some never saw a contract or knew their destination, many had their passports confiscated by Cuban officials once they arrived at their destination, and almost all had “minders” or overseers.  According to the complaints and survivors, Cuban heads of mission in the country subjected workers to surveillance, prevented them from freely associating with locals, and imposed a strict curfew.  Cuba also confiscated between 75 and 90 percent of each worker’s salary.  As a result of the well-founded complaints and information about the exploitative nature of Cuba’s labor export program, at the end of 2023, the UN Special Rapporteur for Contemporary Forms of Slavery filed a new communication outlining the persistent concerns with the program, particularly for Cuban workers in Italy, Qatar, and Spain.

While exploitation, including forced labor, of workers remains the primary concern with the program, Cuba’s practices can also negatively impact a host country’s healthcare system.  Survivors of the program have reported being forced by the Cuban in-country mission director to falsify medical records and misrepresent critical information to justify their presence and need to local authorities.  Some individuals reported discarding medications, fabricating names, and documenting medical procedures that never occurred.  When medical workers refused to comply with the demands of the Cuban in-country mission director, they faced punishment and retaliation.  While the Cuban government promotes workers as highly skilled medical professionals and specialists, these workers often lack adequate medical training to treat complex conditions.  These practices are unethical, negligent, exploitative, and risk the lives of those they serve.

Governments should make efforts to combat human trafficking, and this includes not purchasing goods or services made or provided with forced labor.  Governments that utilize Cuba’s labor export programs despite the serious concerns with the program should at a minimum conduct frequent and unannounced labor inspections to screen these workers for trafficking indicators and employ victim-centered interviewing techniques.  These host governments should ensure all Cuban workers are subject to the same laws, regulations, and protections as for other migrant workers and that they are not brought via a negotiated agreement with the Government of Cuba that limits these protections or exempts Cuban workers from Wage Protections Systems or other tools designed to strengthen transparency.  Officials should ensure workers maintain complete control of their passports and medical certifications and can provide proof of full salary payment to bank accounts under the workers’ control.  They should scrutinize medical reports produced by these workers, offer protection for those who face retaliation and punishment for terminating their employment, and raise awareness of trafficking risks for all foreign workers, including government-affiliated Cuban workers.

• Nothing About Us Without Us:   Human Trafficking and Persons with Disabilities

Human traffickers often take advantage of persons in vulnerable situations including individuals who lack access to services and programs or rely on the assistance of others.  Among this group of potential targets are persons with disabilities, who represent about 16 percent of the world’s population, or 1.3 billion people, according to the World Health Organization.

Of course, these 1.3 billion people are not monolithic.  Some people have a disability from birth; others experience disability later in their lifetime.  Some disabilities are life-long, and others may be temporary.  A disability can be visible, such as a physical disability, or non-apparent, such as an intellectual or psychosocial disability.  People with disabilities are of every age, race, sex and sex characteristics, sexual orientation, gender identity and expression, economic status, and nationality.

Professors Andrea Nichols and Erin Heil have noted the “heightened risk as well as heightened prevalence” of human trafficking involving persons with disabilities, although the authors acknowledged the paucity of existing research.  Even when research about persons with disabilities is conducted, it rarely addresses additional intersecting identities, such as race, ethnicity, age, gender, religion, sexual orientation, gender identity, gender expression, or migratory status, that can exacerbate marginalization.

The intersection between disability and human trafficking can be cyclical.  On the one hand, persons with disabilities are more likely to be targeted by traffickers; on the other hand, the experience of being trafficked can lead to or exacerbate existing disabilities through physical injuries or emotional trauma that in turn could heighten vulnerability.

Even with access to support, persons with disabilities face increased risk of exploitation.  A caregiver may exploit their position to victimize the person they are assisting.  Persons with disabilities who receive financial assistance may be exploited for those benefits.  As the Human Trafficking Legal Center has explained with respect to the situation in the United States:  “While persons with disabilities may be trafficked into sex or labor, many cases include one additional element:  the theft of Social Security or disability benefits.  The opportunity to steal government benefits provides an added incentive for traffickers to target persons with disabilities.”  Persons with disabilities across the globe who receive benefits face similar challenges.

In light of this situation, it is perhaps not surprising that the centerpiece of the United States’ statutory framework to combat trafficking, the Trafficking Victims Protection Act (TVPA), was promulgated in part as a reaction to the Supreme Court’s decision in United States v. Kozminski , 487 U.S. 931 (1988), a case involving two men with intellectual disabilities held in what justices referred to as “slave-like” conditions on a farm.  In the case, the Court held that the law banning “involuntary servitude” was limited to circumstances involving “the compulsion of services by the use or threatened use of physical or legal coercion.”  However, Congress subsequently passed the TVPA, which recognized that psychological coercion and threats of nonviolent coercion can be every bit as powerful as physical force in overcoming the will of targeted individuals.

In 2009, the U.S. Equal Employment Opportunity Commission brought a case involving Henry’s Turkey Service, which exploited 32 intellectually disabled men at a farm in Atalissa, Iowa.  For more than 30 years, the men endured physical and mental abuse and received virtually no pay.  The jury awarded the men what at the time was the largest-ever award in an employment-discrimination case – $240 million – although it was later reduced to $1.6 million due to a federal cap in the Americans with Disabilities Act.

Not only did the TVPA arise in part from trafficking crimes involving persons with disabilities, one of the first major trafficking prosecutions in the United States involved persons with disabilities.  In that case, dozens of immigrants with hearing disabilities, including young children, were forced to work 18-hour days as trinket vendors in New York City.  Traffickers targeted persons with disabilities who were also young migrants and did not speak English, exemplifying how disability can intersect with other forms of vulnerability.  Sadly, this form of exploitation of persons with disabilities continues to this day.

The TIP Report enhanced its coverage of the intersection of disability and trafficking, with the 2023 TIP Report referencing persons with disabilities in 65 country narratives, up from about 50 in the 2022 TIP Report.  These references also highlighted the existence or lack of specialized services for persons with disabilities who are victims of trafficking, and the particular challenges faced by persons with physical or intellectual disabilities.

The U.S. Department of State’s disability rights work is led by Special Advisor on International Disability Rights Sara Minkara.  In this appointed position, Ms. Minkara leads the comprehensive strategy to promote and protect the rights of persons with disabilities across U.S. foreign policy.  Special Advisor Minkara embodies the slogan “nothing about us without us,” which is often used by disability rights advocates to insist that persons with disabilities participate fully in policies affecting them.  The role of Special Advisor on International Disability Rights was first held by Judy Heumann, who served in the position from 2010 to 2017 and is widely regarded as the “mother of the disability rights movement.”  Sadly, Ms. Heumann passed away in March 2023, leaving behind an indelible legacy of disability advocacy in the United States and around the world.

From left:  Former Special Advisor on International Disability Rights (SAIDR) Judy Heumann, SAIDR Sara Minkara, and Special Assistant to the Special Advisor Hanah Nasri attend a celebration of the anniversary of the Americans with Disabilities Act at the official residence of the Vice President of the United States in July 2022.  Photo courtesy of Hanah Nasri. (Photo was published in State Magazine in March 2023:  https://statemag.state.gov/2023/05/0523office/ ) .

• Key Trafficking Issues in the Western Hemisphere Region

Human trafficking manifests itself differently around the world.  In the Western Hemisphere – North, Central, and South America and the Caribbean – there are broad commonalities in trafficking trends countries face and how their governments and authorities approach the crime.  Below is an overview of shared issues in the region to illustrate the overall situation and coordinate the anti-trafficking efforts of governments and other stakeholders .  These regional issues are extrapolated from the individual narratives for the countries in the region, including the United States.

Unprecedented irregular migration in the region affects all Western Hemisphere countries.  Migrants and asylum seekers are especially vulnerable to sex trafficking and forced labor, including by large and small organized criminal groups.  Migrants who rely on migrant smugglers are at particularly high risk of exploitation as many assume debt to pay migrant smugglers.  Irregular migration may also include individuals already exploited by traffickers, as victims may be motivated to migrate and seek protection elsewhere.  While some countries enacted policies aimed at reducing migrants’ vulnerability to trafficking by providing temporary residency and access to formal employment, education, healthcare, and other services, we encourage all countries faced with irregular migration challenges to prevent trafficking and prioritize screening among migrants.

Countries across the region generally have a good understanding of and response to sex trafficking, especially in identification of women who are victims.  Governments also undertake and emphasize the importance of law enforcement and criminal justice approaches to address trafficking, even if implementation is uneven.  Many governments seek to tackle both internal and transnational human trafficking.  In broad terms, there is political will in many countries to address human trafficking, particularly sex trafficking.

Weak efforts targeting forced labor remain a concern in the Western Hemisphere.  Governments generally focus on addressing sex trafficking and have weaker, poorly enumerated procedures to prosecute labor traffickers and protect victims of forced labor.  Labor inspectorates are underfunded and understaffed and typically have limited or no authority to inspect informal sector worksites where many victims are exploited, especially along changing migration routes.  Governments’ lack of attention to labor trafficking leaves victims unprotected in multiple sectors, including agriculture , mining , logging, maritime, and service .

Traffickers also exploit many victims in forced criminality .  Organized crime groups, including gangs and illegal armed groups, exploit girls in child sex trafficking, force children into street begging, forcibly recruit or use child soldiers, and coerce and threaten young men and women to transport drugs, commit extortion, act as lookouts, or commit acts of violence, including murder.  Organized crime groups target groups of migrants unable to enter a country due to border restrictions or awaiting asylum decisions, including at the U.S.-Mexico border.  State-sponsored forced labor is also a concern, specifically Cuba’s labor export program, including its medical missions – which the Cuban government continues to profit from by subjecting workers to forced labor and exploitation.

Gaps in trafficking victim protection are another broad concern in the Western Hemisphere.  For years governments have lacked (or failed to provide the necessary) financial and human resources to screen for and identify trafficking victims and provide them trauma-informed services.  Some governments have developed policies and protocols for screening victims and referring them to care, but implementation has been inconsistent or ineffective.  In addition, governmental interagency coordination is weak, with working groups often disjointed and disempowered, which is particularly detrimental to the cross-sectoral collaboration needed for victim protection efforts.  These problems are particularly notable among migrants, whom governments rarely screen for trafficking indicators.

Furthermore, governments make weak screening and identification efforts even with underserved populations and marginalized groups recognized as at high risk to trafficking, including Afro-descendant, Indigenous, and LGBTQI+ persons, as well as members of other ethnic and linguistic minorities, migrants, refugees, and displaced persons.  These populations also frequently experience discrimination from authorities, often making them fearful to report crimes or access care and justice.  Finally, there are insufficient trafficking-specific services for victims, particularly for men and boys, in most countries across the region.  Governments refer identified trafficking victims to support systems designed to serve other populations, such as migrants, individuals experiencing homelessness, or victims of gender-based violence, which do not meet the specific needs of trafficking victims.  Similarly, access to justice and services is concentrated in large urban areas, while the most vulnerable individuals frequently live in rural areas with limited government presence.  Lack of victim-centered and trauma-informed services can hinder victim identification, prevent healing, increase risk of re-trafficking, and fuel impunity by making survivors less likely to participate in the case against their traffickers.

Criminal justice responses and definitions of trafficking are concerning across the region.  Many governments have weaknesses in their legal systems and uneven judicial application of trafficking laws, including levying fines in lieu of imprisonment for trafficking crimes, imposing penalties not commensurate with those for other crimes, and failing to criminalize all forms of child sex trafficking.  Judges, in particular, may lack adequate training in applying trafficking laws and coercive methods traffickers use, which impacts their decisions and sentences.  Impunity for trafficking crimes fosters misperceptions about trafficking among both policymakers and the public.  Inadequate law enforcement efforts and insufficient capacity-building for law enforcement and other first responders hinders or impacts efforts in low-capacity countries , especially in the Caribbean.  Governments with limited resources often do not recognize or implement low-cost/high-impact anti-trafficking policies.  Official complicity within law enforcement, the prison system, and local government facilitates trafficking crimes across some governments, but criminal prosecution of complicit officials lags behind the already low number of convictions of other traffickers.  Child sex trafficking and extraterritorial commercial child sexual exploitation and abuse are also pervasive concerns, particularly due to the increased use of social media and online platforms to recruit victims.  Many officials conflate human trafficking with other crimes, including migrant smuggling, child labor, sexual violence against children, illegal commercial sex, and illegal adoption.  Because of this confusion, governments may misidentify trafficking victims, fail to give them adequate support, and therefore underreport trafficking crimes.  These problems lead to inadequate data collection and reporting on human trafficking and, therefore, an incomplete understanding of the extent of the crime in the hemisphere.

• A Framework for Balancing Prosecution, Prevention, and Victim Protection Priorities in Criminal Justice Systems

Holding human traffickers accountable is an essential component of the Palermo Protocol’s “3P” paradigm of prosecuting traffickers, protecting victims, and preventing the crime.   Prosecutions make powerful statements that human trafficking will not be tolerated, and perpetrators will be held accountable, and because it is important to recognize that prosecution, protection, and prevention efforts are all inextricably intertwined.   Victims are better able to assist in investigations and prosecutions when they have access to robust protections, and successful prosecutions protect individual victims from revictimization in addition to preventing the convicted trafficker from exploiting others.

Supporting victims throughout the criminal justice process is critical.   Cases often move slowly, leaving victims anxious about the uncertainty of the outcome, fearful of retaliation, re-traumatized by having to recount traumatic events, frustrated by proceedings that can disrupt their lives, and embarrassed, ashamed, or ostracized when information about their victimization becomes public.   These feelings of anxiety, uncertainty, trauma, frustration, and fear can be further intensified by the distrust of authorities that traffickers often instill and manipulate to compel victims’ silence and their compliance with the traffickers’ commands.   Victims often experience conflicting pressures from authorities encouraging them to cooperate, traffickers seeking to silence them, and their own efforts to put traumatic events behind them.   For some survivors, the opportunity to speak out, be believed, and play an active role in bringing traffickers to justice can be empowering and vindicating.   Yet for many, the process can be harrowing, especially when they do not receive sufficient services and support.

The difficulties victims often experience during investigations and prosecutions can further intensify the challenges authorities face when seeking to hold perpetrators accountable, protect their communities, and prevent traffickers from harming others.   In striving to bring traffickers to justice without unduly burdening, re-traumatizing, or endangering victims, prosecutors continually balance the interests of justice, public safety, and protection of the community with the rights and interests of individual victims.   Successful strategies for navigating these challenges will inevitably vary to some extent according to the relevant laws and criminal justice systems across various jurisdictions but the promising practices highlighted below can aid in effectively balancing these complex considerations in a wide range of contexts.   The end goal is to enhance support for victims and decrease the burdens they experience during the criminal justice process regardless of whether they are testifying — while also strengthening investigations and prosecutions to increase accountability for traffickers.

Vigorous Victim Protections at All Stages of the Criminal Justice Process

The best way for authorities to support human trafficking survivors is to ensure the provision and continuity of comprehensive services at all stages of the criminal justice process, including in coordination with civil society organizations who specialize in victim services.   Children survivors require specialized care and interventions.   Robust victim protections, including comprehensive victim-centered, trauma-informed services, are essential to support victims in rebuilding their lives, providing the security and stability they need to safely participate in the criminal justice process, and enabling them to recall and recount their experience.   Such services should include access to identity documents, mental health and medical services, housing, and other forms of relief to support physical and mental healing.   In addition, survivors should have access to legal support and services, ideally through an independent legal advocate.   This support should be tailored to assist the survivor with a range of legal needs, whether related to navigating the investigation and prosecution of the criminal case against the trafficker, to immigration relief, or other legal matters.

Investigators, prosecutors, and victim service providers should collaborate closely to ensure that the victim is stabilized and supported before expecting meaningful participation in the criminal justice process.   Trauma can impede a victim’s ability to recall and recount relevant events, so investigators and prosecutors should develop advanced expertise in victim-centered, trauma-informed, culturally appropriate methods for stabilizing survivors, building rapport, and conducting effective interviews.   Effective interviewing may entail consistent use of professional interpreters to ensure clarity of communication and often benefits from the use of specialized techniques that incorporate the expertise of survivor leaders.   These practices can make the victim’s participation in the process less burdensome and traumatic.   They can also strengthen prosecutions by eliciting more accurate statements, minimizing discrepancies that could later be used to attack the victim’s credibility, and enabling the victim to provide more detailed information that could lead to other sources of evidence.

Protection and services for trafficking victims should not be conditioned on whether the trafficker is charged or convicted.   In cases where a foreign victim chooses to return to their home country, relocation assistance should be provided and authorities should proceed with prosecutions involving repatriated victims when possible, by having them present evidence virtually where authorized by law or by funding their return travel for court proceedings as necessary.   Access to comprehensive support is not only in the best interest of survivors- it also increases the likelihood they will feel sufficiently safe and empowered to assist in the investigation and prosecution.   Whether survivors testify against the trafficker or provide more limited assistance to law enforcement, support for their long-term well-being should be a priority even after the case is closed.

Developing Evidence to Decrease Reliance on Victim Testimony

Another best practice in prosecuting trafficking cases is the use of strategic investigative processes to develop evidence that supports the statements or testimony of trafficking survivors.   In human trafficking prosecutions, every piece of evidence counts because each piece of corroborating evidence is important to reduce reliance on victim testimony, preventing undue credibility attacks, and to increase the likelihood of conviction.

All human trafficking victims who provide statements, declarations, or testimony are inevitably subjected to credibility challenges, whether by jurists in inquisitorial systems that decide whether the victim’s statements are sufficiently reliable or by the defense in adversarial systems.   Victims’ credibility is often scrutinized based on issues such as delays in reporting their victimization, trauma-related inconsistencies in recalling and recounting certain details, or involvement in unlawful acts related to their victimization.   Corroborating evidence can be essential to countering such credibility attacks, increasing the likelihood of the victim’s statements or testimony being believed, and leading to higher rates of convictions.   Investigators and prosecutors should engage in early and continuous collaboration to assess ways to pursue other sources of evidence beyond victim testimony and to corroborate available statements and evidence through sources such as electronic records, physical evidence, and other potential witnesses.

In some cases, other admissible evidence uncovered during a thorough investigation may minimize the need for victim testimony and can become essential to enabling a prosecution to proceed even if the victim is not able to participate in the trial.   Even evidence that provides only limited circumstantial corroboration of one small aspect of a trafficker’s conduct can, when combined with other evidence, provide significant substantiation of a survivor’s account.   Investigators and prosecutors should clearly communicate to survivors that they are not “responsible” for the successful investigation and prosecution, that services and protections are not dependent on the outcome of the criminal case, and that authorities are responsible for gathering relevant evidence from all available sources.   Such evidence can also significantly reduce the burdens felt by the victim and the risks of re-traumatization associated with participating as a witness.

Victim-Centered, Trauma-Informed Charging and Prosecution Practices

One of a prosecutor’s most serious responsibilities is to utilize all available avenues to protect the victim and prevent witness intimidation efforts that could compromise both the victim’s sense of safety and the integrity of the investigation.   Such avenues include seeking court orders, including restraining orders, orders of protection, and no-contact orders to prohibit the defendant from attempting to contact the victim either directly or indirectly.   They also include working with law enforcement and victim advocates to prepare a safety plan and document any attempted contact.   Prosecutors should encourage survivors to seek help from a trusted point of contact with the police or other authorities and to immediately disclose to the prosecutor or advocate any attempt by the traffickers to contact them.   Documented attempts to contact or intimidate the victim should be used in appropriate instances to bring additional obstruction-of-justice or witness tampering charges and may be relevant to explain a victim’s reluctance to cooperate as a witness or recant earlier statements.   Proof of the trafficker’s efforts to contact the victim may also allow the prosecutor to introduce otherwise inadmissible evidence.

Even if the survivor is able and willing to testify, the prosecutor should introduce corroborating evidence to bolster and support their testimony, which is especially important when a survivor’s trauma has caused inconsistency in their statements or memory.   Prosecutors may also consider using expert testimony in appropriate instances to explain the impacts of trauma on memory and recall.   Admissible evidence may include the survivor’s medical records, testimony from first responders or other witnesses to relevant incidents, certain statements made by the accused, electronic messages, physical evidence recovered from relevant locations, and video recordings.   Additional evidence gathered using well-designed and implemented strategic investigative processes can in some instances serve, when possible, as a substitute for the victim’s critical testimony, either completely or on select issues, if the victim becomes unavailable or has difficulty testifying effectively.

Unfortunately, despite all efforts to develop other evidence, some cases of the underlying trafficking offenses cannot proceed without the testimony of the victim.   In those instances, certain practices can be used to pursue prosecutions and accountability while minimizing undue burdens and adverse impacts on survivors.   Prosecutors can strategically focus charges on the most readily provable aspects of the criminal conduct such as assaults, threats, financial crimes, possession of illicit images, or witness tampering, which may be less reliant on victim testimony but may still provide significant opportunities to hold offenders accountable.   Prosecutors can also seek to resolve cases through guilty pleas in appropriate instances to secure substantial justice without the need for victim testimony at trial.

When a victim does need to testify, prosecutors should file all applicable motions to limit the scope of their testimony to relevant facts and preclude inappropriate cross-examination about the victim’s prior bad acts or sexual history.   When allowed by law, prosecutors should consider seeking the court’s permission to present the victim’s testimony virtually or in any other manner that preserves the defendant’s right to confront the accuser while physically separating the victim from the defendant.   Victim services and security should be provided throughout all stages of trial preparation, trial, and sentencing.

Human trafficking survivors with lived experience are uniquely positioned to provide insight, guidance, and expertise on establishing appropriate support systems, strategic investigative processes, and prosecutorial practices that allow victims to be heard and supported at all stages of investigations and prosecutions.   Incorporating survivor-informed expertise is essential to providing the security, stability, and support survivors need to participate safely and effectively as witnesses, while reducing the burdens and risks of re-traumatization often associated with the criminal justice process and strengthening efforts to hold traffickers accountable.

• The Intersection of Forced Marriage and Human Trafficking

The question of whether forced marriage constitutes a human trafficking crime is complex, and the answer can vary depending on the circumstances of the forced marriage and the applicable national laws.

Governments around the world have taken different approaches to the issue, both in terms of the laws they have enacted and of the way those laws are implemented in practice.   While the governing international law on trafficking in persons, the UN TIP Protocol, allows for flexibility in how State Parties criminalize human trafficking under domestic legislation, establishing exploitative intent is critical to considering whether the conduct constitutes trafficking in persons.

What is forced marriage?

The 2022 update to the U.S. Strategy to Prevent and Respond to Gender-Based Violence Globally defines forced marriage as a marriage at any age that occurs without the free and full consent of both parties, including anyone under the age of 18 who is not able to give full consent.   Forced marriage may occur when family members or others use physical or emotional abuse, threats, fraud, or deception to obtain an individual’s agreement.   In such cases, an individual cannot be considered to have consented to the marriage.   The terms “early marriage” and “child marriage” are often used interchangeably to refer to any marriage in which at least one of the parties has not attained the age of 18.   There is overwhelming evidence that child, early, and forced marriages can increase individuals’ vulnerability to future exploitation and abuse – with long-term consequences for their health, wellbeing, safety, and opportunities.

Is Forced Marriage a Form of Trafficking under International Law?

Article 3 of the UN TIP Protocol defines “trafficking in persons” to require three essential elements—an act, conducted using one or more means, for an exploitative purpose.   Article 3 does not list forced marriage explicitly as a form of exploitation; instead, it provides that “exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs.”   Accordingly, when a forced marriage involves any of the acts, means, and purposes of exploitation listed in Article 3, it would be considered trafficking under the UN TIP Protocol.   For example, forced marriages that also involve forced labor or services, or slavery or practices similar to slavery would also be trafficking in persons if the relevant acts and means are present.   However, the non-exhaustive list of forms of exploitation in Article 3 allows State Parties to decide to expand the list of forms of exploitation within their own domestic definition of trafficking in line with the purpose and scope.

While the UN TIP Protocol does not explicitly include forced marriage within the definition of trafficking, many stakeholders argue that if all the elements of trafficking are present (i.e., there is an act, a prohibited means, done for the purpose of exploiting another person), it should not matter that the exploitation takes the form of a forced marriage.   These stakeholders point to the identical practices used by unscrupulous recruiters who are paid by business owners or prospective husbands to deceive and obtain the consent of individuals to marry “loving wealthy husbands” or accept “lucrative job offers,” in both instances only to leave victims trapped and exploited.

Countries that have chosen to include forced marriage within their domestic definitions of trafficking, either explicitly or implicitly, have taken three common approaches:

Forced Marriage Included as a Form of Exploitation

By leaving the list of forms of exploitation under Article 3 open-ended, the UN TIP Protocol allows State Parties to choose to expand the list of forms of exploitation included under domestic anti-trafficking laws.   As such, some countries have chosen to include forced marriage as an exploitative purpose under their respective anti-trafficking laws.   Several countries have taken this approach, including, but not limited to: Argentina, Australia, Botswana, Cambodia, Chad, Costa Rica, Croatia, Ecuador, El Salvador, Haiti, Kenya, Lithuania, Nicaragua, North Macedonia, Seychelles, and Uganda.

“Practices Similar to Slavery” Interpreted to Include Some Forms of Forced Marriage

Other countries interpret the inclusion of “practices similar to slavery” within Article 3 of the UN TIP Protocol to include certain forms of forced marriage.   “Practices similar to slavery” is defined in the Supplementary Convention on the Abolition of Slavery, the Slave Trade, and Institutions and Practices Similar to Slavery.   Under Article 1(c) of this convention, “practices similar to slavery” refers to, inter alia, “Any institution or practice whereby: (i) A woman, without the right to refuse, is promised or given in marriage on payment of a consideration in money or in kind to her parents, guardian, family or any other person or group; or (ii) The husband of a woman, his family, or his clan, has the right to transfer her to another person for value received or otherwise; or (iii) A woman on the death of her husband is liable to be inherited by another person …”   For countries that use this definition of “practices similar to slavery” to interpret the scope of the definition of trafficking in persons under the UN TIP Protocol, some, but not all, forms of forced marriage could constitute trafficking in persons.

Forced Marriage and Trafficking in Persons as Distinct Crimes .

It is also worth mentioning that there are many countries that choose to address forced marriage and trafficking in persons as separate offenses.   In its 2020 Issue Paper “Interlinkages Between Trafficking in Persons and Marriage,” the United Nations Office on Drugs and Crime (UNODC) acknowledges the viability of these different approaches and explains that there is “no one-size-fits-all approach to most effectively counter cases involving interlinkages between trafficking in persons and marriage.”

Establishing Exploitative Intent is Critical in All Approaches

At the heart of the question of whether a forced marriage constitutes a human trafficking crime is the question of whether the intention was to exploit a person or persons through the marriage.   Recently, the European Parliament and the Council of the European Union recognized the gravity of and increasing linkages between forced marriages and human trafficking. They formally adopted a directive noting that the exploitation of forced marriages “fall[s] within the scope of offenses concerning trafficking in human beings…to the extent that all the criteria constituting those offenses are fulfilled.”

While States that choose explicitly to include forced marriage within their definition of exploitation, or implicitly, through the inclusion of “practices similar to slavery,” consider “forced marriage as inherently exploitative,” such an interpretation is neither required nor shared by all States.   As UNODC explains,

…cultural and national contexts are relevant in determining exploitation, especially in relation to forced and servile marriage.   Cultural and other context-specific factors can play a role in shaping perception of what constitutes exploitative conduct for the purposes of establishing that trafficking has occurred.

Marriages generally involve domestic work and sexual relations between spouses, neither of which is generally understood to constitute abuse or exploitation.   However, there are circumstances in which individuals may be exploited in connection with each of these under the guise of marital obligations.   Taking into consideration the cultural and national contexts in which marriages transpire is a complex but necessary task when determining whether all three elements of a human trafficking offense are present in a case involving forced marriage.

While it is understood forced marriage is inherently harmful, rooted in gender inequality, and can often dramatically increase the risks of individuals to trafficking in persons, gender-based violence (GBV), and other abuses or crimes, it is important to acknowledge there may be circumstances in which a forced marriage has occurred, but the offense of human trafficking has not, because the purpose of the marriage was not to exploit another individual.   For example, in some communities, even an untruthful allegation of sexual indiscretion or promiscuity can irreparably damage a girl’s prospects of marriage or place her in physical danger.  Parents in these communities may attempt to protect their daughters by marrying them at a young age to avoid such allegations and safeguard their reputations.  Similarly, families who live in refugee camps or other unstable situations where there is high prevalence of multiple forms of violence, including GVB, may view marriage as a protective mechanism that will prevent their daughters from being victims of physical or sexual violence or offer them greater economic security.   In these instances, such marriages commonly occur without an individual giving their full, free, and informed agreement to marry.   By definition, such an arrangement would constitute a forced marriage and depending on the country, potentially a violation of domestic criminal laws.   However, if no one involved in arranging the marriage (not the spouse, parents, matchmaker, etc.) is participating for the purpose of exploiting the individual , then the necessary elements of trafficking in persons are not met.   Other crimes or human rights abuses may have occurred and should be addressed, but the specific crime of human trafficking has not occurred because the marriage was not for the purpose of exploitation.   To the contrary, taking into account the relevant cultural and social norms, these actors may believe they are acting in the best interest of the individual.   As in all criminal cases, the knowledge and intent of the individual matters and therefore, in the case of forced marriages as a potential trafficking crime, one must consider if an individual intended to exploit someone, or whether they intended, even misguidedly and mistakenly, to do what was believed to be in the individual’s best interest.   These complicated dynamics must be determined in other trafficking contexts as well.

Therefore, when allegations of forced marriage are presented, they must be evaluated on a case-by-case basis to determine whether they constitute trafficking in persons.   Such an assessment neither legitimizes forced marriage nor detracts from serious concerns around such practices.   Rather, it simply ensures the appropriate criminal prosecution, protection, and prevention responses are utilized to address the conduct in question because, as UNODC explains, “….qualifying a particular type of conduct as trafficking in persons has extensive consequences for both the alleged perpetrators and victims of the crime.”

* NOTE:   U.S. law does not explicitly recognize forced marriage as a “severe form of trafficking in persons” or reference it in criminal trafficking laws.   Therefore, forced marriage, per se, is not automatically considered a form of trafficking in persons under U.S. law.   The facts and circumstances of the forced marriage must be considered to determine whether the conduct falls under a relevant definition or legal provision.   Generally, if the person forced to marry is also compelled to work or to engage in commercial sex, then the forced marriage would likely fall within the definition of trafficking in persons and be a crime under U.S. law.   Because the definition of “severe forms of trafficking in persons” established under the Trafficking Victims Protection Act governs the Department’s minimum standard assessments for the purposes of the TIP Report, the Department accordingly includes governments’ efforts to combat forced marriage if there is credible evidence that those efforts address forced marriage in which the objective of the marriage was to exploit another person for labor or services or commercial sex.

An Example of When a Forced Marriage Involved Human Trafficking:   United States of America v. Zahida Aman, et al.

In United States of America v. Zahida Aman, et al., the United States successfully prosecuted and convicted three individuals for trafficking crimes relating to a forced marriage.   On January 24, 2023, the traffickers were sentenced to five, ten, and 12 years of imprisonment, respectively, and ordered to pay restitution to the victim.   The case serves as an example of how forced marriage and human trafficking can intersect and result in complex and devastating exploitation of vulnerable individuals, as abuse often goes undetected for long periods of time due to its hidden nature within the confines of familial relationships.

A federal jury sitting in Richmond, Virginia, found defendants Zahida Aman, Mohammad Nauman Chaudhri, and Mohammad Rehan Chaudhri guilty of conspiracy to commit forced labor for compelling the domestic labor of a Pakistani woman for 12 years.   The jury further found defendant Aman guilty of forced labor and document servitude, and defendant Rehan Chaudhri guilty of forced labor.

According to the evidence presented in court, defendant Zahida Aman arranged for her son’s marriage to the victim in 2001.   The victim moved to the United States and lived in a house in Midlothian, Virginia, with her husband and the three defendants (the husband’s mother and his two brothers).   The defendants compelled the victim to serve the family as a domestic servant, using physical and verbal abuse, restricting communication with her family in Pakistan, confiscating her immigration documentation and money, and eventually threatening to separate her from her children by deporting her to Pakistan.

The defendants slapped, kicked, and pushed the victim, even beat her with wooden boards, and on one occasion hog-tied her hands and feet and dragged her down the stairs in front of her children.   Even after the victim’s husband moved away, the defendants kept the victim in their Virginia home, often forcing her to perform increasingly laborious tasks… 

The evidence further showed that the defendants required the victim to work every day, beginning early each morning.   They restricted her food, forbade her from learning to drive or speaking to anyone except the defendants’ family members and prohibited her from calling her family in Pakistan.

Press Release, U.S. Department of Justice

• 2024 TIP REPORT HEROES

This year marks a major milestone—the 20th anniversary of the TIP Report Heroes awards program.   Each year, the Department of State honors individuals around the world who have devoted their lives to the fight against human trafficking.   These individuals include NGO workers, lawmakers, government officials, survivors of human trafficking, and concerned citizens.   They are recognized for their tireless efforts—despite some working in challenging environments where human trafficking concerns remain pervasive and facing resistance, opposition, or threats to their lives—to protect victims, punish offenders, and mitigate the underlying factors that cause vulnerabilities traffickers often target.

For more information about current and past TIP Report Heroes, please visit the TIP Report Heroes Global Network at www.tipheroes.org .

Al Amin Noyon Manager BRAC Migration Centre

Md. Al-Amin, or Noyon, is a welcoming first face to trafficking survivors and migrants as they return to Bangladesh.  As a fellow trafficking survivor, Noyon is uniquely qualified and motivated to help them rebuild their lives. In his capacity as manager of the BRAC Migration Welfare Centre onsite at the Dhaka airport, Noyon has supported more than 34,000 Bangladeshi trafficking survivors and migrants over the last 15 years.

Born to a family of modest means, Noyon’s dream of a better life turned into a nightmare when he was exploited in trafficking in Malaysia in 2007, beaten, tortured, and held captive in the jungle.  But as the 41-year-old now shares, that is not how his story ends.  His motivation to support fellow survivors has long motivated him to serve as a member of ANIRBAN (‘the flame that will not fade ‘ ), a trafficking support platform made up of survivors who raise awareness about human trafficking and advocate for survivors and their rights.

Noyon believes education is one of the best ways to insulate Bangladesh’s next generation from the perils of human trafficking.  He assists with safe migration campaigns at schools across Bangladesh and has supported thousands of students whose families are migrants or trafficking survivors secure academic scholarships.

Known by anti-trafficking stakeholders in the Bangladesh government, multilateral organizations, and likeminded partners, Noyon steadfastly supports others despite very real risks to his own safety.

Marcela Martinez Activist/Lawyer

Ms. Martinez is an accomplished Bolivian lawyer from La Paz and a leading anti-trafficking activist, who has demonstrably changed the direction of Bolivian and regional efforts to combat trafficking in persons, providing hope for families affected by human trafficking in Bolivia.

In 2017, Ms. Martinez formed the Social Responsibility Area of her law firm, from which the #RedAlertTempranaZar 🦋 hashtag operates.  This hashtag is modeled after the Amber Alert system in the United States to help activate searches for victims in Bolivia.  They also provide training, talks, workshops, and prevention webinars to schools, universities, neighborhood associations, and other civil society organizations.  To date, more than 18,000 volunteers participate in the network and have helped authorities locate more than 150 victims.

Ms. Martinez’s work has been instrumental in the prosecution of traffickers, protection of survivors, and prevention of victims.  She helped draft and lobbied for the passage of the first comprehensive Bolivian national law that gives law enforcement and prosecutors new tools and resources to combat trafficking in persons.  She also created the National Trafficking in Persons Council to coordinate all Bolivian government efforts to fight human trafficking.

She was part of the NinaSonko Heart of Fire Women’s Circle, which provides support and holistic and business coaching to survivors of trafficking and violence and supports social reintegration.  She has also served as a trainer through UNODC, training judges, prosecutors, and police officers on victim care at the national level.  Through her tireless efforts, Ms. Martinez has reduced human trafficking in Bolivia.

Maria Werlau Founder/Executive Director Free Society Project

Maria Werlau is co-founder and Executive Director of Free Society Project, also known as Cuba Archive, a non-profit think tank that defends human rights through information.  She began in 2009 researching, documenting, and denouncing exploitation and forced labor in Cuba’s labor export program and advocating for its victims and survivors.  In 2010, she published her first academic work on the issue and authored an opinion piece in The Wall Street Journal denouncing the labor export program as a trafficking scheme benefiting the Cuban government.  At the time, Cuba’s “internationalism” was mostly known from the slanted narrative of altruistic solidarity.

Since then, Maria has interviewed dozens of Cuban workers, mostly doctors coerced to work across the globe.  Through her work at Cuba Archive, she has exposed the dark aspects of Cuba’s medical missions, emphasizing the abuses faced by the workers: violence, sexual harassment, family separation, exploitation, forced labor, wage confiscation, restriction of movement, passport retention, repression, forced exile, psychological trauma, loss of life, and more.  She has also documented and exposed the labor export program’s lesser-known impact on the public health systems of Cuba and host countries, as well as its economic, political, and geostrategic value to the Cuban regime.

Maria has authored numerous works on Cuba in English and Spanish, including on healthcare, and provided expert testimony on Cuban labor trafficking to the U.S. Congress and at the OAS and the European Parliament.

Mustafa Ridha Mustafa al-Yasiri Director – Anti-Human Trafficking Directorate Ministry of Interior

Brigadier General Mustafa Ridha Mustafa al-Yasiri has courageously worked in Iraq’s Ministry of Interior (MOI) to combat trafficking in persons throughout a career dedicated to defending Iraq’s most vulnerable.  Brigadier General Mustafa vastly improved the Government of Iraq’s efforts to combat trafficking in persons and enhanced services for women trafficking victims, only months after being appointed in March 2023 as the Director of MOI’s Anti-Human Trafficking Directorate.  With support from the Minister of Interior, Brigadier General Mustafa immediately increased government resources dedicated to fighting trafficking in persons; appointed women Trafficking in Persons officers and employees to better assist trafficking victims; and appointed new investigative officers and officials knowledgeable on trafficking in persons, victim identification, and violence against women.  Together with the Iraqi judiciary, Mustafa established a strategy to identify victims more accurately and better address sexual exploitation and other forms of trafficking.

In addition, Brigadier General Mustafa worked with hiring companies to ensure they publish and display signs detailing Iraqi workers’ rights and the MOI’s Trafficking in Persons hotline.  On a weekly basis, he visited shelters to speak with victims, compile lists of needed food and hygienic and medical supplies, and help victims make calls to their families.  He also personally accompanied trafficking victims to court to help with their hearings and legal procedures.  Every day, motivated by personal conviction, Brigadier General Mustafa is realizing a professional goal to serve and protect many of the most vulnerable citizens of Iraq.

Edith Murogo Founder/Chief Executive Officer Centre for Domestic Training and Development

Edith Murogo is a beacon of hope on the frontlines of the fight against human trafficking and labor exploitation.  When Edith started training domestic workers more than two decades ago, she met victims of human trafficking and gender-based violence.  This experience prompted her to pioneer initiatives that transformed anti-trafficking efforts in Kenya.

After establishing the Centre for Domestic Training and Development (CDTD) in 2001, Edith became a leading advocate for domestic workers’ rights and lobbied the government for strengthened protections of migrant workers.  Edith initiated training to professionalize domestic workers and convinced the government to develop the curriculum and establish a certificate program for domestic workers seeking employment abroad.  Since opening, CDTD has assisted over 50,000 domestic workers with advocacy, skills, and knowledge to prevent them from becoming victims of trafficking.

In 2012, Edith opened the Talia Agler Girls Shelter (TAGS) – a safe house providing comprehensive assistance to girls and young women, especially for survivors of sexual and gender-based violence exploited in human trafficking. TAGS has assisted over 1,000 girls with removal from trafficking situations, recovery, and reintegration support services as well as education, mentorship, and leadership opportunities.

During the COVID-19 pandemic, Edith established Kenya’s National Shelters Network to coordinate shelter services across Kenya and ensure all survivors receive crucial protection services.  Edith is a tireless advocate working with government and civil society to strengthen anti-trafficking laws and responses.  The Department of Labor and BBC have highlighted her work in several documentaries about human trafficking.

Oumou Elkhairou Niaré Samaké Coordinator National Integrated Program for the Fight Against Drug Trafficking and Organized Crime; National Committee for the Fight Against Trafficking in Persons and Similar Practices

Oumou Elkhairou Niaré Samaké (Oumou), a well-known Malian magistrate, currently serves as the coordinator of Mali’s National Integrated Program for the Fight against Drug Trafficking and Organized Crime and as Coordinator of the National Committee for the Fight Against Trafficking in Persons and Similar Practices.  Oumou is a fierce advocate for human rights, gender-based violence, and trafficking in persons issues.  She has spearheaded Mali’s recent adoption of a new Action Plan to Combat Trafficking in Persons; championed the development of Mali’s new draft penal code to criminalize trafficking in persons; and fought to increase prosecutions over the past year of hereditary slavery cases.

In 2020 and 2021, the Trafficking in Persons Committee became relatively inactive.  However, upon her appointment in 2022, Oumou reinvigorated Mali’s anti-trafficking efforts.  First, she reestablished regular coordination meetings and published the Trafficking in Persons Committee’s overdue 2021 and 2022 annual reports.  Next, she spearheaded the development, drafting, and adoption of Mali’s new National Action Plan to Combat Trafficking in persons, launched in October 2023.  She has maintained high level standard of contacts with partners, donors, and national and international stakeholders in the fight against trafficking in persons and hereditary slavery.

Samson Inocencio Jr. Vice President International Justice Mission Philippines Program Against Online Sexual Exploitation of Children

Samson “Sam” Inocencio has dedicated over 20 years to combating trafficking in persons through his work with the International Justice Mission (IJM) Philippines.  He has contributed to 147 convictions for commercial sexual exploitation and 220 for online sexual exploitation (OSEC) crimes since 2005.  After becoming National Director of IJM in 2016, Sam assisted in the removal of 544 children from situations of commercial sexual exploitation and 1,237 children who were at risk of OSEC.

Sam led IJM’s efforts under the U.S.-Philippine Child Protection Compact (CPC) Partnership to combat OSEC crimes and advocated for a 347 percent budget increase for the Philippine National Police – Women and Children Protection Center.  As IJM’s representative to the Government of the Philippines’ Interagency Council Against Trafficking, Sam has assisted the Philippines in its efforts to combat the commercial sexual exploitation of children and OSEC related crimes, to hold offenders accountable in courts of law, and to safeguard Filipino children.

He collaborated with the Government of the Philippines in 2016 to develop a “roadmap to Tier 1” in the U.S. Department of State Trafficking in Persons Report.  The Philippines has been ranked Tier 1 for eight years due to the merits of its efforts.  Sam’s leadership and dedicated service have strengthened the government and civil society’s response to trafficking and protected thousands, especially children, from exploitation.

Marijana Savić Founder/Director Atina

Marijana Savić, the founder and director of NGO Atina, is an activist dedicated to advancing women’s and girls’ rights.  For over two decades, she has provided vital support and recovery programs for survivors of trafficking and gender-based violence in Serbia.  Her efforts have led to important progress in policy reform to combat human trafficking and support women and girls, who were victims of commercial sexual exploitation.

Under Marijana’s guidance, Atina has become a pivotal organization in Serbia’s anti-trafficking sector.  Marijana also actively contributes by helping integrates survivor experiences into law and human rights policies, in Serbia and abroad.  Her commitment extends to economic empowerment through the social enterprise Bagel Bejgl, which she founded in 2015.  This initiative – which provides employment to trafficking survivors – supports Atina’s sustainability by directing its profits to anti-trafficking programming.

Marijana works with international bodies, including the Council of Europe, as an expert in combating trafficking, especially labor exploitation.  An alumnus of the Human Rights Advocates Program at Columbia University, Marijana is also involved in global advocacy as a member of the Global Fund for Children’s board, Canada’s Equality Fund Investment Advisory Council, and the UN Voluntary Trust Fund for Victims of Human Trafficking board.

Marijana’s relentless activism and leadership have earned widespread acclaim and numerous awards for Atina, highlighting her role in shaping a safer, more equitable society for women and girls across Serbia and globally. Her work exemplifies a profound commitment to human rights and the empowerment of the most vulnerable groups.

Rosa Cendón Advisor – Human Trafficking and Gender-based Violence Catalonia Regional Ministry for Equality and Feminism

Rosa Cendón has devoted her life to assisting victims, raising awareness, and combating human trafficking in Spain.

As a social worker and educator based in Barcelona, Rosa has led advocacy and institutional relations for SICARcat, the largest anti-trafficking NGO in the Catalonia region, for 20 years.  SICARcat offers assistance to women and children survivors of trafficking by providing them with shelter and legal, psychological, medical, and social support.  Since 2022, Rosa has served as an expert advisor for combating human trafficking and gender-based violence at the Catalonia regional Ministry of Equality and Feminism.  She continues to promote change by raising awareness of human trafficking and designing public policy.

Rosa is at the forefront of anti-trafficking efforts in Catalonia.  Her victim-centered approach has influenced regional and national anti-trafficking and victim protection policies.  She contributed to designing the regional Catalonian and Barcelona city protocols for victim protection.  Under her leadership, SICARcat developed tools for the detection and intervention of human trafficking cases working closely with law enforcement agencies.  She regularly conducts specialized training for key actors.

During the height of the European migration crisis, Rosa helped found the ASIL.CAT network of human rights NGOs that coordinated shelter, protection, and services for the influx of refugees.  She worked to ensure that anti-trafficking efforts were included in the asylum reception system.  As a result of Russia’s invasion of Ukraine, Spain has received over 200,000 Ukrainian refugees and Rosa has been at the forefront in providing support to the refugees arriving to Barcelona.

Letitia Pinas Inspector of Police – Head of the Trafficking in Persons Unit Suriname Police Force

Inspector Letitia Pinas launched her career with the Suriname Police Force in 1998.  After serving in the Youth Affairs Department and the Public Relations Department, she was assigned the role of Acting Head of the 14-person Trafficking in Persons Unit in November 2020, to determine its continued usefulness.  Inspector Pinas overhauled the underperforming unit by drafting a strategic plan that improved the unit’s ability to investigate suspects and identify and serve victims, its presence in and outreach to the community, and the public’s trust in it.

With no NGOs working on human trafficking, Inspector Pinas assumed a disproportionate burden not only to investigate cases properly and effectively but also ensured efforts continued in the areas of protection and prevention, including expanded awareness.  Despite the government facing a multi-year financial crisis, she successfully lobbied for funds from the police to establish an emergency shelter within her office to house victims in the initial stages of an investigation.  She closely collaborated with the Prosecutors’ Office for funding to create a long-term shelter for both male and female victims.  Through improved collaboration with the Maritime Police and the Military Police, the Trafficking in Persons Unit actively participates in inspections of incoming vessels, while also checking for potential victims amongst incoming travelers at the airport.  These efforts have led to increased numbers of identified victims, including many who have trusted the police enough to self-report.  Her collaboration with senior police officials resulted in the development of a website that raises awareness on human trafficking and provides society with a tool to anonymously report suspected cases of trafficking.

• Child Soldiers Prevention Act List

Section 402 of the Child Soldiers Prevention Act, as amended (CSPA) requires publication in the annual TIP Report of a list of foreign governments identified during the previous year as having governmental armed forces, police, or other security forces, or government-supported armed groups that recruit or use child soldiers, as defined in the CSPA.  These determinations cover the reporting period beginning April 1, 2023 and ending March 31, 2024.

For the purpose of the CSPA, and generally consistent with the provisions of the Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict, the term “child soldier” means:

•  any person under 18 years of age who takes a direct part in hostilities as a member of governmental armed forces, police, or other security forces;
• any person under 18 years of age who has been compulsorily recruited into governmental armed forces, police, or other security forces;
• any person under 15 years of age who has been voluntarily recruited into governmental armed forces, police, or other security forces; or
• any person under 18 years of age who has been recruited or used in hostilities by armed forces distinct from the armed forces of a state.

The term “child soldier” includes any person described in clauses (ii), (iii), or (iv) who is serving in any capacity, including in a support role, such as a “cook, porter, messenger, medic, guard, or sex slave.”

Governments identified on the list are subject to restrictions, in the following fiscal year, on certain security assistance and commercial licensing of military equipment.  The CSPA prohibits assistance to governments that are identified in the list under the following authorities: International Military Education and Training, Foreign Military Financing, Excess Defense Articles, and Peacekeeping Operations, with exceptions for some programs undertaken pursuant to the Peacekeeping Operations authority.  The CSPA also prohibits the issuance of licenses for direct commercial sales of military equipment to such governments. Beginning October 1, 2024, and effective throughout Fiscal Year 2025, these restrictions will apply to the listed countries, absent a presidential waiver, applicable exception, or reinstatement of assistance pursuant to the terms of the CSPA.  The determination to include a government in the CSPA list is informed by a range of sources, including first-hand observation by U.S. government personnel and research and credible reporting from various UN entities, international organizations, local and international NGOs, and international and domestic media outlets.

The 2024 CSPA List includes governments of the following countries: Please note that 2024 Child Soldiers Prevention Act-related determinations were not final at the time of releasing the 2024 TIP Report. This section will be updated as soon as possible.

• When the Government is the Trafficker: State-Sponsored Trafficking in Persons

While the TVPA Minimum Standards for the Elimination of Trafficking In Persons and the UN TIP Protocol call on governments proactively to address trafficking crimes, some governments are part of the problem, directly compelling their citizens or other individuals into sex trafficking or forced labor.   Some governments exploit individuals in forced labor in local or national public works projects, military operations, economically important sectors, as part of government-funded projects or missions abroad, or in sexual slavery on government compounds.   Governments extract this work or service by threatening the withdrawal of public benefits; withholding salaries; intentionally failing to adhere to limits on national service; manipulating the lack of legal status of stateless individuals and other minority groups; threatening to punish family members; or conditioning services, food, or freedom of movement on labor or sex.

In 2019, Congress amended the TVPA to acknowledge that governments can also act as traffickers, referring specifically to a “government policy or pattern” of human trafficking; human trafficking in government-funded programs; forced labor (in government-affiliated medical services, agriculture, forestry, mining, construction, or other sectors); sexual slavery in government camps, compounds, or outposts; or employing or recruiting child soldiers.   While the TVPA already directs the Secretary to consider the extent to which “officials or employees of the government have participated in, facilitated, condoned, or were otherwise complicit in” trafficking when determining whether the government is making significant efforts to meet the minimum standards, this section directly links a government’s “policy or pattern” of trafficking to a Tier 3 ranking.

The 2024 TIP Report includes the following 13 countries with a documented “policy or pattern” of human trafficking, trafficking in government-funded programs, forced labor in government-affiliated medical services or other sectors, sexual slavery in government camps, or the employment or recruitment of child soldiers:    

• Afghanistan*
• China, People’s Republic of
• Korea, Democratic People’s Republic of
• South Sudan
• Turkmenistan

* The TIP Report describes the state of human trafficking within a country and with respect to Afghanistan, assesses the actions of Afghan ministries, as well as the Taliban, without implying recognition of the Taliban or another entity as the government of Afghanistan.

• Methodology

The Department of State prepared this report using information from U.S. embassies, government officials, nongovernmental and international organizations, published reports, news articles, academic studies, consultations with authorities and organizations in every region of the world, and information submitted to [email protected] .   This email address provides a means by which organizations and individuals can share information with the Department of State throughout the year on government progress in addressing human trafficking.

U.S. diplomatic posts and domestic agencies reported on the human trafficking situation and governmental action to fight trafficking based on thorough research that included meetings with a wide variety of government officials, local and international NGO representatives, officials of international organizations, journalists, academics, and survivors.   U.S. missions overseas are dedicated to covering human trafficking issues year-round.   The 2024 Trafficking in Persons Report covers government efforts undertaken from April 1, 2023 through March 31, 2024, to the extent concurrent reporting data is available.

Tier Placement

The Department places each country in this report onto one of four categories.   This placement is based not on the size of a country’s problem but on the extent of government efforts to meet the Trafficking Victims Protection Act’s (TVPA) minimum standards for the elimination of human trafficking (see page XX), which are generally consistent with the Palermo Protocol.

While Tier 1 is the highest ranking, it does not mean that a country has no human trafficking problem or that it is doing enough to address the crime.   Rather, a Tier 1 ranking indicates that a government has made efforts to address the problem that meet the TVPA’s minimum standards.   To maintain a Tier 1 ranking, governments need to demonstrate appreciable progress each year in combating trafficking.   Tier 1 represents a responsibility rather than a reprieve.

Tier rankings and narratives in the 2024 Trafficking in Persons Report reflect an assessment of the following:

• enactment of laws prohibiting severe forms of trafficking in persons, as defined by the TVPA, and provision of criminal punishments for trafficking crimes;
• criminal penalties prescribed for human trafficking crimes which are sufficiently stringent and commensurate with those prescribed for other grave crimes;
• implementation of human trafficking laws through vigorous prosecution of the prevalent forms of trafficking in the country and adequate sentencing of traffickers;
• proactive victim identification measures with systematic procedures to guide law enforcement and other government-supported front-line responders in the process of victim identification;
• government funding and partnerships with NGOs to provide victims with access to primary health care, counseling, and shelter, allowing them to recount their trafficking experiences to trained counselors and law enforcement in an environment of minimal pressure;
• victim protection efforts that include access to services and shelter without detention and with legal alternatives to removal to countries in which victims would face retribution or hardship;
• the extent to which a government ensures victims are provided with legal and other assistance and that, consistent with domestic law, proceedings are not prejudicial to victims’ rights, dignity, or psychological well-being;
• the extent to which a government ensures the safe, humane, and, to the extent possible, voluntary repatriation and reintegration of victims;
• governmental measures to prevent human trafficking, including efforts to curb practices identified as contributing factors to human trafficking, such as employers’ confiscation of foreign workers’ passports and allowing labor recruiters to charge fees to prospective migrants; and
• governmental efforts to reduce the demand for commercial sex acts and extraterritorial sexual exploitation and abuse.

Tier rankings and narratives are NOT affected by the following:

• efforts, however laudable, undertaken exclusively by nongovernmental actors in the country;
• general public awareness events—government-sponsored or otherwise—lacking concrete ties to the prosecution of traffickers, protection of victims, or prevention of trafficking; and
• broad-based law enforcement or developmental initiatives.

A Guide to the Tiers

Countries whose governments fully meet the TVPA’s minimum standards for the elimination of trafficking.

Countries whose governments do not fully meet the TVPA’s minimum standards but are making significant efforts to bring themselves into compliance with those standards.

Tier 2 Watch List

Countries whose governments do not fully meet the TVPA’s minimum standards but are making significant efforts to bring themselves into compliance with those standards, and for which:

• the estimated number of victims of severe forms of trafficking is very significant or is significantly increasing and the country is not taking proportional concrete actions;
• there is a failure to provide evidence of increasing efforts to combat severe forms of trafficking in persons from the previous year, including increased investigations, prosecutions, and convictions of trafficking crimes, increased assistance to victims, and decreasing evidence of complicity in severe forms of trafficking by government officials.

Countries whose governments do not fully meet the TVPA’s minimum standards and are not making significant efforts to do so.

The TVPA, as amended, lists additional factors to determine whether a country should be on Tier 2 (or Tier 2 Watch List) versus Tier 3:

• the extent to which the country is a country of origin, transit, or destination for severe forms of trafficking;
• the extent to which the country’s government does not meet the TVPA’s minimum standards and, in particular, the extent to which officials or government employees have been complicit in severe forms of trafficking;
• reasonable measures that the government would need to undertake to be in compliance with the minimum standards in light of the government’s resources and capabilities to address and eliminate severe forms of trafficking in persons;
• the extent to which the government is devoting sufficient budgetary resources to investigate and prosecute human trafficking, convict and sentence traffickers; and obtain restitution for victims of human trafficking; and
• the extent to which the government is devoting sufficient budgetary resources to protect victims and prevent the crime from occurring.

In addition, the TVPA directs the Secretary of State to consider, as proof of a country’s failure to make significant efforts to fully meet the TVPA’s minimum standards, a government policy or pattern of: human trafficking; human trafficking in government-funded programs; forced labor (in government-affiliated medical services, agriculture, forestry, mining, construction, or other sectors); sexual slavery in government camps, compounds, or outposts; or employing or recruiting child soldiers.

The TVPA also provides that any country that has been ranked Tier 2 Watch List for two consecutive years and that would otherwise be ranked Tier 2 Watch List for the next year will instead be ranked Tier 3 in that third year.   The Secretary of State is authorized to waive the automatic downgrade only once, in that third year, based on credible evidence that a waiver is justified because the government has a written plan that, if implemented, would constitute making significant efforts to meet the TVPA’s minimum standards for the elimination of trafficking and is devoting sufficient resources to implement the plan.   The following year, a country must either go up to Tier 2 or down to Tier 3.   Additionally, the TVPA limits a country to one year on Tier 2 Watch List after that country received a waiver to stay on Tier 2 Watch List and was subsequently downgraded to Tier 3.

Funding Restrictions for Tier 3 Countries

Pursuant to the TVPA, governments on Tier 3 may be subject to certain restrictions on foreign assistance, whereby the President may determine not to provide U.S. government nonhumanitarian, nontrade-related foreign assistance as defined in the TVPA.   In addition, the President may determine to withhold funding for government official or employee participation in educational and cultural exchange programs in the case of certain Tier 3 countries.   Consistent with the TVPA, the President may also determine to instruct the U.S. Executive Director of each multilateral development bank and the International Monetary Fund to vote against and use their best efforts to deny any loans or other uses of the institutions’ funds to a designated Tier 3 country for most purposes (except for humanitarian, trade-related, and certain development-related assistance).   Alternatively, the President may waive application of the foregoing restrictions upon a determination that the provision to a Tier 3 country of such assistance would promote the purposes of the TVPA or is otherwise in the national interest of the United States.   The TVPA also authorizes the President to waive these restrictions if necessary to avoid significant adverse effects on vulnerable populations, including women and children.

Applicable assistance restrictions apply for the next Fiscal Year, which begins October 1, 2024.

• TVPA Minimum Standards for the Elimination of Trafficking in Persons

Trafficking Victims Protection Act of 2000, Div. A of Pub. L. No. 106-386, § 108, as amended.

(1) The government of the country should prohibit severe forms of trafficking in persons and punish acts of such trafficking.

(2) For the knowing commission of any act of sex trafficking involving force, fraud, coercion, or in which the victim of sex trafficking is a child incapable of giving meaningful consent, or of trafficking which includes rape or kidnapping or which causes a death, the government of the country should prescribe punishment commensurate with that for grave crimes, such as forcible sexual assault.

(3) For the knowing commission of any act of a severe form of trafficking in persons, the government of the country should prescribe punishment that is sufficiently stringent to deter and that adequately reflects the heinous nature of the offense.

(4) The government of the country should make serious and sustained efforts to eliminate severe forms of trafficking in persons.

Indicia of “Serious and Sustained Efforts”

1. Whether the government of the country vigorously investigates and prosecutes acts of severe forms of trafficking in persons, and convicts and sentences persons responsible for such acts, that take place wholly or partly within the territory of the country, including, as appropriate, requiring incarceration of individuals convicted of such acts.   For purposes of the preceding sentence, suspended or significantly reduced sentences for convictions of principal actors in cases of severe forms of trafficking in persons shall be considered, on a case-by-case basis, whether to be considered an indicator of serious and sustained efforts to eliminate severe forms of trafficking in persons.   After reasonable requests from the Department of State for data regarding investigations, prosecutions, convictions, and sentences, a government which does not provide such data, consistent with a demonstrably increasing capacity of such government to obtain such data, shall be presumed not to have vigorously investigated, prosecuted, convicted or sentenced such acts.

2. Whether the government of the country protects victims of severe forms of trafficking in persons and encourages their assistance in the investigation and prosecution of such trafficking, including provisions for legal alternatives to their removal to countries in which they would face retribution or hardship, and ensures that victims are not inappropriately incarcerated, fined, or otherwise penalized solely for un-lawful acts as a direct result of being trafficked, including by providing training to law enforcement and immigration officials regarding the identification and treatment of trafficking victims using approaches that focus on the needs of the victims.

3. Whether the government of the country has adopted measures to prevent severe forms of trafficking in persons, such as measures to inform and educate the public, including potential victims, about the causes and consequences of severe forms of trafficking in persons, measures to establish the identity of local populations, including birth registration, citizenship, and nationality, measures to ensure that its nationals who are deployed abroad as part of a diplomatic, peacekeeping, or other similar mission do not engage in or facilitate severe forms of trafficking in persons or exploit victims of such trafficking, a transparent system for remediating or punishing such public officials as a deterrent, measures to pre-vent the use of forced labor or child labor in violation of international standards, effective bilateral, multilateral, or regional information sharing and cooperation arrangements with other countries, and effective policies or laws regulating foreign labor recruiters and holding them civilly and criminally liable for fraudulent recruiting.

4. Whether the government of the country cooperates with other governments in the investigation and prosecution of severe forms of trafficking in persons and has entered into bilateral, multilateral, or regional law enforcement cooperation and coordination arrangements with other countries.

5. Whether the government of the country extradites persons charged with acts of severe forms of trafficking in persons on substantially the same terms and to substantially the same extent as persons charged with other serious crimes (or, to the extent such extradition would be inconsistent with the laws of such country or with international agreements to which the country is a party, whether the government is taking all appropriate measures to modify or replace such laws and treaties so as to permit such extradition).

6. Whether the government of the country monitors immigration and emigration patterns for evidence of severe forms of trafficking in persons and whether law enforcement agencies of the country respond to any such evidence in a manner that is consistent with the vigorous investigation and prosecution of acts of such trafficking, as well as with the protection of human rights of victims and the internationally recognized human right to leave any country, including one’s own, and to return to one’s own country.

7. Whether the government of the country vigorously investigates, prosecutes, convicts, and sentences public officials, including diplomats and soldiers, who participate in or facilitate severe forms of trafficking in persons, including nationals of the country who are deployed abroad as part of a diplomatic, peacekeeping, or other similar mission who engage in or facilitate severe forms of trafficking in persons or exploit victims of such trafficking, and takes all appropriate measures against officials who condone or enable such trafficking.   A government’s failure to appropriately address public allegations against such public officials, especially once such officials have returned to their home countries, shall be considered inaction under these criteria.   After reasonable requests from the Department of State for data regarding such investigations, prosecutions, convictions, and sentences, a government which does not provide such data, consistent with a demonstrably increasing capacity of such government to obtain such data, shall be presumed not to have vigorously investigated, prosecuted, convicted, or sentenced such acts.

8. Whether the percentage of victims of severe forms of trafficking in the country that are non-citizens of such countries is insignificant.

9. Whether the government has entered into effective, transparent partnerships, cooperative arrangements, or agreements that have resulted in concrete and measurable outcomes with –

a. domestic civil society organizations, private sector entities, or international nongovernmental organizations, or into multilateral or regional arrangements or agreements, to assist the government’s efforts to prevent trafficking, protect victims, and punish traffickers; or

b. the United States toward agreed goals and objectives in the collective fight against trafficking.

10. Whether the government of the country, consistent with the capacity of such government, systematically monitors its efforts to satisfy the criteria described in paragraphs (1) through (8) and makes available publicly a periodic assessment of such efforts.

11. Whether the government of the country achieves appreciable progress in eliminating severe forms of trafficking when compared to the assessment in the previous year.

12. Whether the government of the country has made serious and sustained efforts to reduce the demand for –

a. commercial sex acts; and

b. participation in international sex tourism by nationals of the country.

• Countries in the 2024 TIP Report that are not Party to the Protocol to Prevent, Suppress and Punish Trafficking In Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime
• Congo, Republic of the
• Korea, Democratic People’s Republic of the
• Marshall Islands
• Papua New Guinea
• Solomon Islands

Between April 2023 and March 2024, Uganda became a State Party to the Protocol.

• Global Law Enforcement Data

The 2003 reauthorization of the TVPA added to the original law a new requirement that foreign governments provide the Department of State with data on trafficking investigations, prosecutions, convictions, and sentences in order to fully meet the TVPA’s minimum standards for the elimination of trafficking (Tier 1).  The 2004 TIP Report collected this data for the first time.  The 2007 TIP Report showed for the first time a breakout of the number of total prosecutions and convictions that related to labor trafficking, placed in parentheses.

The above statistics are estimates derived from data provided by foreign governments and other sources and reviewed by the Department of State. Aggregate data fluctuates from one year to the next due to the hidden nature of trafficking crimes, dynamic global events, shifts in government efforts, and a lack of uniformity in national reporting structures.

“As we work to help people disproportionately affected by human trafficking, including members of racial and ethnic minorities, women and girls, the LGBTQI+ community, and migrants, we remain committed to learning from and partnering with survivors to support their recoveries and to recruit their help in better spotting and preventing these too often overlooked crimes.”

President Joseph R. Biden Jr. President

“I believe history will show that this was the moment when we had the opportunity to lay the groundwork for the future of AI.  And the urgency of this moment must then compel us to create a collective vision of what this future must be.  A future where AI is used to advance the public interest.”

Vice President Kamala Harris, United States

“Combating trafficking requires a strong coalition of local and global partners to share resources and information, better equip front-line workers, and track and respond to evolving trafficking trends.”

Antony Blinken, Secretary of State

“The Intelligence Community in close partnership with law enforcement has been improving its production of detailed data analysis and reporting to better discern patterns and trends in human trafficking of migrants.  And with the help of new tools for conducting such analysis, we’re investing in these efforts, we think to good effect, as we also work to continually improve our connection to both local and federal law enforcement as well as the Department of Homeland Security to assist them in their work to countering the problem.”

Avril Haines, Director of National Intelligence 

“Survivors are the real experts.  Their experiences and their perspectives can help inform and motivate our policies so that we will do more, not less, and accelerate our efforts to combat this heinous cruelty.”

U.S. Representative Chris Smith   (R-NJ)

“Yet traffickers continue to operate with impunity.  Their crimes are receiving not nearly enough attention.  This must change.  We must invest much more in detection and protection.  We must strengthen law enforcement to bring criminals that commodify human beings to justice.  And we must do more to help survivors rebuild their lives.”

A ntonio Guterres, UN Secretary-General

“We need to step up our efforts to reach every trafficking victim, by strengthening detection, investigating cases, and prosecuting the criminals involved.  We also need to proactively identify, assist, and support survivors of this crime to truly leave no one behind.  This requires support from all sectors of society, from healthcare to social services to law enforcement.”

Ghada Waly, Executive Director of UNODC

“The scourge of human trafficking continues to evolve.  Civil unrest and war across the globe, natural disasters, climate change, and the advent and increasing reach of social media all pose significant challenges.”

Sameer Jain, Member of U.S. Advisory Council on Human Trafficking

“If we are to ever defeat trafficking, and this undoubtedly must be our shared ambition, effective approaches to prevention must be the bedrock upon which our anti-trafficking efforts are built.  Preventing trafficking in human beings from taking place is the best way to truly protect vulnerable groups and deprive traffickers of the illicit proceeds the crime generates.”

OSCE Secretary General Helga Maria Schmid

“Traffickers prey on the marginalized and most vulnerable.  But we are witnessing an emerging trend where the demographic profile of trafficking victims is also expanding, at pace with the digital developments in which we are living.”

Dr. Kari Johnstone , OSCE Special  Representative and Co-ordinator for Combating Human Trafficking

“We have to talk about those things that make us uncomfortable, especially if we want to work for an end to human trafficking.  Part of that is acknowledging that when we say nothing and do nothing in the face of many of these issues we are perpetuating the same violence that was done to us.”

Rafael Bautista, Member of the U.S. Advisory Council on Human Trafficking

“Building consensus around an affirmative vision is the first line of our tech diplomacy.  But the rules, the standards, the norms that societies follow are going to determine whether this technology is used for good or whether it’s used for ill.”

• Tier Placements List

A note on Kiribati:  Reports during the 2024 reporting period indicated human trafficking crimes may have occurred in Kiribati.  However, information on anti-trafficking efforts from the Government of Kiribati and the nature and scope of trafficking in persons in Kiribati were insufficient to undertake a full assessment for the 2024 Report.  The Department of State will continue gathering information in the coming year and assess appropriate reporting for the 2025 TIP Report.

• Regional Maps

The Regional Maps will be included in the PDF accessible online version.  Below includes the region-specific Global Law Enforcement Data.

• Stopping Human Trafficking and Sexual Exploitation and Abuse (SEA) by International Peacekeepers and Civilian Personnel

This section summarizes actions taken by the United Nations (UN), the North Atlantic Treaty Organization (NATO), and the Organization for Security and Co-operation in Europe (OSCE) to prevent trafficking in persons or the exploitation of victims of trafficking during calendar year 2023.

• Relevant International Conventions

The chart below shows the Ratification, Accession (a), or Acceptance (A) of relevant international conventions for those countries that have ratified, acceded to, or accepted any such conventions between April 2023 and March 2024.  A complete list that includes the status of all of the countries covered by the Trafficking in Persons Report is available at: https://www.state.gov/international-conventions-relevant-to-combating-trafficking-in-persons/

• International, Regional, and Sub-Regional Organizations Combating Trafficking in Persons

For the 2024 Trafficking in Persons Report, the Framework Documents and other Relevant Guidance section has been consolidated to show only documents published during the reporting year: April 1, 2023 – March 31, 2024.  If you would like to review documents from previous years, please refer to the 2023 Trafficking in Persons Report .

• Annual Report to Congress on the Use of Child Soldiers under Section 405(c) of the Child Soldiers Prevention Act of 2008

This report is submitted in accordance with section 405(c) of the Child Soldiers Prevention Act of 2008 (22 U.S.C. 2370c-2(c)) (CSPA).  Section 1 lists the countries identified as being in violation of the standards under the CSPA in 2023.  Section 2 provides a description and the amounts of assistance withheld pursuant to section 404(a) of the CSPA.  Section 3 provides a list of waivers or exceptions exercised under the CSPA.  Section 4 contains the justifications for such waivers.  Section 5 provides a description and the amounts of assistance provided to countries pursuant to such waivers.

Section 1. Countries in Violation of the Standards Under the CSPA in 2023.

The Secretary of State identified the following countries as having governmental armed forces, police, or other security forces or government-supported armed groups that recruited or used child soldiers within the meaning of section 404(a) of the CSPA during the reporting period of April 1, 2022 – March 31, 2023: Afghanistan, Burma, Central African Republic (CAR), Democratic Republic of the Congo (DRC), Egypt, Eritrea, Iran, Libya, Mali, Russia, Rwanda, Somalia, South Sudan, Syria, Türkiye, Venezuela, and Yemen.

Section 2. Description and Amount of Assistance Withheld Pursuant to Section 404(a).

No security assistance subject to section 404(a) of the CSPA was planned to be provided to Afghanistan, Burma, Eritrea, Iran, Mali, Russia, Rwanda, South Sudan, Syria, or Venezuela in fiscal year (FY) 2024.

Section 3. List of Waivers or Exceptions Exercised under Section 404(a).

On September 15, 2023, the President determined that it is in the national interest of the United States to waive the application of the prohibition in section 404(a) of the CSPA with respect to Egypt; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Türkiye for International Military Education and Training (IMET) and Peacekeeping Operations (PKO) assistance, issuance of direct commercial sales (DCS) licenses, and support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333, to the extent that the CSPA would restrict such assistance or support; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Libya and Somalia to allow for the provision of IMET and PKO assistance, and support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333, to the extent that the CSPA would restrict such assistance or support; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to the Democratic Republic of the Congo to allow for the provision of IMET and PKO assistance and issuance of DCS licenses in connection with the reexport of transport aircraft, to the extent that the CSPA would restrict such assistance; to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to the Central African Republic and Yemen to allow for the provision of IMET and PKO assistance, to the extent that the CSPA would restrict such assistance; and to waive the application of the prohibition in section 404(a) of the CSPA to allow for the issuance of DCS licenses related to other U.S. government assistance for the above countries and, with respect to the Russian Federation, solely for the issuance of DCS licenses in connection with the International Space Station (ISS).  The President has further certified that the governments of the above countries are taking effective and continuing steps to address the problem of child soldiers.

Section 4. Justifications for Waivers and Exceptions.

Pursuant to section 404(c) of the Child Soldiers Prevention Act of 2008 (CSPA) (22 U.S.C. 2370c-1(c)), the President has determined that it is in the national interest of the United States to waive the application of the prohibition in section 404(a) of the CSPA with respect to Egypt; to waive, in part, the application of the prohibition with respect to the Central African Republic, the Democratic Republic of the Congo, Libya, Somalia, Türkiye, and Yemen, including to allow for the issuance of direct commercial sales (DCS) licenses related to other U.S. government assistance for these countries that is not subject to the prohibition in section 404(a); and, with respect to Russia, to waive, in part, the application of the prohibition solely for DCS licenses in connection with the International Space Station.  The President has further certified that the governments of the above countries are taking effective and continuing steps to address the problem of child soldiers.  The justification for this determination and certification with respect to each country is set forth in this Memorandum.

The Central African Republic (CAR)

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to CAR to allow for the provision of International Military Education and Training (IMET) and Peacekeeping Operations (PKO) assistance and has certified that the CAR Government (CARG) is taking effective and continuing steps to address the problem of child soldiers.

Armed groups in CAR continue to threaten civilians and pose a longstanding risk to stability.  The waiver for PKO and IMET assistance for CAR will support the professionalization of the military to better provide security to the people of CAR while respecting human rights and international humanitarian law (IHL).  Additionally, IMET programming allows the United States to invest in CAR military officers to promote professional military education and foster relationships with foreign military personnel rooted in democratic values.

The CARG is taking effective and continuing steps to address the problem of child soldiers through meaningful engagement with U.S. and UN officials in seeking assistance to eradicate trafficking in persons, including the recruitment or use of child soldiers by CAR security forces and armed groups.  Recent efforts have included the adoption of a national plan to counter trafficking in children, government directives prohibiting the presence of children around military bases, and collaboration with the UN and implementing partners to reintegrate children affected by conflict.

The Democratic Republic of the Congo (DRC)

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to DRC to allow for the provision of IMET and PKO assistance and issuance of licenses for DCS in connection with the reexport of transport aircraft and has certified that the Government of the DRC (GDRC) is taking effective and continuing steps to address the problem of child soldiers.

The proliferation of armed groups amidst ongoing conflict in eastern DRC continues to threaten security and stability for the people of the DRC.  IMET and PKO assistance for the DRC enables the United States to continue professionalization efforts of the Armed Forces of the Democratic Republic of the Congo (FARDC) by enhancing its capacity to provide security within its territory while respecting human rights and IHL.  IMET and PKO assistance provide mechanisms to support security sector governance reforms and training in areas such as military justice, civil-military relations, respect for human rights and IHL, military engineering, and resource management and logistics, which enhance security and help make the FARDC a more transparent, accountable institution.

The GDRC is taking effective and continuing steps to address the problem of child soldiers through sustained commitment to implement its 2012 Action Plan to end and prevent the recruitment and use of child soldiers in partnership with the UN.  Additionally, in 2022 the GDRC adopted a national strategy for the implementation of the Demobilization, Disarmament, Community Recovery and Stabilization Program, which signals an important step in prioritizing children affected by armed conflict, particularly in eastern DRC.

The President has determined it is in the national interest of the United State to waive, in full, the application of the prohibition in section 404(a) of the CSPA with respect to Egypt and has certified that the Government of Egypt is taking effective and continuing steps to address the problem of child soldiers.

Egypt is an important U.S. partner in counterterrorism, anti-trafficking, and regional security operations, which advance both U.S. and Egyptian security. The decades-long defense partnership is a pillar for regional stability and key to securing peace with Israel, supporting the Multinational Force and Observers missions, and enhancing security of the Suez Canal.  Since 1978, the United States has provided more than $54 billion in military assistance for Egypt, which has contributed to Egypt’s capabilities to protect and defend its land, air, and maritime borders and to confront an evolving terrorist threat, including in the Sinai Peninsula.

The Government of Egypt is taking effective and continuing steps to address the problem of child soldiers, even as the scope and intensity of the counterterrorism fight in the Sinai continues to see a significant downturn; 2023 is on track to report the lowest levels of violence in the Sinai since the conflict began in 2011.  The U.S. government is not aware of the Egyptian military, police, or other security forces recruiting or using child soldiers.  Consistent with Egypt’s domestic laws and its obligations under the Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict, the Egyptian government effectively prohibits persons under the age of 18 from being forcibly recruited into the armed forces.  The Government of Egypt provides critical influence in addressing the recruitment or use of child soldiers by tribal militias, and the U.S. government will continue to engage the Egyptian government regarding reports of recruitment of child soldiers by government-supported Sinai tribal forces.

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Libya to allow for the provision of IMET and PKO assistance and DoD support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 and has certified that the Government of National Unity (GNU) in Libya is taking effective and continuing steps to address the problem of child soldiers.

The U.S. government selected Libya as a priority country for implementation of the U.S. Strategy to Prevent Conflict and Promote Stability.  The Department of State further assesses that in Libya the most durable solution to the unlawful recruitment of child soldiers, including by GNU-aligned units and the self-styled Libyan National Army, is a negotiated political settlement that ends Libya’s instability and the cycles of conflict.  IMET assistance will facilitate English language proficiency to improve interoperability and promote civil-military relations, including civilian control of a unified military.  PKO assistance will build upon the October 2020 ceasefire and support U.N. efforts to advance Libya’s transition to a unified, democratically elected, and inclusive political system based on respect for human rights.  PKO provides the U.S. government a tool to support UNSMIL in its ceasefire monitoring function.  Department of Defense support will build the capacity of Libyan military institutions in support of progress towards civilian-controlled, accountable, defense institutions that uphold human rights, combat terrorism, and address security challenges.

The GNU is taking effective and continuing steps to address the problem of child soldiers through engagement with the UN and the U.S. government in the context of our recurring bilateral Security Dialogue.  Through cooperation with UNSMIL, representatives of the Libyan 5+5 Joint Military Commission, comprised of senior military officers from both the east and west, engage with UNICEF on preventing child soldier recruitment.  The U.S. government is not aware of the GNU’s military, police, or other governmental security forces recruiting or using child soldiers.  Further, GNU security sector leaders provide critical influence to prevent and end the recruitment or use of child soldiers by armed groups in Libya and mitigate the reliance on external forces or groups for internal security.

Russian Federation

The President has determined it is in the national interest of the United State to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to the Russian Federation to allow for issuance of licenses for DCS solely in connection with the International Space Station (ISS) and has certified that the Government of the Russian Federation is taking effective and continuing steps to address the problem of child soldiers.

It is in the U.S. national interest to work with Russia to maintain the safety of ISS operations.  Maintaining longstanding U.S.-Russia ISS operations requires the ability to issue DCS licenses for defense articles and defense services in support of the ISS until the planned termination of its operation, which the National Aeronautics and Space Administration estimates will be in 2030.  This waiver will allow such activities to continue and will enable the issuance of licenses necessary to support the safe operation of the ISS, U.S.-Russia integrated crew missions to the ISS, and the safety of U.S. and other personnel onboard the ISS.

The Russian Federation is taking effective and continuing steps to address the problem of child soldiers.  In accordance with the Russian Federation’s Law on the Ratification of the Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict of 2008, the Government of the Russian Federation effectively prohibits persons under the age of 18 from being forcibly recruited into the armed forces.

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Somalia to allow for the provision of IMET and PKO assistance, and DoD support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 and has certified that the Federal Government of Somalia (FGS) is taking effective and continuing steps to address the problem of child soldiers.

Foreign terrorist organizations including al-Shabaab continue to threaten security and stability for the people of Somalia.  The waiver for IMET and PKO assistance for Somalia enables the United States to continue professionalization efforts of the Somali National Army (SNA) by enhancing their capacity to provide security within their territory while respecting human rights and IHL.  Further, a waiver for support provided by the Department of Defense pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 will allow for U.S. government assistance to build the Somali military’s capacity to conduct effective, sustained counterterrorism operations against al-Shabaab and help reinforce U.S. values, including those related to preventing and ending the unlawful recruitment or use of child soldiers.

The FGS is taking effective and continuing steps to address the problem of child soldiers through sustained commitment to implement its 2019 “road map” to accelerate progress on its 2012 Action Plan on ending the recruitment and use of children by the Somali National Armed Forces in partnership with the UN.  The SNA’s Child Protection Unit continued to make progress in implementing screening procedures, training, and disseminating media to prevent the recruitment and use of child soldiers.  The FGS also continued implementation of standard operating procedures for the handover of children allegedly associated with armed groups.

The President has determined it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Türkiye for IMET and PKO assistance, issuance of DCS licenses, and DoD support provided pursuant to 10 U.S.C. 331 and 10 U.S.C. 333 and has certified that the Government of Türkiye is taking effective and continuing steps to address the problem of child soldiers.

Türkiye has been an important U.S. security partner and valued NATO Ally since 1952, regulating passage, in accordance with international law, through the straits of the Bosporus and the Dardanelles, which link the Black Sea with the Mediterranean. Further, Türkiye’s military capability and geographic location are vital to the United States’ integrated deterrence strategy and ability to respond to regional events including with respect to counterterrorism, humanitarian assistance, and disaster relief operations. Türkiye’s support, including defense and security cooperation, to NATO Allies and partners deters malign influence in the region. This waiver will assist in maintaining NATO cohesion and continued interoperability, bolster regional security, and advance bilateral cooperation.

The Government of Türkiye is taking effective and continuing steps to address the problem of child soldiers, including those present in elements of the Syrian National Army receiving support from the Government of Türkiye.  The United States is not aware of the Turkish military, police, or other security forces recruiting or using child soldiers.  Consistent with Türkiye’s domestic laws and its obligations under the Optional Protocol to the Convention on the Rights of the Child on the Involvement of Children in Armed Conflict, the Turkish military effectively prohibits persons under the age of 18 from being forcibly recruited into the armed forces.  Further, the Government of Türkiye provides critical influence in addressing the problem of child soldiers with respect to the Syrian National Army.

The President has determined that it is in the national interest of the United States to waive, in part, the application of the prohibition in section 404(a) of the CSPA with respect to Yemen to allow for provision of IMET and PKO assistance and has certified that the Government of the Republic of Yemen (ROYG) is taking effective and continuing steps to address the problem of child soldiers.

It is in the U.S. national interest to support UN-led efforts to achieve an inclusive negotiated political resolution to the conflict in Yemen.  The waiver for IMET assistance for Yemen enables the United States to continue to support professionalization and interoperability efforts of the Yemeni Armed Forces (YAF) by enhancing their capacity to provide inclusive security within their territory while respecting human rights and IHL.  Further, this waiver will improve the YAF’s capacity to conduct effective, sustained counterterrorism operations, ensuring freedom of navigation through the Bab Al-Mandeb Strait, and securing the space for restoring effective governance institutions.

The ROYG is taking effective and continuing steps to address the problem of child soldiers through sustained commitment to implement its 2018 “road map” to accelerate progress on its 2014 Action Plan to end and prevent the recruitment of children by Yemeni Armed Forces in partnership with the UN.  The ROYG established child protection units within all military regions, issued directives banning child recruitment, and conducted numerous senior government field visits to monitor the implementation of screening procedures to prevent child recruitment and remove children from military units.

Section 5. Description and Amount of Assistance Provided Pursuant to a Waiver.

The information provided below only includes assistance obligated as of April 20, 2024.  Additional assistance will be obligated during FY 2024.

Central African Republic

International Military Education Training $101,124

As of April 20, 2024, IMET funding was obligated for the following activity: professional military education and training.

Democratic Republic of the Congo

International Military Education Training $177,238

International Military Education Training $1,352,782

International Military Education Training $31,284

Peacekeeping Operations $31,917,530.44

As of April 20, 2024, PKO funding was obligated for Somali National Army and Somali Ministry of Defense for the following activities:

logistical support; advisory support; equipment; and program oversight.

10 U.S.C. 333 $4 ,668,640.56

As of April 20, 2024, 333 funding was obligated for the following activities: training and equipment.

International Military Education Training $182,098

International Military Education Training $339,662

As of April 20, 20, 2024, IMET funding was obligated for the following activity: professional military education and training.

• GLOSSARY OF ABBREVIATIONS

Notes:  Local currencies have been converted to U.S. dollars ($) using the currency exchange rates reported by the U.S. Department of the Treasury on December 31, 2023.

• Acknowledgments

The Staff of the Office to Monitor and Combat Trafficking in Persons Is:

Mekhribon Abdullaeva

Sylvia Amegashie

Katrina Askew-Alston

Andrea Balint Garza

Shonnie R. Ball

Suzanne Balson

Matt Becker

Getoria Berry

Brooke Beyer

Caris Boegl

Michelle C. Bloom

Alexandria Boling

Katherine Borgen

Gregory Borgstede

Kelsey Brennan

Joshua Bull

Carla M. Bury

Renée Callender

Jessica Cisneros

Kate Cooper

Camila Crowley

Reena Dalwadi

Sarah Davis

Steven Davis

Anca DiGiacomo

Daniel Evensen

Anna Fraser

Lauren Frey

Mark Forstrom

Lucia Gallegos

Beatriz Garcia Velazquez

Brianna Gehring

Chauna Gibson

Natasha Greenberg

Andrew Grimmer

Takiyah Golden

Denise Harrison

Jocelyn Harrison

Emmanuel Hector

Caitlin B. Heidenreich

Ashley Hernandez

J. Brett Hernandez

Matthew Hickey

Crystal Hill

Megan Hjelle-Lantsman

Jennifer M. Ho

Marta Hoilman

Ariana Holly

Moira Honohan

Renee Huffman

Veronica Jablonski

Harold Jahnsen

Sarah Jennings

Devin Johnson

Maurice W. Johnson

Kari A. Johnstone

Chelsea Kaser

Patrick Kelly

Emily Korenak

Kendra L. Kreider

Mary Lagdameo

Valery Lavigne

James Lensen-Callas

Rebecca Lesnak

Abigail Long

Samantha Lord

Jean McAnerney

Cameron Malcom

Bryan Marcus

LaTina Marsh

Sunny Massa

Kerry McBride

Rendi McCoy

Tamara McCoy

Maura K. McManus

Leah F. Meyer

Rebecca Morgan

Ericka Moten

Ryan Mulvenna

Dan Muncaster

Cristina Narvaez

Amy O’Neill Richard

Zury Palencia

Lauren Parnell

Ashlei Perry

Marissa Pietrobono

Sanjana Polapragada

Justin D. Pollard

David Rabinovich

Patrick Read

Andrea E. Reed

Casey Risko

Angie Rivas

Amy Rustan Haslett

Manith Sarik

Aram Schvey

Tori Jamese Scott-Senghor

Adrienne Sgarlato

Jessica Singh

Stephen Shade

Kaela Shear

Soumya Silver

Cornelius Slayton

Susan Snyder

Megan Stalder

Latoshae Summers

Desirée Suo Weymont

Jamie Sutter

Francesca J. Tadle

Atsuki Takahashi

James Taylor

Anna Thiessen

Cecilia Thompson

Juan Jose Tierjo

Wanda Toney

Andrea Ugolini

Melissa Verlaque

Matthew Villemain

Myrna E. Walch

Frances Wallman

Bianca Washington

Pauline Werner

Danielle (Nikki) Wetsel

Terry Whenry

Sharifa White

Joshua Williams

Willow Williamson

Joshua Youle

Salia Zouande

Special thanks to Brian Piaquadio, Julia Maruszewski, LeGrand Latney, Kimberly Ross, and the creative services team at Global Publishing Solutions.  Special thanks also to the ECA Bureau and technical project managers Tasha Wilkinson and Ed Williams.

Special thanks to Bukola Oriola, Dawn Schiller, Christine Cesa, Jeri Moomaw, Harold D’Souza, Jessa Crisp, Jill Brogdon, Megan Lundstrom, Rafael Bautista, Tanya Gould, and other subject matter experts with lived experience of human trafficking from the Department of State’s Human Trafficking Expert Consultant Network for their contributions to the TIP Report.

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Office on drugs and crime, ‘ninety per cent stronger’ families in the philippines helping to prevent drug abuse.

Angelique attended the UNODC-supported Strong Families programme with her mother.

A mother in the Philippines has explained how she feels “90 per cent stronger” after participating in a UN-supported programme which aims to build parenting skills and help children communicate more openly about issues such as drugs.

Rowena Cruz participated in the Strong Families programme run by the local government through the Anti-drug Abuse Council of Pasig (ADCOP) and backed by the UN Office on Drugs and Crime ( UNODC ).

Rowena Cruz (right) and her daughter Angelique met at the Strong Families Programme in Pasig City, Philippines .

Ahead of World Drug Day marked annually on 26 June, Daniel Dickinson spoke to her as well as mother-of-five, Arlene Alvarez and their respective daughters Angelique and Wasmiya. He also met Zenaida Concepcion, an anti-drug abuse officer for Pasig.

Rowena Cruz: I have three children aged 18, 16 and 10, and became concerned about my son, the middle child, when he grew more detached and unable to talk about his problems. There are people selling illegal drugs in our neighbourhood so I was concerned he was being influenced by them, although he told me he never took drugs. He was also depressed and had expressed suicidal thoughts and the whole family was feeling stressed.

Arlene Alvarez: I spent six years as a domestic worker in Kuwait and didn’t see my five children during that time. Up until my return in 2020, they were looked after by my aunt as I am a single mother.

I was informed by a friend three years ago that my son was smoking marijuana and of course I was worried that other young people would lead him to other harder drugs. I felt a big gap between myself and the children because of my absence so wanted to join the Strong Families programme to learn how to communicate with them better and to help them make more informed decisions.

Zenaida Concepcion is an anti-drug abuse officer in Pasig City.

Zenaida Concepcion: Filipino people, and especially parents often do not express their emotions. This can lead to stress, and stressed children can be influenced by other young people, especially when it concerns drugs. That’s why open communication within the family is very important as a preventative measure.

When we started the Strong Families programme in 2019 the Philippines was in the midst of the war against drugs and so people were extremely nervous about even talking about drugs and service providers did not offer community-based solutions to abuse. The Philippines has very severe drug laws; you can be sent to prison for up to 12 years just for being in possession of drug paraphernalia.

Rowena Cruz: I participated in the Strong Families programme with Angelique and I learned a lot about how to communicate more openly. I made progress after I recognized, along with my husband, that as parents we don’t always have the answers; we are not always right. My son is doing better now and can talk to me about his life and recently asked about what he should give his girlfriend as a present. I suggested a teddy bear.

Wasmiya enjoyed playing with balloons at the Strong Families programme.

Angelique: It was a good programme. I became closer to my brother and sister; I used to feel jealous about how close they were. My sister knows more of my secrets because she is a girl. I told her about what I had learned with my mum and she listened. My brother now helps me when I draw.

Arlene Alvarez: As a parent, Strong Families helped me to be more patient and to pay more attention to my children’s needs.  They are now able to speak to me about their feelings and they are now good at asking each other how they are doing. My son is doing well, he understands that talking about issues like drugs can help as he will feel less peer pressure. He has his own child now so I am a grandmother.

Wasmiya: At the meetings we attended, I liked playing with the balloons, but not so much the drawing. At school my favourite subject is English and I like playing volleyball.

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Drivers of Anemia Reduction among Women of Reproductive Age in the Philippines: A Country Case Study

Affiliations.

• 1 Department of Science and Technology, Food and Nutrition Research Institute, Taguig City, Philippines.
• 2 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.
• 3 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Centre of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan. Electronic address: [email protected].
• PMID: 38906382
• DOI: 10.1016/j.ajcnut.2024.06.005

Background: Anemia prevalence among women of reproductive age (WRA) in the Philippines was 25% in 2000, decreasing to 13% in 2018. To date, an in-depth assessment of the determinants associated with this decline has not been conducted.

Objective: To conduct a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in the Philippines between 2008 and 2018.

Methods: Employing standard Exemplars methodology, we conducted quantitative analyses using the Philippines' National Nutrition Survey, the Expanded National Nutrition Survey, and the Philippines National Demographic and Health Surveys. Qualitative analyses included a comprehnsive literature review, program/policy analysis, and interviews with stakeholders to understand country-level enablers and barriers to WRA anemia decline in the Philippines. A final Oaxaca-Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors.

Results: Among non-pregnant women (NPW), mean hemoglobin (Hb) increased from 12.7 g/dL in 2008 to 13.1 g/dL in 2018 (p<0.01), corresponding to an 11%-point decline in anemia prevalence (23% to 12%). Inequities by geographical region, household wealth, and women's educational attainment narrowed considerably during this time. Important direct and indirect nutrition programs were introduced during our study period, including universal healthcare and food fortification. Country experts interviewed credited programs focused on alleviating micronutrient deficiencies and poverty, and improvements in women's health and well-being, for the country's extraordinary success. OBDA explained ∼50% of the observed change in mean Hb among NPW, with family planning (35%), household socio-demographics (29%), and improvement in women's nutrition (23%) emerging as critical drivers of anemia decline, corroborating our qualitative and policy analyses.

Conclusions: To protect these gains, WRA anemia prevention efforts in the Philippines should continue to focus on universal healthcare access, women's empowerment, and poverty alleviation.

Keywords: Philippines; WRA; anemia; family planning; hemoglobin.

Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.

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Conflict of interest statement

Declaration of Competing Interest ☒ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Zulfiqar Bhutta reports financial support and article publishing charges were provided by Bill and Melinda Gates Foundation. Zulfiqar Bhutta reports financial support was provided by Gates Ventures. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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