comparative analysis-5 ilhz

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COMPARATIVE ANALYSIS OF FIVE INTER-LOCAL HEALTH

ZONES: Current Practices, Policy, and Program Directions

Table of Contents

Foreword i

Acknowledgements ii

Acronyms iiiMap of the Philippines and Inter-Local Health Zones Sites vi

COMPARATIVE CASE ANALYSIS EXECUTIVE SUMMARY vii

1. Introduction 1

1.1 Project Objectives 31.2 Significance of the Project 4

2. Methodology 5

2.1 Actual Methods 5

2.2 Data Analysis 8

2.2 Validity and Reliability Checks 82.3 Data-Yield Description and Constraints 8

2.4 Limitations of the Study 8

3. Consolidated Findings 10

3.1 Key Health Operations Profile of Case Study Areas 103.2 Critical Steps in the Formation of ILHZ 15

3.3 Health Operations: Organization, Comparison of Services and Patterns 24

of Utilization

3.4 Organogram 313.5 ILHZ Mandates 32

3.6 Key Players and Collaborative Mechanisms 33

4. Best Practices 41

4.1 Strengths 42

4.2 Weaknesses 43

5. Policy and Programmatic Implications 44


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5.1 Policy of Health System Decentralization and Primary Health Care 44

5.2 Devolution and National Policies and Effects on Health Service Delivery 44

5.3 Policy and Programmatic Issues 455.3.1 Financial Administrative Issues 45

5.3.2 Management Systems and Processes 46

5.3.3 Human Resource Management 465.3.4 Management of Devolution by National, Regional and Local Bodies 46

5.3.5 Quality of Care in ILHZ Health Care Facilities 47

6. Policy and Programmatic Directions 50

6.1 Finance and Administrative 516.2 Management Systems and Processes 51

6.3 Human Resource Management 51

6.4 Management of Devolution by National and Regional NGOs 52

and Local Bodies6.5 Upgrading and Modernization of Health Services Hospital Services 53

and Public Health Services

7. Next Steps 55

Bibliography 56

Glossary 58

List of Appendices 60

1 Consolidated Sources of Data 61

2 Consolidated Sampling Frame 70

3 Number of FGDs / KIIs Conducted in ILHZ Case Study Sites, 2001 71

4 Consolidated List of FGD / KII Participants for the 72

ILHZ Case Study, 2001

5 Milestones in the ILHZ Development, All ILHZ Sites, 2001 89

6 Matrix of Functions and Responsibilities of District Health Boards, 2001 103

7 Examples of Mandates as Templates 112


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7.1 Executive Order 205 113

7.2 Health Covenant 1999, Sta. Bayabas Inter-LGU Health System, 117

Negros Oriental

7.3 Provincial Health Board Resolution No. 5, Series of 1999 119

(Recommendation to the Sangguniang Panlalawigan to

develop six district health systems province-wide)

7.4 Sangguniang Panlalawigan Resolution No. 678, Series of 2000 121

(Authorizing the Governor to enter into a MOA for theSta. Bayabas Inter-LGU Health System)

7.5 Sanggunaing Bayan Resolution No. 274, Series of 2000 123

Municipality of Bayawan

(Authorizing the Mayor to enter into a MOA for the Sta. BayabasInter-LGU Health System

7.6 Memorandum of Agreement for Sta.Bayabas 125

Inter-LGU Health System

8 Proposed National Health Service Delivery Reform Bill 136

9 SEC Registration of CVGLJ Inter-LGU Health Zone 151

List of Tables

1 ILHZ Case Study Areas by Population Coverage and 168

Component Health Facilities, Philippines, 2001

2 ILHZ Health Facilities Analysis Matrix 172

3 ILHZ Cross Case Analysis Matrix 173

4 Nearest Health Care Facility by Province, 214

ILHZ Case Studies, 2001


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5 Health Seeking Behavior by Province, 215


6 Reference Health Facility by Province, 216


7 Common Health Problems in the Family by Province, 217ILHZ Case Studies, 2001

8 Common Family Problems in the Community by Province, 220


9 Satisfaction with Health Services at Reference Health 221

Facility, ILHZ Case Studies, 2001

List of Figures 222

1 Map of the Philippines and Inter-Local Health Zone Sites v

2 Baliuag Unified Local Health System in Bulacan 223

3 Arayat Unified Local Health System in Pampanga 224

4 Local Area Health Development Zone 2 in South Cotabato 225

5 Sta. Bayabas and CVGLJ Inter-LGU Health Systems in 226Negros Oriental

6 Linawa Zone in Kalinga 227

7 ILHZ Organograms 228

7.1 BULHS

7.1.1 District Health Board 229

7.1.2 Baliuag District Hospital 230

7.2 LADHZ

7.2.1 Integrated Health System Provincial Operational 231

Framework


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7.2.2 Norala District Hospital 232

7.2.2 Sto. Nio RHU 233

7.3 AULHS

7.3.1 District Health Board 234

7.3.2 Dr. Emigdio C. Cruz, Sr. Memorial Hospital 235

7.3.3 Arayat Rural Health Unit 236

7.3.4 Mexico Rural Health Unit 237

7.4 Sta. Bayabas and CVGLJ Inter-LGU Health Systems

7.4.1 Bayawan District Health System 238

7.4.2 Bayawan District Hospital 239

7.4.3 Bayawan Rural Health Unit 240

7.4.4 CVGLJ District Health System 241

7.4.5 CVGLJ District Health Board 242

7.4.6 CVGLJ Management Committee 243

7.5 Linawa Zone

7.5.1 District Health System 244

7.5.2 Linawa District Health Board 245

7.5.3 Kalinga Provincial Hospital 246

7.5.4 Tabuk Rural Health Unit 2477.5.5 Rizal Rural Health Unit 248


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.

1. Introduction

In undertaking the present health care sector reform, the Philippine Health Sectorembarks on a quest that will ensure the vitality of the system in assuring adequacy,

accessibility, efficiency and high quality health services that are equitable and thatmaximizes private participation: the organization of Inter-Local Health Zones or

ILHZs. These efforts address the complexities brought about by the advent of theLocal Government Code other wise known as R.A. 7160 of 1991. This law provided

for the devolution of health care services from centralized DOH to local government

health services and brought about quite a few challenges and issues.

First, it was observed that serious fragmentation of public health and hospital services

occurred since devolution. As a result, disintegration of the components of the centralhealth care system (DOH) and local health care became widespread. While provincial

governors took charge of the hospitals, public health remained the sole responsibility

of municipal mayors.

Second, there were reports that the regional health systems or centers for health

development (CHDs) were ill prepared to provide technical support to fledgling local

health care systems. Monitoring and supervision of health operations remained themajor responsibility of the CHDs but these were noted to have decreased

substantially.

Health Human Resource Development was a third area of weakness. Staff training

opportunities and career development activities markedly decreased. These led to low

morale of health care workers especially in economically disadvantaged areas where

training opportunities, staff benefits and support were inadequate. All these led to thefragmentation of local health services and exacerbated the problems related to quality

of care, as well as its attendant efficiency and equity issues.

The concept of the District Health System was initially proposed by the World Health

Organization sometime in 1983 in response to the declaration of Health for All, the

shift toward Primary Health Care, and consequently, the need to decentralize healthcare services, particularly in many developing countries. The Department of Health

of the Philippine government eventually introduced the District Health System in its

national health service in different parts of the country. The system intended tointegrate the public health system and the hospital system for a more coordinated and

effective delivery of health services within the catchment area of the District hospital.A District Health Office was set up to exercise supervision and control over thedistrict hospitals, municipal hospitals, rural health units, and barangay health stations.

At that time, the Philippine government carried out decentralization by

deconcentration, which meant that administrative but not political decongestion of thenational offices was implemented through the set-up of regional offices.

Deconcentration was also intended to bring government services closer to its clients


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and stakeholders. In this centralized but deconcentrated set-up, the District Health

System was operationalized, with budget allocation mainly coming from the national

government.

However, the 1991 Local Government Code was passed effecting decentralization by

devolution that transferred political and administrative powers to the localgovernment at municipal and provincial levels. Under devolution, the municipal local

government managed the public health units-the barangay health stations and the

rural health centers, and in some areas, the municipal hospitals. On the other hand,the provincial local government took over provincial and district hospitals.

The Department of Health found itself grappling with new roles vis--vis local

governments. Previous functions of planning, policy-making, programimplementation, monitoring and evaluation could no longer directly connect to the

public health and hospital system which were operated by local governments. In

many field studies commissioned by the Department of Health and in its own

observations, devolution shifted the burden of responsibility for health to localgovernment units that did not have the technical capabilities and financial capabilities

to manage public health services and hospital operations. There was confusion anddemoralization as DOH personnel were devolved and retained with initial

discrepancies in remuneration. There was a breakdown in the referral system, health

management information system, training and human resources development, and

drug procurement system. This was traced to the problem labeled as fragmentationof the health service system related to disparate levels of political and administrative

authority over health.

The solution seemed to emanate from the Local Government Code itself in section 33

allowing for inter-LGU cooperation through Memoranda of Agreement for mutually

beneficial purposes and sharing of resources. Anchored on this provision, ExecutiveOrder 205 called for the creation of the National Health Planning Committee and the

establishment of inter-local health zones throughout the country. The Department of

Health, Department of Interior and Local Government, and League of Governors also

signed the Health Covenant of 1999.

The Department of Health patterned the Inter-Local Health Zone or Inter-Local

Health System after the WHO District Health System such that these terms will befound conceptually interchangeable. However, it is called by a particular name in the

sites of operationalization-- referring particularly to the study sites in the provinces of

Bulacan, Pampanga, South Cotabato, Negros Oriental, and Kalinga.

Briefly, the concept calls for an integrated system of public health and hospital

services through a referral system within a convergence zone and of the localgovernment units that have the respective jurisdiction. Essentially, this appears to

provide wide latitude of possible levels of cooperation and integration.


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The District Health Board for the inter-local zone provides the mechanism for

integration and cooperation through planning, policy-making, and management.

However, it is not per se the political decision making body. The respective municipallocal health boards or the provincial health boards are the political body for decision-

making mandated by the Local Government Code where health policies can be

formulated.

However, there are existing models of inter-local health zone development initiatives

in different parts of the country that need to be documented and analyzed as casestudies in order to derive valuable lessons that may drive policy development and

health service program reforms. These health service reform lessons may then shape

the future of inter-local health initiatives to ensure integrated, effective and

sustainable local health systems.

The DOH through the Bureau Local Health Development thus requested technical

assistance from the Management Sciences for Health to conduct case studies on fiveexisting Inter-local Health Zones in the country to determine how these concepts were

put into effect. The areas that were examined were Bulacan, South Cotabato,

Pampanga, Kalinga, and Negros Oriental. The MSH in turn, subcontracted the

Institute of Health Policy and Development Studies of the National Institutes ofHealth in UP Manila to conduct these case studies. This document reports the

comparative analysis of the five ILHZ sites and highlights current practices, policy

and programmatic directions of Inter-local Health Zones in these sites.

1.1 Project Objectives

The ILHZ Case Study Project conducted multiple embedded case studies to

determine the processes and initial outcomes of existing models of inter-local health

zones with reference to certain configurations of health zone characteristics that

include organizational, managerial, financing and information variables. It sought todetermine motivating factors in establishing ILHZs and describes organization and

management schemes of current local health systems. Moreover, it described existing

management structures including financing schemes, information systems and toolsused in planning and referrals.

Specifically the project aimed to:1. Identify and describe the contexts of the multiple cases that will be the units of

analysis in this study;

2. Conduct review of documents and literature that will provide valuablebackground information and inputs to the case studies;

3. Conduct interviews of key stakeholders at central, regional and provincial levels

involved in the development of the inter-local health systems;


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4. Conduct focus group discussions of selected key players/implementers of local

health systems and their counterparts at the provincial and regional levels;

5. Conduct a rapid survey of community perceptions of local health care systemperformance and outcomes in selected case study barangays;

6. Conduct review of documents to ascertain the functionality of local health

systems;7. Identify variables that influence viability and sustainability of local health

systems;

8. Accomplish with-in case and cross-case analyses to determine similarities anddistinctions across cases that impact local health system performance and

outcomes;

9. Identify issues and problems encountered by existing local health systems and

their corresponding alternative solutions; and10. Identify policy and programmatic reform directions that may be recommended as

a result of the case studies.

1.2 Significance of the Project

This project is important in describing what occurred in the early stages of ILHZformation in different areas, how they developed and when possible, why. The study

brought out unique features of each site for cross-comparisons of lessons learned and

various nuances that made this possible including cultural, geographic, political,socio-economic, and administrative factors. Primary data that was gathered are vital

to all key stakeholders in the health sector that aim to make health care accessible to

all segments of the population. For the Department of Health at the national and

regional levels as well as for local governments, the information derived from theproject can be used to re-examine the concept and strategies of local health

development. The decisions they make on future directions, particularly on the

clustering of areas, the roles of participating stakeholders and various aspects ofmanaging local health systems can then be better guided.


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2. Methods

2.1 Actual Methods

For this case study, the local health development area zones (LAHDZ) in SouthCotabato were selected to represent AUSAID funded areas through their efforts to

assist in the development of local health systems through their Integrated CommunityHealth Services Project (ICHSP).

To document and analyze the LAHDZ efforts in South Cotabato, this study employedan embedded multiple case study design (Yin,1992). The units of analysis are the

district health systems, also designated as cases, and DOH-BLHD (Bureau of Local

Health Development) pre-determined areas that were documented and analyzed torepresent various models of existing local health zones.

The embedded case study design allowed the investigators to study the contexts of thecases at the municipal, provincial and regional levels. Moreover, the framework and

mechanisms set by central DOH within which the cases were initiated and nurtured

was likewise scrutinized. The district health system was chosen as the appropriate

level of the units of analysis because it is at this level that the integration of publichealth and hospital systems occurs.

Selected study variables that were investigated include ILHZ utilization rates;

budgets, funding and resource generation capabilities- private - public mix;

organization variables such as decision-making structures and processes, sharing or

resources, communication patterns, and information mechanisms; human resourcedevelopment schemes; community and private sector participation patterns; and

selected health service quality measures.

Study methods utilized include review of records of selected district hospitals andtheir selected corresponding catchment municipalities; Key informant interviews of

key stakeholders including, chiefs of hospital, municipal health officers, provincial

health officers, and selected local health board members i.e. mayors and DOHrepresentatives. In order to ensure triangulation of case study results, focus group

discussions were accomplished to determine the perceptions of selected community

members and ILHZ implementers and supervisors. A rapid survey of communityperception of ILHZ performance and outcomes was also conducted in selected

barangays to determine stakeholder satisfaction, which is one of the important quality

measures. A strength of the study is the linking of qualitative data with quantitativedata in order to come up with robust cases. Data collection instruments that were

developed for the study are exhibited in book 2 of the comparative case analysis.


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Review of Records

The five Inter-local Health Zones had exhibited a wide range of quality of

documentation. There were areas such as South Cotabato and Negros Oriental that

were well documented with voluminous data. Other areas had patchy informationwhile a couple had scant information perhaps owing to their young developmental

life. Among those that were reviewed were documents from the Provincial

Governments, the DOH Centers for Health Development, Municipal Developmentoffices, District hospitals and Rural Health Units. Please see appendix 1 for listing of

sources of data.

Key Informant Interviews and Focus Group Discussions

The key informant interviews and the focus group discussions were designed to elicit

important details on the processes of establishing and managing ILHZs. These weremeant to also yield important information to triangulate data that was derived from

the review of records and survey on perceptions of health services utilization andparticipation patterns. These interviews and discussions were likewise vital in

identifying key factors that influenced the success or failure of local health system

operations. The study team initially drew a list of key informants and participants in

the FGDs on the basis of known key stakeholders in the ILHZ. However, these wererefined in the field as soon as changes in assignments or identification of other key

informants and participants was recognized.

Rapid Survey

The rapid survey method utilized in this study was in accordance with the WHOprescribed method of RSM (Frerichs and Tar, 1998b and 1989). It aimed to gather

data on community perceptions and existing help seeking behavior with regards to

health that will describe utilization patterns at different levels i.e. at the Barangay

Health Station, Rural Health Unit, District Hospital and at the Provincial Hospitallevels. It also sought to determine satisfaction rates with these different health

services that they utilized. Finally, the investigators attempted to identify key factors

that influenced their utilization and satisfaction patterns. All these are meant to morecompletely describe the current health environment in the study sites.

SamplingA two-stage cluster sampling was utilized to determine the population sample to be

interviewed. Clusters of barangays within the catchment municipalities were selected

at the first stage and households within the clusters at the second stage. From a list ofall barangays and municipalities within the catchment area of the reference hospital, a

municipality cluster was randomly identified from which a cluster of barangays was

derived, with the probability of selection proportionate to the size of the resident

population (PPS or probability proportionate to size). The defining criterion is their


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location from the core referral or district hospital utilized in the study. The population

was differentiated according to whether they lived close to the reference hospital, i.e.

within five kilometers or whether they lived beyond five kilometers from the hospital.At the second stage, the first household to be visited is randomly selected. Thereafter

households to be interviewed are sampled from the nearest households until the

determined proportion for the barangay has been fulfilled.

Respondents

As a result of systematic sampling, a total of 2,239 respondents in all case study siteswere interviewed in the rapid survey comprising about 5% of the population they

represent. Of these, 1256 people or 56% were from areas within five kilometers from

the district hospital (more accessible areas) while 983 or 43.9 % made up the

respondents that came from the less accessible areas as shown in appendix 2. A totalof 41 key informants shared their detailed insights into the development of the ILHZ

in their area. Forty- three focus group discussions were likewise conducted involving

353 people to triangulate the validity and reliability of responses derived from the

rapid surveys and the key informant interviews.

Data collection was accomplished from in four waves. The first team comprising of

the whole study team but with the following designated roles: one case study writer,

three co-investigators, four research associates, and ten research assistants collected

data in Bulacan from January 22-26 2001. Two teams went out to South Cotabato andPampanga in the second wave of data collection from February 5-9,2001. One team

went to Negros Oriental From February 19-23 2001 and the last team left for Kalinga

and collected data from February 27 and 28 up to March 2, 2001. Each team wascomposed of one case study writer, one co-investigator, two research associates and

ten local research assistants who assisted in the survey except for the first team that

went to Bulacan.

Information gathered from the areas was validated at least two times: the first time

was during the debriefing sessions at the end of the data collection phase. The secondopportunity for validation happened during the second trip to the areas when the draft

of the case study was presented for comments, revisions and approval of the key

stakeholders in the area. After the information was validated and approved, cross-caseanalysis was then accomplished.

2.1 Data Analysis

Data derived from the Focus Group Discussions and the Key Informant Interviews

were transcribed, coded and displayed in qualitative data matrices using Microsoft

Word. Survey data was encoded using Epi-Info 6 and summarized, and organized

using Microsoft Excel. Statistical analysis including trend analysis was accomplishedusing STATA 7. Data display tables were crafted using Microsoft Word to aid the

report.


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2.2 Validity and Reliability Checks

Pre-testing the instruments in Maragondon, Cavite, safeguarded validity andreliability of the research instruments used, the FGD and KII topic guides and the

survey questionnaire. Furthermore, researchers ensured triangulation by source andmethod was achieved during the data collection process. Some information sought in

the review of records was validated in the rapid survey as well as in the FGDs andKIIs. Also, similar questions were posed to different respondents to determine the

degree of concurrence and variance of perspectives.

2.3 Data Yield Description of data gathered and

constraints

The data set is a mix of qualitative and quantitative data. The former consistingmainly of transcriptions of interviews and discussions and the latter comprised of

tables of summarized survey results. The corresponding data matrices that were

crafted to organize and display data are useful in determining patterns and trends.

However, the body of information is constrained by some factors.

An initial list of respondents for the FGDs and KIIs were initially drawn as pre-determined from the proposed methodology of the study. However, it was found that

many of the respondents had multiple responsibilities and titles. Hence, in the end

there were fewer interviews conducted than planned, as the same people comprised

the different groups that needed to be interviewed. The quality of available recordsand reports that were reviewed varied widely. There were areas like South Cotabato

that was meticulously documented so that trend analysis of their data was possible

while there were areas where the records were patchy or worse, where documentationwas not maintained. The records and documents that were reviewed were voluminous

and necessitated meticulous organization and analysis so that they could be useful to

achieve triangulation.

2.4 Limitations of the Study

While the study initially aimed to analyze selected trends in health status and healthservices indicators that would cover 10 years to account for the pre-devolution,

devolution, and post-devolution periods, due to unavailability of data for some years,

trend analysis was limited to 5 years at best for some indicators.


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Also the findings in this study are limited to observable phenomena regarding the

development of the Inter-local Health Zones in the study areas that were only

formally launched in 1999 except for Negros Oriental areas. While achievementsfrom inception up to the study period were described along with their plans for the

future, it may be possible that it was too early to discern the effects of some of their

efforts and strategies. Hence, this cross case analysis is only able to compare andcontrast what was evident and documented at the time of data collection and

validation.


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3.Consolidated Findings and Analysis

3.1 Key Health Operations Profile of Case Study Areas

These ILHZ case studies document efforts in the provinces of Bulacan, Kalinga,

Pampanga, Negros Oriental and South Cotabato. Each ILHZ area varies in terms of

population coverage and land area as shown in table 1. The largest populationcoverage in the study sites was reported in the Baliuag Unified Local Health System

covering 277,384 people and the smallest population coverage was found in Kalinga.

All of the case study sites were predominantly rural areas except for Bulacan and

Pampanga that were shown to be rurban, or a rural area developing into an urbancommunity. The Negros sites also incorporated cities within their catchment areas.

The relatively inaccessible rural areas of Kalinga were found to be the most sparsely

populated (pop. density 50/sq.km.) and the rurban areas namely Pampanga and

Bulacan were very densely populated with population densities of 1000, and 724.6respectively.

The case study sites are relatively poor with most municipalities classified as third to

fifth class municipalities or areas with annual average incomes of 5 million pesos and

less (DILG, 1997). However, the provincial sites have been shown to be well off with

their income classifications ranging from first class (Bulacan, Pampanga and NegrosOriental) to second class (South Cotabato) and third class (Kalinga). This may have

important policy implications as it seems essential that local resource generation and

sharing is vital to the viability of the organized inter local health zones. If networkedareas were all low-income areas from the regional level all the way to the municipal

level, local resource generation and sharing can prove to be difficult if not impossible.

All the study areas have been shown to have functional and extensive networks of

health facilities but some areas have been shown to be more endowed than others:

The BULHS in Bulacan reports 143 health facilities, 100 of which are public health

facilities and the rest private. In Kalinga on the other hand, there are only 21 healthfacilities, 15 of which are public and 6 private. South Cotabato LAHDZ 2 has been

shown to have an almost equal number of public and private health care facilities in

the area with 23 public facilities and 24 private facilities as shown in Table 1.

The case study areas also vary in terms of catchment area size and core referral

hospital size. The ILHZ areas with five municipalities in their catchment areas areBulacan ULHS and the CVGLJ District Health System in Negros Oriental. The others

have smaller catchment areas of two or three municipalities each.


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Table 1. ILHZ CASE STUDY AREAS BY POPULATION COVERAGE AND

COMPONENT HEALTH FACILITIES, PHILIPPINES, 2001

ILHZ Study Areas

their Catchment

Municipalities and

income classification

Coverage

(Population and Land

Size)

Network of Health Facilities

Bulacan, Region 3

-Baliuag Unified

Local Health System

Angat,-3rd class

Baliuag, -1st class

Bustos, -4th class

Dona Remedios

Trinidad- 3rd class

and

San Rafael-3rd class

Population Coverage

(277,384 people) accounts

for almost 14% of total

Bulacan pop. And 46,767

households ( 11.5%) of

Bulacan households in

land area of 45.05 sq.km

Population density

724.6people per sq.km.

Unified Local Health Zones clustered geographically

around core referral hospitals. BULHS is one among

15 ULHS in the region and has a total of 143 health

facilities

100 Public Health Facilities

Baliuag District Hospital- a 75-bed public

secondary core referral hospital refers to Bulacan

Provincial Hospital, a 200- bed public tertiary

hospital

Rural Health Units - 9; Baliuag- 4 , San Rafael 2

one each in Angat, Bustos and DRTBarangay Health Stations-85 ; Baliuag-26, San

Rafael-24, Angat 13, Bustos 14 , DRT 8

Lying In Clinics- 5 ; San Rafael 2, one each in

Angat, Bustos and DRT.

43 Private Health Facilities

Private Hospitals 11; Baliuag 6, Bustos 4, San

Rafael 1

Private Clinics 32 ; Baliuag 17, Angat 6, San

Rafael- 5 and Bustos 4.

Kalinga , CAR

-Lin-awa HealthZone

Tabuk,- 1st class

Tanudan

and

Rizal-5th class

Services 86,923 people or

36.5% of total Kalingapopulation; 16,056

households or 37.2% of

all households in the

province, in land area of

1,108.3 sq. km. or 35.5%

of population with a

population density of 50

people per sq.km.

Health Zones clustered geographically around core

referral hospitals. Lin awa health zone is one among3 health zones in the province of Kalinga

15 Public Health Facilities

Kalinga Provincial Hospital in Tabuk is a 100- bed

public secondary core-referral hospital that refers to

the regional hospital, Cagayan Valley Regional

Hospital, a tertiary hospital

Public hospitals - primary municipal hospital in

Tanudan

Rural Health Units 5; Tabuk- 3, one each in

Tanudan and Rizal

Barangay Health Stations- 9; Tabuk-4, Rizal 3 and

Tanudan 2


Private hospitals - 5 in Tabuk with total of 77 beds.


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ILHZ Study Areas

their Catchment

Municipalities and


Coverage


Size)


Negros Oriental,

Region 7

- Sta. BayabasDistrict Health

SystemCity of Bayawan-1st

class,

Sta. Catalina, 2nd

class

and Basay 4th class

CVGLJ District

Health SystemCanlaon City, 3rd

class

Vallehermoso, 4th

class

Guihulngan,La Libertad 4th class

and Jimalalud 5th

class

Sta. Bayabas covers171,979 people in

1483.4 sq. kms with

average population

density of 107.7 per sq.

km

CVGLJ covers 209,074

people in 930.4 sq.km.

with average population

density of 366.9 per

square km

District Health Systems clustered geographically

around district hospitals composed of one city and

component municipalities

Public Facilities

Bayawan Distict Hospital is the District Core

Referral Hospital that networks with 4 RHUs

(Bayawan I and II, Sta. Catalina and Basay two

Primary Hospitals (Kulombayan and Amio Primary

Hospitals)

Barangay Health Stations-

Provincial Hospital-

Governor William Villegas Memorial Hospital is

the District Core referral hospital


Medical Clinics- 13, STA. BAYABAS-6, CVGLJ-7Dental Clinics- 4 STA. BAYABAS

Optical Clinics-2 STA. BAYABAS

Pampanga, Region 3

Arayat ULHSArayat-3rd class

Sta. Ana- 4th class

Mexico- 3rd class

Services 215,611 or

13.1% of total Pampanga

population or 36,997

households or 12.2% of

total households in the

province in land area of

283.1 sq. km or a

population density of1000 people in one sq. km

Unified Local Health Systems clustered

geographically around core referral hospitals.

AULHS is one among 15 ULHS in the region and

has a total of 11 health facilities

AULHS has a total of 11 health facilities.

Public Health FacilitiesArayat District Hospital (DECCS Memorial

Hospital) secondary public hospital with authorized

bed capacity of 25 beds and implementing bed

capacity of 50 beds that refers cases to the Regional

Hospital in San Fernando, Pampanga, a 200 bed

tertiary public hospital 18 kms away

Rural health Units - 8 Arayat-3, Mexico 4,

Sta.Ana-1

Private Health Facilities

Private Clinics 3


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ILHZ Study Areas

their Catchment

Municipalities and


Coverage


Size)


South CotabatoLAHDZ 2 Norala, -

4th class

Sto. Nino- 4th class

Selected barangays

from Surrallah, 1st

class

Banga, 3rd class

Sultan Kudarat-2nd

class

Covers about 94,000people

Services mostly Ilonggos,

but also some Ilocanos,

Blaans and few Muslims

Local Area Health Development Zones (LAHDZs)organized around core referral hospitals

LAHDZ 2 has a total of 46 health care facilities:

Public Health Facilities

South Cotabato Provincial Hospital

Norala District Hospital - primary hospital core

referral hospital that refers to a tertiary provincial

hospital

Rural Health Units 2 main health centers with

Barangay health stations-19 (13 in Norala and 8 in

Sto, Nino)

Private Health Facilities

Private Hospitals 3; 2 primary and 1 secondary

Medical clinics 9

Dental Clinics -12

The hospital bed to population ratio in the case study areas have been shown to vary

widely from 1 hospital bed to 537 people in South Cotabato to 1 hospital bed to 958

people in Pampanga as shown in table 2. This finding is remarkable as the expectedlydeficient areas in terms of hospital beds to population ratio are the Mindanao areas

such as South Cotabato which is not observed in this study. The areas showing a

dearth of hospital beds are now the rapidly urbanizing areas of Bulacan andPampanga where the local number of beds has not increased proportionately with

population increase. Perhaps, this is also due to the fact that these areas are near to

Manila and with good roads have access to Metro Manilas hospitals.


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Table 2. ILHZ Health Facilities Analysis Matrix

No. of Health Facilities Health Facilities Adequacy

RatiosILHZ Area/

Province(ILHZ Popn.)

Hospital OPD

Facilities

Total Hospital

Bed/Popn

OPD Facilities/

Popn

BULHSBulacan

(253,044)

Public

Private

Total

2

11

13

99

32

131

101

43

144

1: 920 1: 1,931

LAHDZ 2

S. Cotobato

(94,000)

Public

Private

Total

2

3

5

23

21

44

25

24

49

1: 537 1: 2,136

AULHSPampanga

(215,611)

Public

Private

Total

2

0

2

92

1

93

94

1

95

1: 958 1: 2,269

STA.BAYABAS

CVGLJ

Negros Oriental

(381,053)

PublicPrivate

Total

Public

Private

Total

30

3

3

0

3

6212

74

55

7

62

6512

77

58

7

65

1:573

1: 696

1: 2,324

1: 3,372

LINAWAKalinga

(86,923)

Public

Private

Total

3

6

9

14

0

14

16

6

22

1: 620 1: 6,208

The ratio of OPD facilities to population has not varied as widely as this rangesbetween one OPD facility to 1,931 people in Bulacan to one OPD facility to 3,372 in

Negros Oriental. The exception to this observation was found in Kalinga howeverwhere we observed a ratio of one OPD facility to 6,208 people. Peripheral publichealth units seem to be sorely deficient in Kalinga.

Furthermore, it was observed that private health care providers have not been

sufficiently networked with public health facilities in terms of being formallyintegrated into the referral system of public health facilities. This is unfortunate as in

some areas, as in Cotabato LAHDZ 3; no other secondary health care provider was

available other than the private hospitals. Also many public hospitals have been foundto be downgraded by hospital accreditation and licensing bodies such as Philhealth

and DOH due to deficiencies in vital health human resources such as surgeons,

anesthesiologists, pathologists and other physicians with specialty training. Moreover,inadequate facilities, equipment and consumable materials such as diagnostic

reagents, sponges, cotton, etc. were rampant. Some private health care providers and

their facilities may be the answer to improve the functional capabilities of public

hospitals, if they were sufficiently linked to each other. On the other hand, the privatehealth providers will have access to more patients if they provided their services hand

in hand with public health care facilities.


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These findings are significant in pointing out that there seem to be enough health

facilities in the ILHZ study areas. However, only the public health facilities are

networked together through an organized referral scheme. In areas like SouthCotabato where there is a dearth of public hospitals in some areas, the need to relate

with private health care providers at different levels, especially at the secondary and

tertiary care levels become more acute.

Moreover, the clustering of the inter-local health zones are mostly based on

geographic considerations. These geographic clustering does not always provide thebest arrangements to ensure access especially to secondary and tertiary care facilities.

As a result, some residents of the ILHZ areas do not access the designated core

referral hospitals but access others such as provincial hospitals or regional hospitals

even, when the utilization of these facilities are more efficient as found in theAULHS in Pampanga and Linawa Health Zone in Kalinga.

3.2 Critical Steps in the Formation of ILHZ

In each of the cases study sites, there were key steps that were undertaken towards theformation of ILHZs as shown in the Milestones in ILHZ development as shown in

Appendix 5.

In the Baliuag Unified local Health Zone, the following were undertaken:1. Development of the Unified Local Health System Concept at the CHD level.

2. Orientation of Municipal Local Chief Executives, Local Health Board, Health

Staff at the Regional and Provincial level on the Unified Local Health System.3. DOH supported orientation live-in training for local health board members

(1993)

4. Securing the commitment and leadership of the provincial governor as chair of theULHS boards.

5. Mayors of the five participating municipalities together with the Governor of

Bulacan and the Director of the Center for Health Development of Region 3

signed a memorandum of agreement unifying the five municipalities throughcommunity participation, sharing of resources and expertise and effective

collaboration among local government units. (1999)

6. Provincial Health Office organized monthly meetings of the association of LocalHealth Board Chairman on health in 24 municipalities for 5 months until they

were capable of holding their own meetings.

7. Powerpoint presentation of Health Programs to local health board members byCHD 3 in every municipality.

8. Dissemination of IEC materials from CHD including health programs with policy

basis (RAs and EOs)9. Regular updates regarding health programs given to LCEs during health

municipal board meetings. The local health board meets monthly with the SB or

Mayor as chair.


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10. DOH representative designated as the coordinator of BULHS activities and acts

as liaison officer between provincial health office and the District

11. DOH- CHD 3 provides continuing technical supervision, training, planning,monitoring and evaluation of health programs, formulation or renewal of policies,

protocols and standards, promotion of health information system and research and

development.

In South Cotabato, the LAHDZ system was formulated in three phases, the

preparatory phase, the pre-implementation phase, and the implementation phase. Onlythe first two phases have been completed.

Preparatory Phase:

1. The South Cotabato Integrated Provincial Health Office (SCIPHO)

conceptualized the Integrated Health System (IHS) and specifically the LAHDZ

system after they identified factors in the derailment of health services in South

Cotabato.

2. The SCIPHO developed the concept paper and project proposals were submitted tofunding agencies. Multi-sectoral consultations were conducted for this.

3. Proposals for funding the LAHDZ systems were prepared and submitted to the

provincial government, DOH, USAID, and AUSAID.

Pre-implementation Phase:

4. Provincial Health Office finalized agreements with key stakeholders:

ICHSP planned to reintegrate the district hospital with the RHUs through theLAHDZs (1993)

Local Government Performance Project (LPP-USAID) was launched in 1994with a project life until 2000

ICHSP was terminated in 1994 and revived in 1996 and formally launched in1997

South Cotabato Integrated Health System (IHS) was officially proposed tothe provincial government at the Provincial Health Summit (1999)

South Cotabato Governor de Pedro signed a pledge of support for South

Cotabato IHS (1999)

IHS was formally launched (August, 1999)

5. Securing Mandates and legal bases

Provincial LHB Resolution no.1 s of 1999, endorsing the adoption of the IHSand the issuance of the Executive Order, signing of MOAs (March 1999)


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Provincial Governors Executive Order 99-08, series of 1999, establishing theIHS and creation of Local Area Development Zones (LAHDZs) (April 1999)

LAHDZ MOAs signed by the Governor and Mayors of componentmunicipalities (April-May, 1999)

Provincial Development Council (PDC) resolution for adoption and full

implementation of IHS (May, 1999) Sangguniang Panlalawigan (SP) resolution for adoption and full

implementation of IHS (May, 1999)

Presidential Executive Order No. 205 establishing Inter-local Health Zones(January, 2000)

6. Widespread Social Marketing of the Integrated Health System

First Provincial Health Congress was held to solicit consultation andfeedback on the IHS (July 2000)

Once a week radio program on health to address continuing issues in IHSimplementation.

7. Planning for Implementation

The CHD for Southern Mindanao set the planning and managerial supportsystems in motion by specifying the time frames for each phase of

development; no replication phases were specified (2000)

Implementation Phase

8. Phased and Province-wide dissemination of the IHS

On going planning

9. Development of Financing Options Counterpart funds for LAHDZ implementation provided by

Provincial and Municipal Local Governments in terms of salaries of

contractual workers

Municipal Local Governments provided funds for participationin PHIC Indigent program

Local Health Insurance Schemes and other financing options inthe planning process

10. Monitoring and Evaluation of the pilot and expansion areas

On going planning

The Kalinga Health Zones experienced similar critical steps in the formation of

ILHZs. However, it should be noted that even during devolution, the province of

Kalinga already started experimentation with the Balbalan Zone, now known as theBumilgan Health Zone. The province of Kalinga undertook the following in the

formation of the Kalinga Health Zones:


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Preparation Phase

1. Conceptualization of the Kalinga Health Zones

Conceptualization of the Balbalan Zone (1994)

ICHSP Conceptualization (November 1995)

Kalinga Apayao separated by RA 7878 (1995)

Province of Kalinga identified factors affecting the delivery of health

services: poor communication, transportation, difficult terrain, constraintsof mobility and inaccessibility and high cost in relation to low income

profile of municipalities especially those belonging to the 4th

and 5th

class.

DOH rationalized the national health system through the drafting of theHealth Sector Reform Agenda (January 2000)

DOH took the initiative to conceptualize the District Health System withInter-LGU cooperation (2000)

2. Developing Concept Paper and Project proposals

Preparation for the Balbalan MOA: one hospital and one municipalitymodel with the province of Kalinga Apayao (1993)

3. Finalizing proposals to funding agencies

Inception of the AUSAID/ADB supported Community Health Services(ICHSP, 1997)

4. Finalizing Agreements

ICHSP included the District Health System in its subsystems (1994)

ICHSP workshops for Kalinga-Apayao, South Cotabato, Guimaras and

Palawan (1994)

Signing of MOA between Kalinga Province and ICHSP

5. Securing Mandates

Signing of the Balbalan MOA (1994)

Health Covenant where the DOH, DILG, LGU and the League of Governorshave adopted an Executive Order directing all LGUs to establish Inter-localGovernment Cooperation and defining their mechanisms, structure, functions

and power of the zones (1999)

Signing of the Linawa MOA (1999)

Presidential Executive Order no.205 establishing Inter-local Health Zones(January 2000)

6. Conduct of Social Marketing

Consultative meetings with the Regional Health Office, Local ChiefExecutives, Provincial Health Office, Provincial Planning and DevelopmentOffice, Sangguniang Bayan and Panlalawigan and Integrated Community

Health Services Project (ICHSP)


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Consultation and workshop sponsored by ICHSP for its District HealthComponent (1999)

Consultation with RHO and PHO for financial support (1999)

7. Planning for Implementation

Tour to South Cotabato and Palawan for Health Cooperatives (1999)

Conceptualization of Ambigatton Multipurpose Cooperative for ILHZ support

(1999)

Implementation Stage

8. Activities in support of legal mandates

District Health Board and Provincial Health Board meetings

Accomplishment of activities such as medical missions with the participatingmunicipalities (2001)

Advocacy and sustained implementation of the MOA in spite of political

instability at governors level

9. Development of financing options

Installation of supports systems such as the PhilHealth Indigency Program(2001) and the Ambigatton Multi-purpose Cooperative (2000)

Expansion of support systems by organizing the Bumilgan Multi-purposeCooperative, and the Rizal Barangay Health Workers Multi-purpose

Cooperative

10. Developing pilot and expansion areas

Setting of Chico River District (2000) and the pursuit of the Balbalan-

Bumilgan Health Zones (MOA signed in 1994)

11. Monitoring and Evaluation

ICHSP monitoring and evaluation

Provincial technical team monitoring and evaluation

12. Achievements

District Health Plans

Medical and Surgical Missions

Phil Health Insurance enrollments

Ambigatton Multi-purpose Cooperative and its expansions to other areas

13. Sustainability Updates

Reconvening of the District Health Board where decisions for sustainability

were made. These include the enforcement of the rotation of mayors as hostand chairperson, review and reemphasis on the functions of the DHB,

approval of a better referral tracking system and form, conceptualization of

the MOA to transfer funds of the PHO to Tanudan Municipal Hospital and


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Juan M. Duyan Memorial Hospital based on the Balbalan MOA, scheduled

regular meetings for the board for year 2001 and establishment of a Trust

Fund of the DHB.

In the CVGLJ and Sta. Bayabas District Inter-LGU Health Systems of Negros

Oriental, the following were accomplished:

Preparatory Stage:

1. Identification of convergence area

Gathering of baseline data of the community was done in both CVGLJ DistrictHealth System and in the Sta. Bayabas district. The location of the district

hospitals has become the most important consideration in determining theboundaries of the district catchment areas.

2. Orientation and Training

Inter LGU health conferences were initiated at the provincial level to sell the ideaof health districts to various cities and municipalities.

The district hospital chief and the provincial health office perform socialmarketing functions among targeted LGUs.

3. Action Planning

Health district boards are organized and MOAs are endorsed to SBs ofmember LGUs in the catchment area.

Securing legal mandates for both DHS

Provincial Sangguniang Panlalawigan approved provincial health boardresolution creating the various health districts.

Joint SB Sessions at the municipalities of Bayawan, Basay and Sta. Catalinawere

held (STA.BAYABAS, 2000)

Planning- Workshops on the Implementation of the District Health System

MOA signing

Signing with participating stakeholders of CVGLJ in 1999 and STA.BAYABAS in 2000

Implementation Stage

4. Monitoring and Evaluation

Monitoring is done internally by the health district boards. The St. Goretti Foundation is the external monitor for Sta. Bayabas and

BIARSP is the external monitor for CVGLJ.

From the consolidated experiences of the different case study ILHZs, we can derivecritical steps in the formation of ILHZs that need to be undertaken to ensure their

viability and sustainability. These include:


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1. Undertaking extensive and meticulous pre-implementation preparation of ILHZ

stakeholders.

2. Deciding on effective organizational structures and arrangements that areeffective and feasible relative to site characteristics.

3. Securing enduring functional linkages and mandates among key stakeholders to

forge strong working relationships and teamwork.4. Finalizing and securing commitments for resource support, and networking of

services.

5. Massive social marketing to disseminate the concept, the ILHZ system, itsmission, vision and objectives to generate widespread community buy-in and

participation.

6. Conducting joint management sessions among local government and health

managers to oversee ILHZ operations.7. Developing local health financing options to ensure sustainability of ILHZ

operations

8. Phased and province-wide dissemination of the ILHZ

9. Monitoring and evaluation of the pilot and expansion areas

First, an extensive and meticulous pre-implementation preparation seems to be

extremely valuable. In this step, valuable strategic plans to determine the direction of

ILHZ organization efforts can be carefully laid out. More detailed annual operational

plans can also be hatched to determine vital contributions of key stakeholders.

Proposals for external funding may also be crafted at this time. Most importantly, thisperiod will allow process champions to secure necessary mandates to legitimize ILHZ

organization and to ensure its sustainability over time.

A second important step is making decisions on effective organizational

structures and arrangements that are required by context of the area to ensurethe feasibility of initiating the inter-local health zone system as well as its

sustainability over time. There were several examples of this step as a keydeterminant of success of ILHZ over time. In Bulacan, Cotabato and Bayawan, it was

decided early that the District Health Board needs to be chaired by the Provincial

Governor to ensure that the participation of the Mayors of the componentmunicipalities would be coordinated more effectively and so that provincial support

can be facilitated. In Pampanga, it was decided to experiment with CHD3s model 2

that required one Mayor to lead the district health board on a rotation basis. There is aneed to examine and decide on other organizational arrangements such as the

inclusion of an external funding agency such as AUSAID and USAID into the formal

organization of the ILHZ. Identification of key partners and clear delineation of theirroles and functions in the ILHZ is vital to ensure that organizational arrangementswill be made to work. The identification of key partners especially NGOs and POs is

also important to ensure that networking to ensure quality health care provision is

feasible.


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Third, securing enduring and functional linkages and mandates between health

managers at the DOH, the local health managers and the local government

managers is important to forge strong working relationships and teamwork to

facilitate a robust and integrated health operations system. At South Cotabato, the

provincial health office exerted great effort in securing necessary mandates fromdifferent administrative levels namely, the national, regional, the provincial, and the

municipal levels, to ensure that the LAHDZ system will withstand political changes

and upheavals. Among mandates secured that assured enduring and functionallinkages were: EO 205 at the national level establishing national Inter-local Health

Zones; Provincial Executive Order 99-08 establishing the IHS creation of Local Area

Health Development Zones (LAHDZ); Provincial Development Council resolution

for adoption and full implementation of the Integrated Health System (IHS); LAHDZ2 MOA among the participants of the LAHDZ 2; and Local Health Board Resolution

No. 1 endorsing adoption of the integrated health system, issuance of Provincial

Executive Order and signing of MOAs . While other case study areas were not able to

develop as extensive inter-local policies, there were vital key mandates developed inall areas except Pampanga, such as the MOA among component municipalities and

the provincial government to formalize their commitment of participating in IHLZdevelopment.

As the mandates were secured, the support of local government executives wassimultaneously won, as local government executives perceived that they had no

choice but to follow national legislation mandates. At the same time, local

government managers and health managers at different levels had to work on this

common task so team building eventually was facilitated. Working on securing thenecessary mandates provided a focus that bound them together in the preparatory

stages of setting up the IHLZs.

A fourth step that is related to securing mandates is finalizing agreements and

securing commitments for resource support, financial and human resource

arrangements, and networking with other agencies and organizations including

NGOs and POs. In this process, counterpart-funding commitments were secured

from local government executives as initial or continuing commitments.

Massive social marketing comprised the fourth critical step in ILHZ formation .

In Pampanga and Bulacan, CHD 3 went to such lengths as developing Power Pointpresentations for local government executives and government managers to convince

them on the importance of setting up and supporting ILHZs. These were instrumentalin winning over the governors and mayors and supporting ILHZ development. These

events were likewise utilized to communicate advantages and disadvantages of setting

up health districts as well as conveying that financial incentives were available to thelocal areas that were willing to initiate and operate ILHZs. Sustained social marketing

was also identified as valuable in the implementation phase. South Cotabato used tri-


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23

media- radio, local newspapers and other printed materials to disseminate information

about the progress of the LAHDZ system. They developed a weekly radio program

where the Provincial Health Officer (PHO) discussed issues and addressed problemsand criticism of health care delivery.

In this case, health managers were able to address tensions stemming from local

health care delivery as expressed by the recipients of care. The success of Dr.

Fidencio Aurelia in securing community participation in health care financing wasalso a vital output of social marketing. It is envisioned that this step will be priceless

in securing widespread community participation and buy-in to improve the utilization

and quality of local health systems. An important outcome is the fostering of

community empowerment and ownership of the health system such that thecommunity will realize that they have an important stake in the success or failure of

their local health system.

Joint planning sessions conducted to oversee implementation of ILHZ operations

were likewise identified as vital to ensure full integration of health operations

into local government operations. These means that regular, well attended meetings

were organized to ensure that health operations among participating local

governments synchronized well. These sessions also provided oversight in the

networking of the component municipalities to facilitate information and resourcesharing. This step was successfully demonstrated in all the ILHZ case study areas.

Development of financing options was an important component fully developed

in some of the ILHZ study areas but underdeveloped or non-existent in others. In

Negros Oriental, the Peso for Health was successful in mobilizing community interestand support for local health development while setting up health financing options for

the area. The financing decisions moreover facilitated the development of autonomy

and independence in supporting and maintaining local health system operations. In

Kalinga, a cooperative pharmacy was set up as well as a community-based healthcooperative. Moreover, all the areas participated in the PhilHealth Indigent Program.

The sixth important step in ILHZ formulation would be phased and province-wide dissemination of the ILHZ. Although not many of the new ILHZ pilot areas

have reached this phase, this seems to be an important step to ensure deliberate andcontrolled expansion of ILHZ areas. In this step learning from other mature ILHZ

implementation areas would be beneficial before implementing the ILHZ system full

blast. Some ILHZ managers like those in Kalinga visited other areas that wereidentified as successful models of ILHZ, in this case, South Cotabato before it fully

implemented the system in their area. South Cotabato developed only one

convergence zone that could be used as a model that may be utilized for pilot testing

new strategies, training, and a source of a wealth on information about success and


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failure factors in ILHZ formation. For areas like Negros Oriental that had models of

District Health Systems since 1985, this step was experienced in the development of

the Sta. Bayabas District System as an expansion area of CGLVJ District HealthSystem.

A final step would be monitoring and evaluation of the pilot and expansionareas. With full implementation, monitoring and evaluation of activities is a necessity

that would allow IHLZ areas to learn from the experiences of the pilot and expansion

areas that would allow them to replan and introduce changes more systematically.While none of the areas was able to demonstrate the achievement of this step, the

Province of Kalinga was able to refine the ILHZ models that it introduced in the area

so that the cultural requirements of indigenized systems were respected and upheld.

3.3 Health Operations: Organization, Composition of Services, and Patterns of

Utilization

Health Services and their Support Subsystems

The BHS usually provides health services that include symptomatic or definitive

management of common illnesses (e.g., antipyretics for fever, analgesics forheadaches, Chemotheraphy for TB) and preventive/promotive services in relation to

the DOH programs (e.g., EPI) through the Barangay Health Workers (BHWs) and

Rural Health Midwives (RHMs). The rural health unit (RHU) main health centers,services include simple laboratory examinations (e.g., urinalysis, fecalysis) and dental

services provided by medical technologists and dentists correspondingly.

At the District Hospitals, there are pharmacy, laboratory and x-ray services asidefrom in-patient and out-patient services. The in- and out-patient services are

classified into general medicine, pediatrics, minor and surgery and obstetrics-

gynecology including Caesarian operations and D & Cs. Only the District Hospital inArayat provides rehabilitation services through a tie-up with a private foundation

serving students of physical therapy schools.

Some of the hospitals in the case study sites were licensed as primary hospitals as

Norala in South Cotabato and Guihulngan in Negros Oriental while others wererecognized as secondary hospitals such as in Bayawan, Negros Oriental and Tabuk,

Kalinga. However, the Tabuk hospital is also a provincial hospital and caters topatients outside of the catchment areas. In the same manner, those in the catchment

areas do not utilize some of these facilities. They go to the nearest hospital (e.g.,

residents of Mexico, Pampanga go to the nearer regional hospital in San Fernandorather than to the farther DH in Arayat. The residents of Rizal, Kalinga on the other

hand, go to another district hospital and not to the designated core referral hospital,

the provincial hospital in Tabuk).


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The BHS, RHUs and hospitals manage a mix of communicable and non-

communicable diseases especially in the urbanized areas of the districts. Such a mix

is characteristic of communities in development transition.

Integrative Planning and Development Mechanisms

There are varying degrees of participation in planning in the five areas, ranging from

a non-integrated (i.e., the district hospital and each RHU come up with their ownplans) operational planning in Pampanga, to the integrated strategic planning in the

LAHDZ of South Cotabato through the involvement of Provincial Technical

Advisory Groups (PTAGs) and area coordinators, and to the annual planning of the

Linawa Zone with participation by the mayors and municipal health committeemembers in addition to those in the health system. In Bulacan, the DOH

representative consolidates the municipal plans and the resulting plan is approved by

the district health board headed by the Governor. In Negros Oriental, strategic

planning occurs from the BHS/RHU and DH levels to the ILHZ level.

Policy Making Processes and Mechanisms

In terms of the organizational structure and management processes, the ILHZ district

health board is the unifying and coordinating body composed of representatives fromdifferent agencies and organizations that contribute to the health zone operation:

Provincial LGU representative, Sangguniang Panlalawigan (SP) representative to the

health zone, Integrated Provincial Health Office (IPHO) representative, MunicipalLGU representative, Association of Barangay Captains (ABC) President, DOH

representative, Health insurance organization representative, Chief of Hospital,

Municipal Health Officer (MHO) and, Non-government organization (NGO) /Peoples Organization (PO) representative.

The ILHZ district health board has financial and policy-making functions to

supplement existing LGU policies. New ILHZ policies are presented and approved bythe Provincial Health Board and the Sangguniang Panlalawigan. It also approves the

integrated health work and financial plan.

The ILHZ Technical Management Committee (TMC) is composed of the technical

staff from the RHU and hospital personnel and assisted by the administrative staff

designated by participating LGUs on a part-time or full-time basis. Other membersmay include the DOH representative or a patient representative.

Usually, the first policy governing the ILHZ is the MOA between the stakeholders

(GOs: health and political; and NGOs). In general, policymaking is vested in the

District Health Boards.


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In South Cotabato, policy making is multi-level, from the Sangguniang Bayan, the

LAHDZ Board and the Expanded Provincial Health Development Board asexemplified by the process they utilized to change provincial hospital pricing.

In Pampanga which still does not have a completed MOA, its sole policy is withregard to the referral system and the decongestion of the district hospital.

In Bulacan, an example of a policy is the focus on the malnutrition problem leading toULHS-wide planning and implementation on nutrition improvement including

income-generating activities at various levels.

Policymaking in Negros is vested in the various health boards which havemultisectoral representation. A technical management committee made up of health

workers at various levels is formed to provide inputs to the board which acts on their

recommendation.

Financing and Budgeting Mechanisms

Certain mechanisms have been put in place in support of the local health systems.

Negros Oriental is one of the few provinces that have allowed public hospitals to keep

their income held in trust by the Provincial treasurer. Aside from the regular budgetallocation from the province, the income earned by hospitals from user fees are

plowed back to the hospital for their maintenance and operating expenses.

Up to the present, user fees are remitted to the provincial treasurer and an accountant

is assigned to keep records and keep track of all hospital remittance forwarded to the

Provincial Treasurer. The hospital makes periodic requests for release of funds and abudget sub-allotment is prepared and approved by the Sangguniang Panlalawigan.

Each hospital has its own board that decides how the funds are to be spent.

The creation of hospital boards also prepared various sectors of Negros Orientalsociety for participation in district health boards. The hospital board has multi-

sectoral members and is given policy making as well as financing functions. It

approves the work and financial plan prepared by the hospital staff and disbursementby the province is in accordance with the approved plan and budget.

Negros Oriental stands head and shoulders above the other ILHZ that were studied in

terms of community health financing.Their ILHZ board established a common healthfund from the LGU appropriation of member municipalities in the catchment area, in

addition to other funds from other sources like foreign funding. They may also tap

into a health insurance fund, DOH grants, community financing fund and otherprivate sector contribution.


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All funds are deposited to the ILHZ account and disbursed in accordance with the

integrated work and financial plan. The common health fund is deposited under one

collaborating LGU as agreed upon by participating LGUs and managed by the ILHZTechnical Management Committee. The ILHZ Health Board and the Technical

Management Committee (TMC) maintains separate books of account and keep

financial records available anytime for monitoring and auditing by an authorizedagency. The TMC submits a financial statement and narrative report.

In CVGLJ, the health district board maintains a common health fund derived from

BIARSP funds and contributions from participating municipalities. The CVGLJdistrict has been registered with the Securities and Exchange Commission and the

board has opened a bank account for the common fund. (See Appendix 9 for the

Articles of Incorporation of the CVGLJ ILHS)

In Sta. Bayabas, all areas agreed to put up a common health fund. The amounts

pledged reflect the financial position of each of the three towns with Bayawan,

recently converted into a city paying the highest contribution, Sta. Catalina next andBasay, a fourth class municipality and the poorest among the three paying the least.

The District Health Board met to decide on how the common fund should be

allocated among the 7 components of the Sta Bayabas ILHS. Of these components,the Peso for Health Program gets the highest percentage for funding.

Both Bayawan and Guihulngan have the local Peso for Health insurance scheme andtrust funds for health coming from a variety of sources (e.g., LGU, health insurance,

revolving drug funds). It also has separate district and hospital board budgeting.

Kalinga has similar mechanisms (multi-purpose cooperative pharmacy and trust

fund). It also has inter-LGU sharing of resources for medical missions (e.g., human

resources, transportation, fuel).

On the other hand, there is no health insurance in South Cotabato but there is anintegrated budgeting at the LAHDZ. There is an on-going Indigency Health Insurance

Program through the PhilHealth in certain municipalities of South Cotabato, Kalinga,

Bulacan and Pampanga.

Referral Processes and Mechanisms

Referrals are usually shunted from one primary level of care to a secondary of tertiary

level. In CHD of Central Luzon, there is a uniform referral system, with multi-colored forms that is implemented in the ULHS of Bulacan and Pampanga. InKalinga, the referral chain is not generally followed. Referrals are dictated by

proximity (e.g., skipping the RHU because the district hospital or the provincial

hospital is geographically accessible). In South Cotabato, a two-way referral system,the integrating factor in the health information system, is in place. Here, the LAHDZ

is the focus for development. The referral system addresses problems such as

underdeveloped health services as in the downgraded hospital license of the Norala


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district hospital, lack of coordination with private practitioners and confusion among

the community members regarding points of access to health care. Such a two-way

referral system is also operational in Negros Oriental such that people know whichservices are available in the existing health facilities. A common problem is the lack

of back referrals.

Human Resources Management

Generally, the HRM functions belong to the respective LGUs (i.e., the provincialgovernment for the DH staff and the municipal government for the RHU staff).

Oftentimes, politics play a part in recruitment and selection, promotion and

performance evaluation. There are also inadequacies in staff development especially

for the non-medical personnel and insufficient career path. Some incentives such asawards are provided, however, as exemplified by the provincial government of

Bulacan. There are also complaints of inadequate remuneration such as the absence

of hazard pay and among LGUs, the higher salaries of MHOs/RHPs than the mayors.

There are still many DHs and RHUs with incomplete staffing. Such problems resultin low morale and low levels of motivation. As far as human resources for the ILHZ

are concerned, Negros Oriental and South Cotabato are two areas with specificstaffing for a district health system. The former has the Management Committee

while the latter has the PTAGs and the area coordinators.

Management Information System

The FSHIS started by the DOH is still in place. In CHD No.3, the lack of staff for

ULHS operations contributes to the difficulty of having a MIS. Thus, data from theRHUs bypass the ULHS and go straight to the PHO resulting in the absence of

planning at the district level. In the ICHSP areas of South Cotabato and Kalinga, this

is being developed. In the former, the LGUs contribute in the procurement ofhardware. Presently, networking is not yet completed despite the presence of

computers. In Negros Oriental, it was noted that there is better information sharing

with the use of computers. However, in general, information has yet to be generated

for better decision making at the ILHZ.

The most developed health services subsystems are the planning and development as

well as the policymaking subsystems. All case study areas have three- year strategicplans both at the provincial and local levels. They also have corresponding annual

operating plans. Most of these plans are crafted during joint planning meetings of the

District Health Boards. Due to the short implementation phase of Pampanga, thesejoint planning meetings were not as evident there. However, it must be noted that

integration of health operations into local health system operations is no yet complete.

Policymaking subsystems are operating at high levels. They are able to churn out

important supportive policies for ILHZ implementation. At the same time the more

mature systems like South Cotabato and Negros Oriental have been shown to


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influence central DOH and the executive and legislative branches of government to

craft policies that would support inter-local health systems.

The least developed sub systems are the management information and human

resource development systems. The ICHSP project has provided funding for South

Cotabato and Kalinga for investments in the development of local health informationsystems that would integrate both field health services and hospital services to each

other. While the initial hardware has been procured, the software development has not

been completed yet. These areas are hopeful though that this system can be developedin the near future. Human resource development has also lagged behind the other sub

systems.

Organization of Health Services

As previously described, health operations in the study areas are clustered

geographically around core referral hospitals at the District level. While thefunctional capabilities and resultant services of the district core referral hospitals

varied, they were all expected to be capable of providing secondary hospital services.There were a number of problems associated with this. First, not all areas clearly

delineated the essential services provided at the primary secondary and tertiary levels

that should be provided. South Cotabato did this well by designating primary,

secondary and tertiary health packages that should be provided at different levels ofcare. The other case study sites assumed that this was already done and thus

exhibited more overlaps and gaps in their service delivery. Second, not all core

referral hospitals were shown to be capable of delivering secondary hospital services.In the case of South Cotabato, the Norala District Hospital was downgraded by the

PHIC to a primary hospital. Hence, the services that the District hospital overlapped

with those provided by the RHU. The same was true in the Guihulngan DistrictHospital. Hence, in Norala because there was no secondary hospital capability, people

had no choice but to go to private hospitals or go to the distant provincial hospital.

However, when Provincial hospitals provide only secondary hospital services, then

tertiary services will have to be availed of in a more distant Regional hospital as whathappened in the Kalinga experience.

Patterns of Health Services Utilization

In all the study areas, the most accessible health care facility identified in this study isthe Barangay Health Station followed by the private hospital and the RHU as reported

by Table 4. The district hospital and provincial hospital are perceived to be the fourth

and fifth most accessible health facility respectively. However, reported healthseeking and health facility utilization behaviors show preference for private

practitioner and private hospital over BHS, RHU and self-medication. Please see

Tables 5 and 6. The results from these two tables seem to correlate well with each

other and validate the preferences indicated by these two measures. One set of


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responses were answers to What do you do when you or any family member fall

sick? The other responses were in reply to the query, What health facility do you

usually go to?

These responses were matched with what they said were what common health

services they sought as shown in Table 7. Respondents indicated that they mostlyutilized the following ranked services: check-ups/consultation/ BP checks all in first

rank, immunizations in second rank, followed up by family planning, maternal care

and free or refill of medicines. Moreover, Table 8 shows that the family healthproblems that they seek consultation for are best addressed at the BHS and RHU

levels.

Common health services that the respondents utilize for their most common familyhealth problems are all provided in the BHS and RHU but why do the respondents go

to private hospitals and physicians? Perhaps, the perception that private physicians

and hospitals are more complete and capable of providing needed services is still

dominant. Conversely, even if some public health facilities are accessible, they areperceived as incapable of providing quality care due to lack of medicines, necessary

equipment and personnel. This perception surfaced during the focus groupdiscussions.

Responses on satisfaction of respondents with health services provided at the

reference health facility was shown in Table 9 to be positive, i.e. 79% of allrespondents indicating that they were satisfied with health services. However, there

was a sizable proportion of respondents (20%) who either did not respond, had

inapplicable responses or indicated that they were only sometimes satisfied. Theinvestigators construe these responses as negative. True to the Filipino behavior of

not wanting to offend or displease others, these responses may have been masked to

soften their expression of dissatisfaction.

In addition, all district hospitals were expected to have technical supervisory

responsibilities over RHUs, but it seemed that it was not clear to all of them that they

should also be operating district health offices with organized technical staff to do thejob. The District Hospitals that were able to do this included Kalinga and South

Cotabato while the rest merely functioned as secondary health care referral centers.

Perhaps the reason for this is that the core referral hospital in Tabuk for the LinawaHealth Zone is also the provincial hospital that houses the technical staff. In South

Cotabato, the Provincial Hospital acted as core referral hospital for LAHDZ 3 that

was not included in the case study sites. For this LAHDZ, the technical supervisionfrom the District Hospital was evident. But it was not so for LADHZ 2 that the

Norala District Hospital was supposed to technically oversee. In the latter case, the

District hospital merely acted as a referral unit. While technical supervision waslacking in the other areas, the critical role of the DOH representative was highlighted

by this situation. In Bulacan where the DOH representative was very active and on

top of all IHLZ developments, he was able to discharge the technical oversight that

was necessary in the local areas. He thus linked the Provincial DOH technical staff


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capabilities with the needs of the developing BULHS. In other areas, the DOH

representatives did not actively figure in providing this link.

3.4 Organograms

The different models of ILHZs, as shown in Appendix 6, present us with varyingcomplexities of organizational structures in terms of: the number of structures

working within the framework of an integrated health system; the expanded

membership found at the provincial level and, the functions and powers inherent toeach structure.

Comparing the District Health Board of the different ILHZs shows stark differencesin the chairmanship of the board and composition of members. In some models like

the ILHZs in Bulacan and Negros, the Governor heads the board. On the contrary, the

LAHDZ board found in South Cotabato has designated the Sangguniang

Panlalawigan member as the chairperson of the board. A different case was alsoobserved in the Linawa Zone Health Board in Kalinga and the AULHS District

Health Board in Arayat. The chairmanship is rotated among the mayors involved in

the catchment area of the district health system.

District Health Board membership also varied depending on the institutional context

of each ILHZ. Some models of the ILHZ are jumpstarted with the help of a foreignfunding agency such as the BIARSP and AusAID through ICHSP. Hence, their board

membership included external agency representatives as board members. Those that

are locally initiated either by the regional health offices and/or by key persons in thehealth sector also had representation in the district health board.

The Guihulngan Model was locally initiated but was also heavily supported by a

foreign funding agency BIARSP. The membership to the board, was thus, madeavailable to the representative of the foreign funding agency. It also included a

Department of Agrarian Reform representative since BIARSP targets agrarian

communities as its beneficiaries.

The Kalinga Model, on the other hand, is also backed by AusAID through the ICHSP

that helped implement the subsystems of the district health system. This, however,has not affected the composition of the Linawa Zone Health Board and has

conserved its membership to the mayors of participating municipalities, SP and SB

board representatives, loc

comparative analysis-5 ilhz

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