Background
Decision space, capacity and accountability
Exploring the synergy in the Philippines
Methods
No. of interviewees | 27 |
Males | 17 |
Females | 10 |
Highest educational attainment | |
MD plus Master’s degree | 17 |
MD | 5 |
Law degree | 3 |
Master’s degree | 1 |
Bachelor’s degree | 1 |
Average duration of service in the public sector (years) | 23.6 |
Average duration of the interviews (min) | 64 |
Category of current roles | |
Career health officers (provincial, municipal and city health officers) | 10 |
DOH directors (national and regional directors) | 6 |
Local politicians | 6 |
Executive of PhilHealth | 1 |
“Doctor to the Barrio” (i.e. DOH-hired physician deployed to serve under a local government) | 1 |
Medical school administrator | 1 |
Government hospital administrator | 1 |
Head of an NGO | 1 |
Organisational affiliation at the time of interview | |
Local governments | 15 |
DOH | 6 |
NGOs | 2 |
PhilHealth | 1 |
Government hospital | 1 |
Philippine Congress | 1 |
Academe | 1 |
Level of decision-making at the time of interview | |
National level | 7 |
Regional level | 3 |
Provincial level | 4 |
City level | 3 |
Municipal level | 9 |
Not applicable | 1 |
Geographic focus of role at the time of interview | |
Nationwide | 6 |
Luzon | 13 |
Visayas | 1 |
Mindanao | 7 |
Health sector functions
Health sector function | Indicator | Decision Space | ||
---|---|---|---|---|
Narrow | Moderate | Wide | ||
a. Planning | Local decision-makers prioritise and develop their own health plans | Local planning possible only if with assistance from the central level | Local planning already taking place, but only optimal if accompanied by significant assistance from the central level | Local planning optimal despite minimal involvement of the central level |
Local decision-makers implement the plans that they developed | Implementation possible only with central level support | Implementation being done but only completed if central level support is available | Full implementation possible even without central level support | |
b. Financing and Budget Allocation | Local decision-makers have their own sources of income to finance health services | Financing mostly dependent on central sources of funds | Mixed financing, such that local sources of financing are augmented with central sources | Financing mostly provided by local sources of funds |
Local decision-makers spend the budget allocated for health services | Spending mostly restricted by guidelines imposed by the central level | Some of the budget controlled by the local level, and some regulated by the central level | Spending mostly follows how local decision-makers wish to use the budget | |
c. Programme Implementation and Service Delivery | Local decision-makers implement their own health programmes and services | Local programmes and services mostly follow only what is promulgated from the central level | Local programmes and services follow nationally mandated programmes but also include locally initiated and innovative programmes that address local needs | A good number of innovative programmes and services implemented at local levels with little supervision from the central level |
Local decision-makers deliver health services with good quality | Local programmes and services implemented with poor quality | Local programmes and services implemented with good quality when central level provides additional support and training | Local programmes and services implemented with good quality despite minimal central level involvement | |
d. Management of Facilities, Equipment and Supplies | Local decision-makers put up the number and type of health facilities needed in their areas | Local facilities built and upgraded mostly through central support | Some facilities built and upgraded by the local level but still a large number of constructions or renovations provided by the central level | Local facilities built and upgraded mostly through the local level’s own efforts and resources |
Local decision-makers ensure functionality of these facilities with adequate equipment and supplies | Local facilities mostly rely on central support for equipment and supplies | Mixed, such that equipment and supplies are provided by both the local and central levels | Local facilities adequately equipped and supplied from the local level’s own efforts and resources | |
e. Health Workforce Management | Local decision-makers hire (and fire) the health workforce needed by the local population | Local levels unable to hire the workforce needed | Local levels able to hire some of the workforce required, but central level augments many vacancies through deployment of its own staff | Local levels able to hire most of the workforce on their own |
Local decision-makers support the career development of the health workforce | Few opportunities at local levels to support the career development of their workforce | While local levels can support the career development of their workforce, a big chunk of training is still provided by the central level | Training and support for the career development of the workforce sufficiently provided by local levels | |
f. Data Monitoring and Utilisation | Local decision-makers collect the relevant indicators | Data collection delayed and poorly validated, unless the central level requires and enforces it | Local levels collect the data in a timely and accurate manner when assistance is provided by the central level | Timely and accurate data collection despite minimal intervention from the central level |
Local decision-makers use the data to inform actions | Utilisation of the collected data for actions at local levels not practiced | Local levels collect the data, but central level provides guidance on how to use the data | Data clearly used for actions by the local levels themselves |
Results
Planning
Health sector functions, i.e. activities or tasks that involve decision-making | Illustrative quotesa | What is the decision space at local levels? | What capacities of local decision-makers are desired? | What accountability mechanisms can be put in place by the national/central level? |
---|---|---|---|---|
Planning | Mayor of a low-income municipality who is also a medical doctor, 26 years in government: “National government wants LHBs to be functional, but it’s up to us to make it functional. We meet for the municipal health action planning, which flows from the Barangay [village] health action planning. So the municipal plan is a consolidation of the various Barangay plans. The DOH has a representative in the LHB, and that is very good because the mayor does not know everything. It’s a coincidence that the mayor here is a doctor, but how about those areas whose mayor is not a doctor? We need help from the DOH for the technical aspects, for example, in the family planning programme, immunisation, etc. We also review our shortcomings. But, you know, it varies from one municipality to another [laughs]. That is the disadvantage of devolution, right? The way things are is not uniform and depends on municipal leadership.” | Moderate | Institutional: • Institutional commitment to perform the planning process regularly • Openness to the participation of multiple stakeholders in the planning process Individual: • Strategic planning skills | Currently in place but may be enhanced: • Technical assistance to local governments for performing planning effectively • Local plans reviewed and approved at central/regional levels to ensure alignment with national objectives • Monitoring by the central/regional levels of local plan implementation Potential policy consideration: • Continuing augmentation for local health services conditional on local government’s regular conduct of planning and satisfactory implementation of previous plans |
Financing and Budget Allocation | Provincial Health Officer of a high-income province, 21 years in government: “About 25–27% of our Internal Revenue Allotment is allocated for our hospitals, and about 5–7% for preventive services. I have an income recovery scheme here. The province provides the budget for maintenance and other operating expenses of hospitals, but I tell the hospitals to recover at least 90% of that and return the funds to the province. The hospitals are able to recover it through their PhilHealth income, and also through income from services not covered by PhilHealth but outpatients pay for, such as ultrasound or CT scan. So majority of our local budget is used for hospital operations, and that’s curative, right? That means we spend so little for preventive services, which should have a bigger investment. This is what I want to ask from DOH, to provide additional funding to enhance our delivery of public health programmes.” | Moderate-to-narrow | Institutional: • Ability to create alternative income sources (except user fees which may reduce access) that are earmarked for local health services Individual: • Skills for priority-setting, with an emphasis for primary/preventive care • Capacity for evidence-informed, rather than politically motivated, funding decisions | Currently in place but may be enhanced: • Strict implementation of PhilHealth guidelines that limit local governments to use their PhilHealth income exclusively for health-related needs Potential policy consideration: • Accreditation of local health facilities to be eligible for reimbursements from PhilHealth may include a requirement for local governments to provide a minimum allocation (depending on income class) from its own local budget as counterpart to finance local health services |
Programme Implementation and Service Delivery | High-level official of the DOH Central Office, 28 years in government: “As the devolution process evolved, and as local governments become more capable to handle their health services, there were circulars issued by the DOH programmes in the central office to ensure quality, for example, on how to package the tuberculosis control programme for their locality. Some of these guidelines sought to remedy the negative aspects of devolution, and so the concept of interlocal health zones or service delivery networks to group local governments together emerged to encourage different local governments serving the same catchment area to deliver health services in a harmonised manner.” | Moderate | Institutional: • Willingness to cooperate with neighbouring local governments for a functional service delivery network for sharing of resources and inter-facility patient referrals Individual: • Innovation in the delivery of local health programmes (while maintaining fidelity to national objectives) that address unique health needs and are suitable to the local context | Currently in place but may be enhanced: • Development of technical guidelines that maintain fidelity in the delivery of nationally mandated programmes at local levels • Training of local government staff in implementing these programmes • Strengthening of service delivery networks by strategically grouping local governments together and facilitating their interlinking with one another Potential policy consideration: • Wider recognition and promotion of models of innovative service delivery programmes by local governments |
Financing and budget allocation
Programme implementation and service delivery
Management of facilities, equipment and supplies
Health sector functions, i.e. activities or tasks that involve decision-making | Illustrative quotesa | What is the decision space at local levels? | What capacities of local decision-makers are desired? | What accountability mechanisms can be put in place by the national/central level? |
---|---|---|---|---|
Management of Facilities, Equipment and Supplies | Director in the DOH Central Office, 28 years in government: “If you would look at how the DOH works with local governments now, it seems that a bulk of our budget actually goes to them. It’s as if it is not devolved. During the last years, DOH upgraded their facilities. DOH is also providing the commodities for the programmes. DOH is giving them the drugs, TB drugs, and now even hypertensive drugs, diabetic drugs. So there is always that question, are we really in a devolved set-up? It has been observed that the local governments really do not have the capacity for health services. I am not saying that this is happening across the country, but in most municipalities and provinces, most especially in the low-income ones, well, even in some first-class provinces. Why? Because the population has increased but there was no increase in the infrastructure and the personnel. That’s why the DOH augments the local governments.” | Moderate | Institutional: • Creativity in partnering with the private sector to enhance the delivery of care in local health facilities Individual: • Management skills for running health facilities and public health programmes effectively | Currently in place but may be enhanced: • Licensing and accreditation of local health facilities that meet the standards of quality, while supporting those facilities that do not qualify to eventually meet the standards • National/central support for upgrading local health facilities (especially in resource-poor settings to achieve equity) conditional on the local government’s provision of counterpart Potential policy consideration: • Central-procurement of selected equipment and supplies on behalf of local governments to gain leverage in negotiating prices; provision of these resources as augmentation to local governments but conditional on satisfactory utilisation of past augmentations |
Health Workforce Management | Provincial Health Officer of a low-income province, 29 years in government: “A poor province could only afford this much, and cannot provide salaries like a wealthy province could. In my case, my salary is only for a second-class province, because my province has the capacity of only a second-class local government. If the province becomes first-class, then the salaries will go up too. That is why when you compare the salaries in different classes of provinces or municipalities across the country, the rates would be different. I think salaries should be standardised across the country, regardless of where one is serving, because we are all doctors anyway, same with nurses and midwives. We are all health professionals, right?” | Moderate-to-narrow | Institutional: • Sufficient financial capacity and regulatory authorisation to: ◦ Hire (and fire) the cadres and number of health workers needed to serve the local population ◦ Provide health workers’ full range of salaries and benefits, including security of tenure Individual: • Deeper appreciation at various levels of governance on the important role played by the health workforce at local levels | Currently in place but may be enhanced: • Deployment of centrally hired health workers to local health facilities that lack them, but conditional on the local government’s: ◦ Provision of counterpart support for the deployed health workers ◦ Commitment to eventually allocate the budget required to hire health workers on their own Potential policy considerations: • Central/regional levels to be officially responsible for providing capacity-building of local government health workers across the country • Implementation of a national policy that discourages local health workers form being partisan during local elections |
Data Monitoring and Utilisation | Assistant City Health Officer of a highly urbanised city, 22 years in government: “Perhaps if you ask the DOH, they would tell you that they are having a hard time with the data because of devolution. It takes a long time for us to submit reports to them. Why am I taking a long time? For my part, I am consolidating all of the reports, including those from our hospitals. So, it is difficult, right? Oh, we do our own surveillance and DOH also does its surveillance, that’s why it is difficult. Actually, there are instances when DOH detects cases first before we do. And there was a time also when we detected it first before they did. So before the DOH even learns about it, we already have a report. That is why maybe for them the DOH is saying that it’s more difficult. Because they feel there is an extra step before the data gets to them, and the city still needs to gather the data from all our health centres.” | Moderate | Institutional: • Systemic capacity for an integrated and harmonised manner of data monitoring and utilisation in spite of decentralisation and the use of interoperable electronic medical records Individual: • Basic knowledge of epidemiology to understand the relevance of the indicators collected • Skills for evidence-informed public health, or for translating data into action at local levels | Currently in place but may be enhanced: • Deployment of centrally hired data collectors to local governments to validate the local data collected and accelerate data transmission to the central level • Maintenance of a central electronic database, into which local governments will be required to transmit data in a timely manner Potential policy consideration: • Publication of rankings of local governments in achieving selected target outcomes |