The Devolution of the Philippine Health System:

A Success or Failure of Governance?

An Embedded Multiple Case Study Analysis

Submitted to Dr. Jennifer Santiago Oreta

School of Social Sciences

Ateneo de Manila University

In Partial Fulfillment of the Requirements for the Course

POS 100: Politics and Governance

Aguilar, Benedicto Juan Enrique P. Herrera, Neill Johnson A.

Roderos, Ma. Via Jucille M. Sy, Jeremy Edward A.

17 October 2014

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Table of Contents

List of Tables i

Table 1: A Comparison of Selected Philippine Health

Statistics from 1980 and 2010

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Table 2: A Summary Assessment of the Devolution Policy

by Case Study

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Introduction 1

Statement of the Research Problem 2

Review of Related Literature 3

Analysis and Discussion 7

Conclusion and Recommendation 19

Bibliography 21

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CHAPTER 1

INTRODUCTION

The Philippines has been traditionally under a formal, centralized form of government.

Because of the country‟s geography, effective communication under a highly centralized

structure is theorized to be ineffective because the distances between the different islands make

travel and effective communication very inefficient. Consequently, many of the cities and

municipalities away from the central city suffer because of the lack of proper development and

the slow response of the government to their needs (Atienza 2004).

For decades, and peaking with Marcos‟ dictatorship, a formal centralized structure failed

to effectively and efficiently deliver services. The consequences were especially relevant in an

archipelagic country. The overly centralized structure limited the prospects for development in

the countryside. The first term of Ferdinand Marcos saw the creation of the Decentralization Act

of 1967 (also known as Republic Act 5185), “an act granting local governments greater freedom

and more means to respond to the needs of their local constituents effectively, and to effect a

more equitable and systematic distribution of governmental powers and resources.” The act

enabled the faster response of local governments to the agricultural and health sectors because of

the increased funding and access to resources. In 1972 during Marcos‟ second term, the

Philippines experienced the declaration of the Martial Law. The 1973 Marcos Constitution still

allowed for local autonomy, resulting in the creation of the Local Government Code of 1983

(Batas Pambansa Bilang 337). However, it would not be consistent for an authoritarian regime

would grant genuine autonomy to its local government units (Brillantes and Moscare 2008).

The Philippine Revolution of 1986 (also known as People Power Revolution)

successfully overthrew Marcos and installed Corazon Aquino as President. A year later, the 1987

Constitution was created and implemented, including specific provisions guaranteeing autonomy

to local governments. Even after this power was still very concentrated in Manila, with local

units being very dependent upon the central city. As a result, the Local Government Code of

1991 was formulated (Brillantes and Moscare 2008).

Republic Act (RA) 7160, otherwise known as the Local Government Code of 1991, was

the beginning of the devolution many of the services provided by the Philippine government

(Azfar and Gurgur 2001). Many functions of the government were reallocated from the national

to the local government.

Allocated to the local government was the responsibility of health, in particular:

Primary health care

Maternal and child care

Non/Communicable disease control services

Health services that access to secondary and tertiary health services

Purchase of medicines, medical supplies, and equipment needed to carry out the services

Social welfare services including:

o Programs and projects on child and youth welfare

o Family and community welfare

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o Women‟s welfare

o Welfare of the elderly and disabled persons (Dumogho 2006)

Devolution is theorized to be ideal for developing countries that are suffering „double-

burden‟ with regards to health due to epidemiological transition in disease prevalence from those

diseases typical of underdeveloped countries (communicable diseases) to those of developed

countries (non-communicable, often lifestyle diseases); that is, there is high prevalence of both

communicable and non-communicable diseases; all the while growing in population. In

particular the Philippines, with a culturally diverse population owing to many geographical

barriers and yet having a developed Local Government Unit (LGU) system seemed ideal for a

devolutionary policy (Atienza 2004).

And yet policy enactment is not easy to achieve, according to dominant policy setting

schools of thought. Both the Hall and Kingdon model of policy agenda setting cites several

factors that have to be present for an agenda to be set, factors that do not often come into

alignment and are often difficult to bring to cohesion (Hall 1993;, Larkin 2001;, Wong 2014).

Thus in the decades since RA 7160 was passed research on the impacts of the legislation

on health has been limited. Furthermore, the studies that have been conducted have shown that

the impact of the devolution of the Philippine health system is at best mixed (Romualdez et al.

2011; Magno 2001; Bossert et al. 2000; Hartigan-Go et al. 2013; Lieberman 2002). In as recent

as 2012 the DOH has specified three goals that are related to the devolution: a) better health

outcomes, b) more equitable financing, and c) increased responsiveness and client satisfaction.

And yet despite advancements in health outcomes the Philippine health sector remains mired in

inequity (Romualdez et al. 2011). From a political perspective, this research paper seeks to

assess the success of the Local Government Code of 1991 through its provisions for the

Philippine health system, particularly with regards to its social, and public health aspects.

Statement of the Research Problem

This research paper seeks to answer the following question: is the Devolution of the

Philippine government successful in delivering better health system outcomes? To formulate

an answer for this question, three specific questions will be answered as well.

1. Has RA 7160 improved the sensitivity of the local governments towards its constituents?

2. Has RA 7160 improved the responsiveness of the local governments towards its

constituents?

3. How have the local power relationships affected the implementation of RA 7160?

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CHAPTER 2

REVIEW OF RELATED LITERATURE

This review of related literature (RRL) will look into previous studies that will aid in the

body of this research paper, with three specific agenda. First, the RRL considers the methods

used in some previous similar studies, and next, it analyzes the frameworks used within said

studies. The RRL aims to demonstrate the gap in the devolved Philippine health system,

formulate a viable methodology for the research paper, and construct a tool that will be used to

analyze the government institutions to be examined.

Methods

This segment of the RRL explores the study designs and methods of previous studies to

guide the methodology of this research.

Study Design: Embedded Case Study

An embedded case study involves more than one unit, or object, of analysis and is usually

not limited to qualitative analysis alone. The embedded case study allows for multiplicity of

methods that may be applied, leading to the formulation of hypotheses, sampling of qualitative

data, and application of statistical analyses. It also allows for multiplicity of units, objects, or

levels at which analysis is conducted; the evidence is thus investigated in what are termed

subunits (Scholze and Tietje 2013).

The various levels of government organization at which analysis will be conducted, as

well as the various types of data that will be examined classifies the research as embedded. Some

embedded case studies that have been conducted on the devolution of the Philippine health

system are DOH - Bureau of Local Health Development 2001, Atienza 2004 and 2008, and

Lavado and Pantig 2009.

To demonstrate the embedded case study design, Lavado and Pantig 2009 assess the

health service delivery of the LGUs of Agusan del Sur and Dumaguete City. They gather data

with the use of interviews, surveys, and statistics, and analyze on the Barangay, Municipal, and

Regional health unit levels, with health workers, doctors, intra-unit systems, and patients as

subunits.

Study Design: Multiple Case Study

The multiple-case study design allows for the exploration of differences within and

between cases. The goal is to replicate findings across cases (Baxter and Jack 2008). While the

case study design should ideally answer the question Why or How, the compound,

complementary nature of the multiple-case study design allows for the proof of a central question

or argument (Yin 2003). Incidentally the aforementioned studies also use Multiple Case Study

design.

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Study Design: Deviance Case Study

In particular, Levy discusses a case design wherein anomalies in existing theoretical

propositions are examined, with the aim of explaining why the case deviates from theoretical

expectations and in the process refines existing theory and generates additional hypotheses (Levy

2008) which is effectively the aim output of our recommendations. While the data that this

research will present as anomalies to existing theory will be qualitative, quantitative data and

statistics will be used when possible.

Data Gathering: Primary Sources

In particular DOH - Bureau of Local Health Development 2001 employed extensive

interviewing efforts coursed through government research assistants. Okwaroh 2013 and Azfar

and Gurgur 2001 utilize surveys to obtain their data. This research will utilize interviews and

observations gathered by health sciences students operating as research teams across the

Philippines. That such data are gathered as teams should help minimize any bias and form an

objective picture of the situations of the health care systems in the places of interest.

Data Gathering: Secondary Sources

The majority of studies utilize secondary sources, reviewing statistics of localities

to make conclusions and test hypotheses. Notable examples are Atienza 2004 and 2008, Azfar

and Gurgur 2008, Bossert and Beauvais 2002 Capuno 2009, Capuno and Panganiban 2010,

Grundy et al. 2003, Hartigan-Go et al. 2013, and Lavado and Pantig 2009.

In sum, the research paper is an embedded multiple case study design, which will attempt

to present deviant cases to formulate recommendation. It will utilize observations gathered and

interviews conducted by the researchers with the various stakeholders of the health service

delivery process in various localities in the Philippines, as well as statistics, findings, and

conclusions of other research.

Framework

This section of the RRL examines a) the theoretical basis behind the devolution of the

Philippine health system, and b) the frameworks that previous studies have formulated with

regards to devolved government health services.

The devolution of such services comes from a particular school of thought that argues

specific advantages for devolution:

Improved „allocative‟ efficiency by allowing the mix of services and expenditures to be

shaped by local user preferences;

Improved „technical‟ efficiency through greater cost consciousness at the local level;

Service delivery innovation through experimentation and adaptation to local conditions;

Improved quality, transparency, accountability, and legitimacy owing to user oversight

and participation in decision making; and

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Greater equity through distribution of resources towards traditionally marginalized

regions and groups (Bossert and Beauvais 2002; Schwartz et al. 2002; Capuno and

Panganiban 2010).

The group will analyze and evaluate the effectiveness and efficiency of the devolved

health sector based on the improved sensitivity and response, power relationships, and the power

relationships, namely: (a) the role of local strongmen and (b) local patronage and clientelism.

These will serve as measures for the effectiveness of the health system in a highly centralized

and devolved government structures.

Improved Sensitivity and Response

Decentralization instituted as the Local Government Code of 1991 was established as a

response the dilemma of the concentration of power to the capital. Furthermore, it was intended

to address the the problem of inequitable development in some of the regions in the country and

to facilitate delivery of services specifically tailored to the needs of the community. It also

creates an avenue for the members of the community to participate in governance (Brillantes and

Moscare 2008).

The Local Government Code entailed for the devolution of responsibilities to the Local

Government such as facilitating delivery of services in health, education, environment, social

services, public works, telecommunication, and housing projects. Moreover, the LGU shall also

institute enforcement of regulatory powers and certain legal proceedings. Through this, the

government also provides the local government with sufficient financial resources in the form of

greater taxation powers and increased share in national wealth and Internal Revenue Allotments

(Brillantes and Moscare 2008).

Through the Local Government Code, the local autonomy is promoted through less

reliance on the national government. Furthermore, it promotes dependence of the local

government to its internally generated revenues and resources. In sum, it encourages the local

government to become more entrepreneurial to enable them to provide quality services to the

community (Brillantes and Moscare 2008). Bossert and Beauvais 2002, and Schwartz et al. in

particular cite that this should be an aspect of the health service delivery system where marked

improvement will be observed.

Power Relationships

The political power structure in the Philippines could only be described as elitist and

patrimonial among other things. Patrimonial political structures fosters massive dependence

especially of the poor and marginalized sectors of the population to those who possess power and

wealth. Hence, this allows the few elite to monopolize power and resources among themselves

. As patronage politics entails concentration of power to the elite clans, Patron client

relationships breeds grounds for unequal distribution of resources, violence, and corruption

among many others (Pingel 2010). According to Sidel, the most rampant occurrence of patron-

client relationships and local strongmen can be found in the Philippines (2005 cited in Pingel

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2010). Azfar and Gurgur cite that power relationships can adversely affect the devolved health

systems (2001).

This research will conduct an embedded multiple case analysis, analyzing based on the

demonstrated sensitivity, responsiveness, and power relationships of the devolved health system.

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CHAPTER III

ANALYSIS AND DISCUSSION

This research paper will analyze five case studies: the state of the Philippine health

system during the Marcos Era and Post-Marcos era conditions, the health systems of Palo, Leyte;

the health systems of Brgy. Sta. Cruz, Sto. Tomas, Batangas; and the health systems of Olongapo

City.

Pre-Devolution Conditions of the Philippine Health System: Marcos Era

Before the implementation of the Local Government Code of 1991, the Philippine

government structure was centralized, and the Marcos era the peak of the centralized structure.

There was local autonomy during Marcos‟ rule, however the central government‟s rule was

much more pronounced. The pre-devolved health system had both central and local dimensions.

At the central level was the Department of Health (DOH) as the administrator of national health

services, operating basic health facilities and hospitals located from the barangay level , up to

the national levels. There were some notable chartered cities exempted from the DOH‟s direct

authority over their health sectors (i.e. Davao City, Cebu City), although they were still subjected

to DOH regulations.

In order for the DOH to effectively supervise and regulate local government health

services, provincial health officers were granted authority over financial decisions, personnel

management, and operational decision-making (Atienza 2004). The goal wsa to provide the

Filipino with universal health care that was consistent in its delivery and quality with that of the

rest of the country. The centralized health care system was also able to provide funds for local

units and assign them functions in order to improve the delivery of services, resulting in a

somewhat devolved system.

At the peak of the centralized government system was Proclamation no. 1081, or the

declaration of Martial Law by former president Ferdinand Marcos. Following this, Marcos

issued General Order no. 1 declaring that “all powers had been transferred to the President who

was to rule by decree.” Following was the declaration of General Order no. 3, granting “all

executive departments, bureaus, offices, agencies and instrumentalities of the National

Government, government-owned or controlled corporations, as well as all governments of all the

provinces, cities, municipalities and barrios throughout the land” the ability to function under

their present officers until otherwise so ordered by The President. This may seem like Marcos

granted autonomy to the local government units, however, Marcos is still in control of the

funding and resources, as well as having the power to seize control of the unit at command.

From the late 1970s to the mid-1980s, during the Marcos era, the performance of the

national health system was less than exemplary (Atienza 2004). From 1970 to 1980, the

Philippines saw the lowering of incidence and mortality rates of notifiable diseases except for

Tuberculosis (all forms), Infectious Encephalitis, Malignant Neoplasms, and Influenza which

peaked in 1979. The incidence of Typhoid and Paratyphoid Fever, Gonococcal Infection and

Infectious Hepatitis showed a generally increasing trend during the 10-year period. Better

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diagnosis and improved notification were mainly responsible for the increase in the number of

cases, On the other hand, the incidence of Malaria, Rabies, Whooping Cough, and Tetanus had

generally decreased from 1968-1978. Measles and Influenza present irregular trends on account

of outbreaks, at almost yearly intervals. Malignant Neoplasms on the other hand has consistently

increased in incidence and mortality.

The data presented by the Health Intelligence Service in the Philippines Health Statistics

Report of 1980 show an inconsistency of the health trends. There were no great reductions in the

morbidity or mortality rate of notifiable diseases. However, there were decreasing mortality rates

in some diseases. The possible reason for the decrease in these rates may be because of the

improving medical technologies during the time.

In the same report, are the regional statistics on mortality by attendance. This reports the

percentages of the the deaths attended by private doctors or public services (health officers and

public hospitals). In the National Capital Region where power is centralized, 74.3% of the

infections and diseases were attended by or accounted for by either physicians, health officers

and/or hospitals. But in Regions away from the capital mainland such as Regions 5 to 9, this was

not the case. In these regions, an average of 57.58% of the mortalities from notifiable diseases

were unattended; i.e. they occur outside of health institutions, or without the supervision of

doctors or other health practitioners. This, despite the leading types of illness causing mortality

pneumonia and tuberculosis, which kill gradually and can be treated when brought to the

attention of medical personnel (DOH 1980, World Health Organization 2010).

The glaring problem in the centralized system was that there was little to no response to

the diseases in regions away from the capital. This resulted in a great number of unattended

deaths from notifiable diseases unlike in regions with chartered cities or regions close to the

capital, where there is great access to resources and services. Diseases that are prominent in

some regions may not very prominent in others, so a centralized health system would not be

appropriate to cater to the needs of some local units. Rather it could attend to only the nationally

trending diseases. Furthermore, regions away from the capital may not be as well-equipped in

terms of medical instrumentation or of resources when it comes to treating certain types of

diseases, resulting to the poor treatment of local patients.

A region away from the capital, Region 11 (Davao Region) did not suffer as much as

Regions 5 to 9, even with its geography. However the difference in Davao is because the local

strongmen in the main city, Davao City, are more closely tied with the Marcos clan. Because of

their connections with the local government, they are able to gain more favorable incentives

from the central government, such as better development of local health centers and the

development and establishing of the Davao Medical Center as the medical Center for Mindanao.

In summary, the pre-devolved health system of the Marcos Era was sensitive and

responsive in that they were able to identify the diseases affecting the people and respond to

them immediately as evidenced by the decline in the incidence and mortality rates. However, this

was not reflected in regions away from the capital, where response was slow and inefficient. In

regions with chartered cities such as Region 11 (Davao Region), response was effective because

of their access to resources. Additionally, the status of Davao City as a chartered and

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autonomous urbanized city allows for the local strongmen to have greater control of the local

health sectors, resulting in favorable services for the locals. Across the Philippines, the

development of the health sectors is inequitable due to the central government‟s preferential

treatment of towards the more urbanized areas.

The table below summarizes the condition of the Philippine health system pre-devolution

(1980) and post-devolution (2010).

Table 1: A Comparison of Selected Philippine Health Statistics from 1980 and 2010

1980 2010

Total Population 48,316,503 94,013,200

Total Deaths 298,006 488,265

Top Causes of Mortalities

1. Pneumonias - 15.8%

2. Diseases of the Heart -

9.9%

3. Tuberculosis, All Forms

- 9.7%

1. Diseases of Heart - 21.1%

2. Diseases of Vascular

System - 14.0%

- Cerebrovascular Diseases -

12.2%

3. Malignant Neoplasms -

10.2%

% Mortalities caused by other

notable diseases

Diseases of Vascular

System - 7.1%

Malignant Neoplasms -

5.4%

Diarrhoea - 4.5%

Pneumonias - 9.3%

Tuberculosis, All Forms -

5.1%

Diarrhoea - 3.9% (All-time

low)

% Mortalities by attendance 26.4% 65.8%

Infant Mortality Rate 40.2 12.6

Attended Livebirths 54.3% 75.4%

Statistics with regards to current health outcomes yield mixed results. While unattended

mortalities has increased to 65.8%, this may be due to the changing prevailing ecologic factors in

the Philippines. For example, while leading causes of mortality were once pneumonia and

tuberculosis, currently by far the leading cause of mortality is Diseases of the Heart; Diseases of

the Vascular System is next in line, and far outstrips the succeeding causes of mortality (DOH

2010). Thus while unattended mortalities may have increased this may be due to the increased

this may be because the leading causes of mortality now (heart and vascular diseases) a) go

undetected more easily (Boland et al. 2002), b) arrive faster in terms of the fatal sequence of

events, which is within minutes (CDC 2005), c) and are exacerbated by poor medical emergency

response times (according to field investigation) and an ageing population (Australian Institute of

Health and Welfare 2011).

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There are indices that do suggest an improvement, however, in the Philippine health

system. Attended live births has increased, coupled with a significant reduction in infant

mortality rates, which may be attributable to the advancements in midwifery programs and

legislature in the Philippines, which make midwifery education more accessible and provide

more midwives to the local health units (Philippine Nursing and Midwifery Data Bank) .

Another statistic that may indicate the efficacy of the devolved Philippine health system

would be the drastic decrease in Tuberculosis, which the DOH committed to reducing with

devolved programs such as the Tuberculosis-Directly Observed Treatment Short-Course (TB-

DOTS; 2003). This program has been appraised and lauded in its effectiveness by Co and

Concepcion (2007).

It is arguable whether or not the devolved Philippine health system has been effective

with regards to the overall health outcomes of the Philippines, as many studies conclude for and

against its effectiveness. However it can be said that it has indeed made treatment for certain

diseases more accessible to the indigent population who would otherwise be unable to afford

treatment.

The Politics of Municipal and Regional Health Systems: Palo, Leyte

Palo is a third class municipality in the province of Leyte with a population of 62,727

(NSO 2010) and subdivided into 33 barangays. The Local Government Unit of each barangay is

composed of a Barangay Captain and his/her constituents (Barangay Kagawad). Each of the

Barangay Kagawad is in-charge of the different Barangay departments such as the Committee on

Peace and Order, Committee on Health, Finance Committee, Youth Committee, and Committee

on Education. They handle matters concerning the whole community especially health and social

services programs including immunization, health education, and monitoring of the 4Ps. Each

barangay also receives an allocated budget from IRA which they use for their operational costs

and allowance.

The health system of Palo is based on a referral system where each barangay has a health

center to handle non-complicated health issues and cases beyond the capacity of those running

the health centers are referred to the Municipal Health Office. The MHO, in turn, refers more

complicated cases to the hospitals. However the patient can opt to directly receive treatment

from any facility depending on the perceived severity of their condition.

The appointment of new health workers in the MHO including the doctor, dentist, nurses,

midwives are approved by the current local government of Palo. On the other hand, old health

workers who were appointed by the preceding local administration may still retain their post.

The local government also allocates the budget needed to operate the MHO.

Based on interviews, it was found that the devolution has greatly affected the system in

the MHO. There were quite a number challenges met by the health workers especially in the

allocation of the budget for the various operations of the MHO such as the budget for their

nutrition month program which was not pushed through since the budget was not approved.

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There is also a discrepancy between the grievance of the employees and appealing to those in

power as the tension between the health workers and the local government is palpable. Some

workers also receive special assignment and favors from the local government causing conflicts

among the health workers in the MHO. This, in turn, causes inefficiencies especially in the

delivery of health service in the establishment. Lapses are also evident in the referral system

since there are redundancies in the treatment offered in MHO and the hospitals as the service

offered in one is not coordinated with the services offered in the other. As a result, the quality or

the health service delivered is inadequate and ineffective.

Leyte Provincial Hospital (LPH) is also situated in Palo, Leyte. It caters to 250

outpatients and 120 in patients per day. The latter is significant because the hospital‟s supposed

inpatient capacity is only 50 beds. Regional health units refer cases they cannot treat to the LPH.

An incident wherein the devolved system demonstrated heightened sensitivity and lent an

increased responsiveness to the LPH was during typhoon Yolanda. In this situation organizations

that wished to lend aid, including foreign operations such as the Korean Armed Forces, Mercy

Malaysia, Unicef, and Habitat for Humanity directly interacted with the local government and

the LPH. Because of the good standing of the governor and the provincial hospital with its

constituents, as well as its knowledge of the situation on the ground, relief response was pointed,

accurate, and systematized.

The local government, particularly the office of the governor, was able to organize a

program wherein kids who were on summer vacation could go to the LPH where they would

learn about the systems and could assist with the menial tasks that had to be done post-Yolanda,

such as cleaning and repairs. Instead of payment they received a package which provided them

with additional education, a sizeable allowance, and other peripheral items such as collared shirts

and bags. This program was announced through the barangays. This demonstrates how the

devolved system allows for facilitated information dissemination and operations; it also shows

how constituents are able to participate in the operations of their health care system.

However the devolved health system severely curtailed the budget of the hospital. The

hospital received its budget from the “munisipyo”; while it did decrease processing time of

documents, the hospital budget officer stated that very often the town government would not

send the full requested budget. The officer cited that the amount of budget received also

depended largely on the priorities of the current local head; certain mayors prioritized health

while others chose to allocate budget to other matters.

Other complaints the budget officer stated were that the process of procurement of

equipment was hampered. When the system was centralized certain disbursement packages came

in the form of equipment itself instead of money; the hospital had only to request to DOH and

wait for the equipment. After the devolution however the procurement of the equipment itself

became the task of the hospital, with the local government only providing the funding. Also,

when requesting for supplies such as medicines before the devolution, the effective cost was

much cheaper because when DOH purchased it was by volume since it purchased for the supply

of the entire Philippines; through this it could incur significant discount from pharmaceutical

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companies. Now hospitals have to interact directly with drug manufacturers, and hospitals have

significantly reduced financial bargaining power.

The problem within the financial systems of the hospital led to an inability to respond to

needs properly. While the devolved health system has allowed for the hiring of health workers

such as nurses to be faster in response to an increase in demand, the sheer capability to do so has

been curtailed significantly. Nurses claim that when the hospital was DOH-funded the pay was

significantly larger than how much it currently is. Furthermore nurses are extremely overworked

due to the hospital having to operate over its capacity.

Of note however is the high satisfaction of patients with the service they receive. The

hospital holds surveys, where patients can submit their opinions on what must be improved

within the hospital. The hospital being devolved in its operations are thus able to adjust

accordingly. This demonstrates how constituents are able to participate in affecting the service

the health care system delivers.

While interviews with the hospital patients indicate that patients are largely satisfied with

hospital service, hospital personnel are extremely dissatisfied, indicating a lack of responsiveness

with regards to the needs of its personnel. This is in contrast with the Schistosomiasis Center

(SC), which is run by the DOH. While supposedly primarily only a hospital for basic services,

with its focus on Schistosomiasis research, the hospital has an incredible amount of resources,

owing to its compound source of income: it can conduct its operations with a certain amount of

income (that is, not all its services are government-funded), which adds to its already sizeable

allotment from DOH.

Because of this the SC is considering expanding to a tertiary-level hospital, which will

still operate at a lower price when compared to the private hospitals within the vicinity. This also

allows for the SC to pay their employees at all levels adequately. That the SC is considering

expanding despite its mandate to be primarily a research institution demonstrates a high level of

sensitivity and responsiveness.

However the interactions between the LPH and the SC are highly politicized. The SC

looks down on operations in the LPH. The LPH regards the SC as an institution only for

Schistosomiasis research. The SC has higher financial capability, and yet it refuses to lend any

assistance to the LPH, citing political machinery in the LPH being too messy to get involved

with. This creates a glaring gap in the system: while the SC holds an abundance of resources, it

refuses to lend any form of assistance to the LPH and instead decides to transform its institution

to deliver a wider range of services, which renders it redundant. The SC can afford to withhold

its assistance or interaction because it operates sufficiently on its own. Because of this the SC

sometimes refers patients to private hospitals instead of the LPH; given that private hospitals are

much farther than the LPH and that most patients within the region cannot afford private

services, this procedure most certainly must contribute to detrimental health outcomes,

particularly with regards to emergency cases and maternal concerns.

Within the LPH certain individuals use their connections to those higher up in the

organizational structure to further their own agenda. Nurses cited how other nurses maneuvered

their co-workers out of their position to gain a higher “plantilya”, or item. A particular niche of

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power within the organization is the monitoring team, a particular team whose mandate is to

ensure that no corruption occurs within the organization. This team is answerable directly to the

governor. Another niche is the administrative director, who favors certain individuals according

to his perception of their performance.

The devolved system has allowed for an abolition of certain detrimental power structures,

however. The said monitoring team, since their arrival, was able to eliminate corruption

particularly within the practices of the doctors. Because of the monitoring team the LPH was

able to restructure its operations to ensure that the patients paid directly to the hospital, after

which the hospital delivered the payment to the doctors. This versus the previous system where

the patients submitted all their money to the doctors, allowing the doctors to pad the cost of their

services and drugs administered. The process of organizational adjustment would have been

much more difficult if the LPH had to pass through the national government.

In summary, while the system is sensitive, lack of financial capability severely curtails

the responsiveness of the devolved system in Palo, Leyte, on multiple levels of the health system.

In contrast a centralized institution sees very little problem financially and thus is able to respond

accordingly. The devolved system does however allow for operational adjustments and a

heightened participation by the constituents in the healthcare system. Finally the politics between

institutions hampers what should be expedient interaction, which adversely affects health

outcomes.

The Politics of Barangay Health Systems: Brgy. Sta. Cruz, Sto. Tomas, Batangas

Santo (Sto.) Tomas in Batangas, Philippines has a population of 124,740 people. While it

has been classified as a first-class municipality, this is misleading due to its size; that is, some

barangays in the more rural areas are still largely grassroots. In particular, Brgy. Sta. Cruz boasts

a meager population of 2,104 individuals (NSO 2010b). By census, more than 50% of their

households still do not use LPG for cooking; the average income per household is less than

P15,000 per month; a majority of households do not own cars or refrigerators,

Chronic Obstructive Respiratory Disease (COPD) and Acute Lower Respiratory Infection

(ALRI) are cited to be the leading disease morbidity in Batangas (Department of Health -

National Epidemiologic Council 2009). And yet, the vast majority of the population surveyed for

respiratory health reported that they were healthy, and did not experience any problems. This

despite the increased risk of poor respiratory health: 100% of households surveyed used wood or

charcoal for cooking, and the nature of the occupation of most individuals (jeepney drivers,

farmers) increased their risk of respiratory disease (Salvi and Barnes 2009; Ayres, Maynard, &

Richards 2006).

While the cause of their hale conditions remains to be studied, the barangay remains an

example of an extremely heightened sensitivity of the local government with regards to the needs

of the constituents. This was demonstrated by the intimate and immediate knowledge the 9

barangay health workers (BHWs) possessed about their constituents; they knew the pregnancy

status of women in their barangay, the addresses of individuals particularly prone to contracting

disease; they had a general knowledge of the demographic information of the population, among

other things. Response to emergencies is almost immediate.

14

Many factors lend to this sensitivity: the small population and geographic size of the

barangay may lend to this. The barangay captain is well liked by his constituents: he is extremely

visible, approachable, and hands-on. Essentially he is a neighbor of his constituents; in contrast

the captain of the neighboring barangay, Sta. Elena, lived in a house much more conspicuous

when compared to the rest of the residences in the barangay. The barangay captain discusses

matters with the men and women of the barangay over communal meals and drinking sessions.

The barangay health workers gain their knowledge from constant interaction with the

community; essentially, they themselves are members of the community that they take care of,

and they know the problems facing the community because of first-hand experience.

In particular one event occurred during the visit of the research team to the target area: a

scheduled follow-up check-up was missed by a pregnant woman, and the BHW in charge that

day had been assigned to check on the whereabouts of the woman. A tricycle driver of the

community was willing to ferry the BHW to the household free of charge; the BHW jokingly

said that the mother might have been giving birth, which demonstrated the intimate relationship

the health workers had with their constituents.

This heightened sensitivity has lent to the appropriate responses by the local government.

The barangay has regular town meetings after mass, in which health-related information is

disseminated. Programs such as dengue prevention drives and projects from external

organizations are facilitated and easy to enact.

That the local government unit was on good terms with the population facilitated public-

private development efforts. Students from the Ateneo brought thirty fuel-efficient stoves

designed to consume less fuel while producing more heat and less smoke to the community. The

process of selecting households to provide the stove to for the study was greatly facilitated due to

the encyclopedic knowledge the BHWs had about the community‟s demographics. Through

them the possible ideal sites for deployment of materials were identified. Members of the

community accepted the Ateneo project team as the BHWs explained the purpose of their

project. When introducing the project team to a household, the BHWs would open by saying,

“Good morning po! May magse-census lang, nay.” Notably, that the BHWs knew what language

to use to introduce the concept of the project to the members of the community demonstrated

their sensitivity to their constituents. After initial introductions the BHWs would converse with

the members of the household about topics particular to the members of the household; whether

related to the health status of the household members or more personal questions. In contrast, the

project team could not establish relationships with the DOH Region 4A division to further the

project.

Within the experience of the project team, in Barangay Sta. Cruz there were no local

strongmen. The barangay captain utilized his position largely for the benefit of the community.

He served as the organizer of community events such as feasts and parties. His influence

stemmed from the barangay‟s willing respect. The barangay captain was able to find a jeepney

driver to ferry 30 stoves as close as was accessible by car; after this the barangay captain was

able to ask some of his male constituents to assist in carrying the stoves to a site where the

disbursement of the stoves would be held.

15

The BHWs held considerable respect as well from the community. Most households

offered refreshments to the BHWs as they made rounds, and many children would show respect

by pressing their foreheads to the hands of BHWs. While most of the BHWs were in their late

40s or older, two were in their twenties; and yet the community held the same respect for them as

they did for the senior BHWs. All in all, the good relations between the barangay captain and the

BHWs with their constituents may contribute to the positive health outcomes of barangay Sta.

Cruz.

In summary, barangay Sta. Cruz demonstrates how the devolved health system can have

heightened sensitivity and responsiveness to the needs of the community. It also demonstrates

how government leaders can utilize their powers for the development of the community.

The Politics of Urban Health Systems: Olongapo City

Olongapo City consists of 17 barangays 9 of which we were able to observe and immerse

ourselves in the structure of the political system. There is a strong presence of the Local

Government Unit in all areas, with the existence of a purok leader system where several streets

of a barangay are managed by one person. This complements the structure of kagawads

managing certain issues for the barangay such as health, human rights, etc. These kagawads are

managed by the barangay captain, the official representative of the area. Each barangay has

around 3,000 to 8,000 population, with the outlier of Barangay Sta. Rita, which consists of

40,000 people. (NSCB 2010) However, each barangay varies in geography, some have wide

areas with terrain separating the population and others are urbanized. The same political structure

is present in each barangay, resulting in varying effects in health service delivery, population

participation, and other factors. The effectiveness of this management system is evident in the

strong social capital amongst the people, the various programs designed for the masses, and

openness of the officials to listen to what their population asks for. This government is further

supported by the Mayor and other city hall officials with their solidarity with the people.

However, despite these strong structures present they still do not prevent all people suffering

from deprivation in capabilities from a lack of access to health services, income, and education.

The extent of decentralization in Olongapo coupled with strong and competent officials

has prevented the proliferation of local strongmen and political warlords and the violence that

comes with their existence. The streets of Olongapo are considered safe on most parts, with a

low rate of crimes occurring, according to interviews with the barangay captains. However, the

city does not avoid involvement in patronage politics along with the patronage-based coalition

formed by the political dynasty of the Gordons. This is evident in the current P5 billion debt of

olongapo due to power crises, where the previous Gordon administration continuously

subsidized Public Utilities Department despite huge losses due to corruption and inefficiencies

and further delaying the privatization. (Olongapo City Website 2011). Aside from budgeting, the

presence of the national government is not evident in Olongapo City. Much of the programs and

policies are instituted and managed by the local leaders acting within the bounds of the legal

system and mandates by the national government.

In 2013, an outbreak of Leptospirosis struck Olongapo city where 580 people were

infected with 11 people dead. (DOH 2008) During the outbreak, people had to fall in

16

excruciatingly long lines for services in public facilities such as James Gordon Hospital, while

those willing to spend money found access in private facilities. The fact that income or wealth

determines the level of access to health services a person is entitled to highlights inequities in the

healthcare system. Furthermore, this outbreak shows that no matter how well a LGU allocates

funds and ensures the availability of health services to a population, there is still a need for

resources and strong support from the national government.

In summary, while the devolved health system has allowed for better sensitivity leading

to better responsiveness, as evidenced by policies enacted, the system heightens the capabilities

of local government officials to enact corruption, not necessarily within the health system; the

effects of the corrupt system however are felt across the board of government services,

particularly within the health system.

Synthesis

Overall, the devolved health system seems to heighten sensitivity and responsiveness

across all four case studies. However a glaring deficit seems to be in budget allocation,

particularly in higher levels of organization where larger sums of money are necessary. In this

case budget allocation depends largely on the priorities of the local government. Power

relationships can have a positive effect on the health system, particularly if there is a sense of

shared ownership of the community between the local government and the constituents. On the

other hand power relationships can be used to further individual agenda, to gain better position or

more money; this can have negative effects on the health systems.

Table 2: A Summary Assessment of the Devolution Policy by Case Study

Sensitivity and Responsiveness

Positive Negative

Pre-

Devolution

Heightened due to:

Improved health services in

urbanized cities

Improving technologies and

access to medicine and

facilities

Slow response in far-flung regions due

to

Lack of access to proper

funding and proper medical

instrumentation

Lack of access to medical

supplies due to the inequitable

development of health centers

and hospitals in regions away

from the central city.

Palo, Leyte Heightened due to:

Immediate interaction

between individuals higher

up in the organization and

constituents

Curtailed by:

Lack of available funding

Grievances of workers are often

overlooked

17

Immediate consolidation of

data; i.e. information does

not have to travel from

ground to central national

government office

Brgy. Sta.

Cruz, Sto.

Tomas,

Batangas

Heightened due to:

Intimate relationship between

local government and

community

Immediate feedback between

constituents and local

government

Relatively small population

and geographic size

Active involvement by local

government in activities of

constituents

Good standing between

government officials and

constituents

Evidenced by:

Immediate emergency

response time

Acute awareness of

constituent status

Enactment of programs

appropriate to community

Facilitated interaction with

external organizations

Olongapo City Quick Response time during

the 2013 Leptospirosis

outbreak

Strong relationships with the

people and the local

government officials

Detached National Government,

lack of support

Prevalence of people with

deprivations in capabilities for

health and education.

Unequal Access to Health

Power Relationships

Positive Negative

Pre- Urbanized cities and regions near Highly politicized with the central

18

Devolution the capital gain better health

services and responses from

hospitals and local health sector

units.

government favoring highly urbanized

cities, resulting in inequitable health

development across the country.

Palo, Leyte Constituents have better ability to

affect health care delivery due to

devolved system

Highly politicized intra- and inter-

organization machinations, negatively

impacting the employees in terms of

salaries, ascension in organization

hierarchy, and working conditions

Brgy. Sta.

Cruz, Sto.

Tomas,

Batangas

Used to develop community, not to

further personal agenda

Possibly due to intimate

relationship between local

government and

constituents

Perception of shared

ownership of community

Olongapo

City

No evidence of local

strongmen

Good participation of the

people in local government

(barangay level)

Patronage Politics remains

existent among some officials in

City Hall

19

CHAPTER IV

CONCLUSION AND RECOMMENDATION

The devolved Philippine health system is a different approach towards addressing health

problems in the country. Whether or not the devolved health system has led to better health

outcomes is still up for debate; however it is safe to say that the implementation of the

devolution process is not entirely successful, and far from ideal.

Devolution of the Philippine health care system, if executed and implemented well,

would result in improved delivery of health services tailored to each and every need of the

community. Looking into the Philippine situation, in different contexts in the country‟s health

system an improvement in sensitivity from the government with regards to the health of the

people is needed. However health seems to be a low priority with local governments, particularly

on a municipal level, which leads to a lack of funding. Devolving certain powers to the local

government may help accelerate the development of the community as it encourages the LGUs

to take on a more autonomous approach in terms of providing quality services to their

constituents. It also allows the constituents to participate in matters concerning the community

through working together with the local government. This, in turn, will allow the LGUs to be

more sensitive in responding to the needs of the community. Hence, devolution cultivates

democratic governance in the community through heightened sensitivity to the needs of the

people and participative governance.

However, devolution can be a double-edged sword as it may breed grounds for highly

politicized systems and operations in the community. Despite devolution, there remains a threat

of the power being monopolized to certain positions in the local government resulting to

dependence of the constituents to those who hold the power. This may affect working relations

of the community with the LGUs which will also take a toll on the quality of services delivered

in the community and, in totality, the development of the whole community. Ultimately, the

situation may foster patron-client relationships between the local government and its

constituents.

Recommendations

We conduct these recommendations loosely following the prescriptions of IDEO, an

award-winning innovations firm, as prescribed in their Human-Centered Design (HCD) Toolkit.

Our four years of fieldwork and interaction with the Philippine health system serve as the first

stage of the HCD design process, i.e. the Hear Phase.

The output of the second stage of the design process, the Create Phase, is the following

prescription: to address the issue of lack of budget allotment and resources for the health system,

the researchers advise the creation of a task force answerable directly to the DOH in a each

specific region, similar to the monitoring team formulated by the governor of Leyte, which is

responsible evaluating systems efficiency, operational activities, and recommending solutions for

LGU and national government cooperation. It becomes the team‟s task to reform problematic

institutions according to the feedback of the constituents and the desired health outcomes of the

20

region. This task force has the role of forging a stronger link for the LGUs and the national

government.

The current health system in the Philippines is highly devolved in that the national

government has taken a much lesser role than it is capable of in managing the health of the

population. Given that this monitoring and evaluations team is implemented, the national

government would possess a better understanding of the needs of each region and gain the

capacity to create synergistic programs for the strategic plan for health of the country. Using this

information, the national government can create plans specific for each region and each LGU,

which are applicable to the current situation and context in each location. Furthermore, the

national government can use each individual LGU and make interconnections across

communities in order to form a strongly integrated web of health systems that complement each

other‟s needs and services. Instead of each LGU fending for itself, it has the assurance of the

national government‟s funding and dispensable resources for the region and the support of its

neighboring LGUs in case it cannot meet the demands of its population.

The third phase in this prescription, the Deliver Phase, will require prototyping. The

challenge then becomes for the government to attempt to establish the aforementioned team,

whereby the prescription of the HCD toolkit would be to start small in any attempt to replicate,

with perhaps the example of the Leyte monitoring team.

21

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