devolution matters - DOH Central Library - Department of Health

! ,.- 

DEVOLUTION 

MATTERS 

A Documentation of 

.. , , " , ' , . 

Post-Devolution Experiences 

. . , .. ,.,.." ....."...,.....,....". 

in the Delivery of Health Services 

..... , . , . , , , , , . , . 

---------- 

Department of Health 

. 1111111111111111111111\1111111 . 

, D113 

, Hl07,9 D49/ Devolution matters 

"--- ---- ------"--

.., 

Editor : Bernardita A. Quimpo 

Writers : Rosemerita Amar 

Fidel Bautista 

Regi Greja Canda 

Virgilio Crisostomo 

Pedrito B. de la Cruz 

Janice Day B. Edrozo 

Asuncion E. Sia 

Carlos Francis Taparan 

Ma. Teresa Urmanita 

Editorial Staff: Mary Rossalyn P. Atanacio 

Maricel Salazar 

Design: Oscar H. de Castro 

Project Manager: Noriel P. Devanadera 

Publisher : Local Government Assistance 

and Monitoring Service, 

Department of Health 

2 DEVOLUTION MATTERS

, VII J 

Contents 

6 Introduction 

9 Can the Devolution Work? 

15 Primed for Autonomy 

22 Getting Things Done 

28 Visioning for Health in Every 

Home by the Year 2000 

37 A Town Helps Itself 

43 Community Participation in 

Health Services Delivery 

53 Empowering the People and the 

LGUs through Health Insurance 

60 Accessing Provincial Trust 

Funds for Devolved Hospitals 

67 ALAYKA: Leading Palawan 

to People-Powered Health 

74 Making the Most of Devolution 

81 On their own: La Trinidad 

88 Adapting to a Decentralized Set-up 

DEVOLUTION MATTERS 3

Acknowledgment 

This book is the result of the collective efforts of a 

number of people and institutions whose contributions 

are significant not to be mentioned for some kind 

words of thanks. In fact, this publication would have 

been possible without their ideas, time, logistic or moral 

support, all too important not to be acknowledged. 

First, we owe special thanks to the former Secretaries of 

the Department of Health, Dr. Juan M. Flavier and Dr. Jaime 

Galvez-Tan who conceived of the project believing that 

there are success stories which can be considered as gems 

and jewels of devolution amidst problems and controversies 

in the transfer of health services from the na tional 

government to the local government units, and to Dr. 

Hilarion Rarniro, and Dr. Carmencita Noriega- Reodica. the 

incumbent Secretary, who have supported and inspired us to 

continue with the project. 

Our profound gratitude to the local chief executives 

whose accomplishments during the turbulent period of 

devolution are subjects of this book. Their performance 

provides optimism to the direction and future of local 

autonomy. Special acknowledgments are also extended to 

the League of Provinces, and League of Municipalities of 

the Philippines for assisting in the identification of cases. 

We also wish to recognize the contributions of the 

devolved health workers, and other local government 

personnel who have given their time to share their 

experiences. 

4 DEVOLUTION MATTERS 

-. 

'. 

•

• 

\ 

INTRODUCTION 

Can devolution work? As the lead article in this 

collection of stories shows, the answer depends 

on who you're talking to. Advocates of 

devolution can present as many factors which 

favor it and those against can easily muster just as many 

arguments against it. So who is to say who is right and 

who is wrong? 

That devolution works can probably be proven by 

the close to a dozen cases which are the subject of this 

book. We believe they constitute a fair sample of what is 

going on all over the country. 

We started gathering these stories in 1994, at a time 

when devolution was the subject of much controversy, 

not only in both houses of Congress but also among the 

devolved health personnel and local elected officials. 

And so the first stories were documented amid the 

birthing pains of devolution. These include those on the 

municipalities of Balilihan, Bohol ("Primed for 

Autonomy"), San Luis, Aurora ("Getting Things Done") 

and La Trinidad, Benguet ("On Their Own"). These 

were told by local chief executives and devolved health 

workers feeling their way through, determined to make 

sense of the devolution. 

Collecting stories went on until early 1996. You will 

note that, as time has moved on, local government units 

have become more innovative and confident in their 

initiatives. 

Sarnpaloc, a 5th class municipality in Quezon, has 

implemented a local health insurance program to bring 

down health costs and make health services available to 

all. 

6 DEVOLUTION MATTERS

• 

lrosin, the only inland town in Sorsogon, works 

closely with a network of NGOs to improve basic 

services and to promote livelihood activities. 

The province of Negros Oriental has put up safe 

water facilities in its mountain communities and 

pioneered the establishment of lO-bed Community 

Primary Hospitals. 

The province of La Union has a committed and 

active Local Health Board pushing for the 

implementation of its "Health in Every Home" 

program. 

You will also note that the local government units 

featured in this collection of stories have all, without 

exception, harnessed their constituents' participation to 

get their health programs going. 

The towns and provinces we have written about 

are different from one another. Some are resource-rich, 

others are dirt-poor. Some are heavily populated 

provinces, others are sparsely-populated communities. 

What then do these gems and jewels of devolution have 

in common? All of them have shown a willingness to . 

give devolution a chance and have had tremendous 

faith in their capacity to make it a reality. 

Aldous Huxley once said, "Experience is not what 

happens to a man. It is what a man does which 

happens to him." Devolution, in this sense, has been 

very much like experience. It is not something that is 

happening to local government units but what local 

government units are doing with it. And as the 

following stories show, some are working miracles 

with it. 

DEVOLUTION MATTERS7

even before the devolution so the problem of apathy that initially bogged 

down and continue to bog down some municipalities did not exist here. 

Through the CAP, we were already involved in the delivery of basic health 

services long before these services were transferred to the LGU. The CAP 

" became our harmonizing linkage. In fact, if we talk about the principle of 

. autonomy, we already had certain aspects of it in place here since the CAP 

began in 1989," says Chatto. 

The MHO agrees, "The devolution was not really difficult because 

we had thesupport of the mayor, and the mayor had our support." 

Some New Challenges 

Still, the devolution was not totally devoid of problems. Recalls 

Chatto, "we had to adjust to some changes. First, there was the formality 

of transferring the personnel to the LGU. Second, we had to set up our 

own system of reporting. Finally, we had to get used to managing the 

financial aspects of the program; we had very limited knowledge of how 

much money was to be spent for which program."· 

One thorny issue after another had to be addressed. The devolved 

personnel worried over their salaries and benefits, now "an uncertain 

issue" in the hands of the LGUs. Little details such as who should get 

traveling allowance, who should sign which document, and who should 

monitor whom, had to be settled. "We had several meetings to thresh 

out these matters. What I did as a policy was to give all devolved 

personnel whatever it was that they used to get from the national 

government." 

But other issues remain unresolved, although these are not unique 

to Balilihan. Like many other towns, Balilihan, a fifth-class municipality, 

18 D E VOL UTI 0 N MAT T E R S

• 

faces severe financial constraints. The national government has taken on 

the responsibility of paying for the funding requirements of thefirst 

phase of the Magna Carta of Public Health Workers but the workers are 

not reassured. "Our LCU cannot afford the devolution," is MHO 

Dobias's succinct way of putting it. 

Corazon Danila, the town's budget officer, says the municipality 

allots about 10% of its budget to health. Of the 1994 total budget of more 

than P7 million, for example, about P750,000 is allocated for health. 

Much of the money is spent on salaries; only about P90,000 goes to the 

purchase of medicines, repair of health centers and basic sanitation 

services. It is barely enough to buy medicines and medical supplies; 

Danila concedes. 

At the frontline, the budget shortfall takes on a more human-and. 

more urgent-dimension. Davelinda Chatto, public health nurse, says, 

"We lack medicines. Some people complain, but what 

can we do except write a prescription and explain that 

the municipality simply cannot afford to give them all 

the medicines that they need?" Some people, 

especially TB patients, may never get the prescribed 

medicines, she adds. "TB drugs are too expensive for 

, many of our patients." 

Dobias is concerned about yet another matter, what 

he calls the "politization of health services." If the MHO 

would have his way, he would have health services returned 

to the national government. Says he, "We have 

no problems right now, because the Mayor is a real professional. 

But with the devolution, politics will come into 

play in the delivery of health care-there will always be 

the prospect of local politics hindering public service. 

We may be permanent government employees, but we 

are still appointed by a politician, and we must follow 

his directives. In the old setup, we were appointed by a 

highly technical man whose concern is health and health 

alone." 

A Changing Order 

To Chatto, all these are just manifestations of a 

changing order. Lack of funds is a real problem, he admits, 

but one that can be solved. Like other mayors, he 

looks to the national government for assistance, but he also says there is 

much that can be done at the local level. "We have successfully revised our 

municipal tax laws. In the beginning, people resisted this move, but they 

have since supported it and everyone is now enjoying the benefits of the 

new tax measures," he relates. . 

The question of "politization." the mayor says, is valid, but the law 

provides some coverage against it. "Under the new Code, the mayor no 

longer controls the budget. It is the municipal council, presided by the 

DE VOL UTI 0 N MAT T E R S 19

center) at no cost to the municipal government. Nenita Geangan, purok 

secretary, says "the center was finished in one month through 

concerted effort. Our members donated the materials. We did the work, 

• and those who could not work contributed cash." 

Since the purok was organized, says Geangan, it has become easier 

to get people to help in maintaining the cleanliness of the area. "We 

conduct lectures on health, so people are more aware now about what's 

healthful and what's not. Also, there are less malnourished children. We 

have our own vegetable gardens, and we actively participate in the : 

immunization program of the government." 

Are their projects co-terminus with the Mayor? Geangan's answer is 

a categorical "no". "May huluoan nanunt knmi. We have our own incomegenerating 

projects. And we are members of an income-generating 

cooperative." In fact, even now, all their projects are sariling sikap, she 

says. "We cannot expect the Mayor to help us financially, because other 

puroks might be jealous." 

In any case, the Mayor has set his eyes on other projects. Before his 

term is up, Chatto hopes to further strengthen health care by setting up 

lying-in stations in every barangay center "so the midwife will 

not have to go to the mountains, and if there are complications, 

the patient can easily be transferred to a nearby hospital." 

It has become 

He is also pushing the BHW botika, a brainchild of the barangay easier to· get 

health workers (BHWs). "The botika will sustain itself through the 

purchase and sale of over-the-counter medicines such as commer people to help In 

cially produced analgesics and antipyretics," he says. 

maintaining the 

In addition, the Mayor wants to implement a Medicare II program 

covering all households in the municipality. "There are existing 

models that wecan follow, such as the one initiated by Mayor Agnes 

Devanadera of Sarnpaloc, Quezon, so we know it can be done. Our 

clusters are already strong-they have their own income-generating 

projects, so they have the money and the capability to finance 

and sustain not only this project but other projects as well." 

MHO Dobias remains unconvinced, "Our people are very 

patriarchal. If the mayor goes for it, they go for it; if not, then they 

don't. Devolution is in itself a good concept. In fact, I would say 

that we have a working devolution in Balilihan right now. But 

we're fearful of the unknown. Our CAP has yet to be tested with 

a change of administration." 

But Chatto is steadfast, "For me, the test is how well we bring the 

government to the people. Even if the material results of the program 

are not yet fully evident, the mere fact that the people are now more 

aware of the issues involved and can talk about them is to me a very 

positive indication that we're headed in the right direction." o 

o E VOL UTI 0 N MAT T E R S 21 

cleanliness of 

the area. We 

conduct lectures 

on health, so 

people are more 

aware now about 

what's healthful 

and what's not. 

' ... .. . 

to., 

,,", ,

SAN LUIS, AURORA 

Classification : 4th 

Population : 16.740 

No. of Barsngay : 1S 

Land Area : 675.29sqkms 

TNE PEOPLE 

Most of the inhabitants are migrants 

from nearby provinces. Tagalog 

and lIocano are the languages commonly 

used. There isalso a substantialNegrito 

population. theDumagats. 

COMMERCE AND INDUSTRY 

Aurora's basic economy isagricul· 

tural; copra and rice are the principal 

products. Weaving. especially of 

buntal hats, isan important cottage 

industry. 

Fishing production can be increased 

in Casiguran Sound and 

Oingalan Bay, but Baler Bay's is expected 

to diminish due tooverfishlng 

and sedimentation. 

Aurora has maintained its forest 

cover but is under serious threat from 

logging. 

Isolation. inaccessibility and exposure 

to typhoons have hampered the 

province's development. 

Getting Things Done 

San Luis is hard to reach. It takes seven hours to get there by land. 

The road traversing the Sierra Madre is often winding, rough, and 

narrow. Sometimes, it is blocked by landslides-or even a stalled 

trailer truck. 

The town is in the central part of Aurora Province, seven kilometers 

away from the capital town of Baler. It is the largest (land area: about 675 

square kilometers) of the eight municipalities of the province. The 

population of 16,789, spread out in 18 barangays, is relatively small. 

Most live in the rural areas. 

Getting from the adjacent barangays to the poblacion is even harder. 

Dirt roads connect these barangays. "Mahirap kumuha Ilg sasakvan," 

complains one resident. Transport is usually by tricycle. The coastal 

barangays are accessible only by sea transport, which has no regular 

schedule. 

But, for a fourth-class municipality, the town is thriving well under 

the conditions, thanks to the leadership of an energetic and hands-on 

mayor. "Field worker talaga aka," she describes herself. "Pumupunta aka 

kUllg saall-saall. I believe in consultation. To govern well, I must be able 

to talk with the people. If they cannot come to the poblacion then I have 

to go to wherever they are. It's the best way for me to assess and address 

their needs." 

Among her constituents, Mayor Annabelle Tangson has a reputation 

for being responsive to the basic needs of the community. "Y011g health, 

priority talaga niua," is a common observation, one that the Mayor is 

quick to qualify: "Actually, my first priority is social services, but health 

is an integral part of any social welfare program," she points out. 

Something New 

A hands-on mayor who puts health near the top of his or her agenda 

would be expected to welcome the idea of having more control over the 

health sector, and this one is no exception. Tangson is a strong advocate of 

the devolution of health services to the local government units (LGUs) as 

provided in the Local Government Code of 1991 (Republic Act 7160). "I 

have always wanted to do more in the area of health," she says. "Before 

the devolution, 1found it very frustrating that I could not do much in this 

regard. If I found the performance of a health worker wanting, there was 

not much I could do except complain. 1would go to the rural physician, 

and he would tell me, sulat ka Ila lang," 


,

• 

, 

But-at least initially 

Mayor Tangson's positive views 

about the devolution were not 

shared by everyone, certainly not 

by the health workers. Many 

were apprehensive about what 

the new set-up might entail. This 

was especially true with Dr. 

Maria Pura Valenzuela, the municipal 

health officer (MHO). 

Fresh from taking the board 

exams, Valenzuela, 28, came 

into the job in 1992 at the same 

time as the newly elected 

officials assumed office. At that 

time, the devolution was 

already in the making. Aware that by 1993, she would be under the local 

government, she understandably felt more than the normal anxiety of a 

new graduate out on her first job. "It's as if I was entering two unknown 

terrains," she relates. "There were apprehensions talaga. Baka raw hindi 

kayanin." 

Mayor Tangson herself says that everyone had to contend with 

head-splitting administrative problems in the beginning, or "growing 

pains," as she prefers to call them. And she was not just talking about 

the process, but also about herself, about having to cope under 

sometimes trying circumstances. The supplies from the region 

dwindled. Responsibilities and functions were transferred to the LGU 

even before the new system was fully in place. The centers were 

hampered by lack of medicines. People complained. "Millsall, konting' 

diperensiua lang, nagrereklamo na sila," midwife and field worker Aida 

Cabasug relates. 

Aware of the qualms among health personnel and the people in 

general, the Mayor called all devolved employees to several meetings. "I 

explained to them what the devolution means," she says. "I even gave 

the MHO a copy of the new Local Government Code so the health 

workers would know what to expect from it." 

She also consulted with the field workers. She relates, "I involved all 

concerned parties in the discussions because I knew that no matter how 

hard I worked I would not be able to accomplish much without their 

cooperation. My first question was, 'How do you work? What do you do 

in the barangay?' I'm the type of manager who wants to know how 

people do their jobs, so I will know how to assist them." 

Initially, poor discipline among health workers was a problem 

"sakii Ilg 1110," is how the Mayor puts it-and even patients complained 

, about it. 


Julita Porbido of Barangay 

Ditumabo, a mother of seven, 

says she stopped going to the 

municipal health center a few 

years ago after being sent away 

when she was very sick. 

According to her, she was told 

to go to the barangay health 

center, but she found that there 

was no health worker manning 

the place. 

That was before the 

devolution, Tangson explains, 

"Ivuttanda Ila kasiallg dating 

doktor Ilg Sail Luis. To be fair, he 

tried to cooperate with our 

office, but he was just not up to 

the job." She wanted a new 

health officer, she says, but it 

was difficult to get one because "I did not have the authority over health 

personnel, and all I could do was make representations with the DOH." 

In the end, she did manage to get a new doctor assigned to her town. 

The old doctor was transferred to a place where there were three 

physicians-"Hilldj kagaya sa aniin Ila kung hindi siya mag-perform, patay 

allg serbisvo." But this, she stresses, would not have happened if she was 

not "very persistent." 

All that is in the past. Now that health programs are under the 

LGU's control, she can make sure that the people will get quality health 

service, Tangson promises. The Mayor describes herself as a 'strict 

manager'. "I expect everyone in my office to perform; if they don't, I 

don't hesitate to reprimand them. Umiiyak pa Ilga allg mga 'yall, pero aka 

llamall performance lang, zaalallg personulan, I expect everyone to do his 

job, otherwise he has no business staying in government and being paid 

money from the people," she says. 

The tough boss isn't evident, at least not from the staff's 

pronouncements. "Si Mayor Ilamall talaga, allg support niun, 

wholehearted," the MHO says. Even Cabasug, who, according to the 

Mayor, has been at the receiving end of one of her famous 'reprimands: 

declares, "Mabait llaman sa alliin si Mayor." 

The health workers take special note of the fact that now "our 

salaries come on time, and we don't have to go to Baler to get them." 

Adds Michaela Gatmen, a midwife, "Even the procurement of supplies 

is now easier and faster. There is less red tape, and the Mayor always 

finds ways to provide us with the supplies that we need." 

Rationalizing the health budget has not been an easy task for 

Tangson. "In the beginning, I asked the devolved personnel, 'How much 

24 D E VOL UTI 0 N MAT T E R S 

'. 

,

, 

• 

finally to the target beneficiaries. Observes Chatto, "Traditionally, the 

na tional government would lookat the statistics and say, 'This barangay 

is big and has this number of people,' and it would draw up its . 

programs based on these numbers." That was just fine, except that every: 

department was doing the same thing, forgetting that the other agencies 

might be pushing the same programs to the same people in the same 

community. So there was duplication of work. 

The health department had its own barangay health workers who 

did most of its field work, but the other agencies would go to the 

barangay captain and expect him to do everything. 

Chatto saw in the clusters an opportunity to build the capability of 

the people so that they themselves could take care of their community's 

basic needs. The challenge was in making the concept work. "We had to 

set up the structure so that all the agencies had to do was fit in and 

encourage, develop and strengthen the community as self-reliant 

organizational units," Chatto relates. 

Easing Into Full Autonomy 

Today, the political drama of 1989 has played itself out, but the main 

players remain. Chatto is still mayor, having won the 1992 elections, 

where he earned his first term under the new Local Government Code. 

Dobias is still the town doctor, but with a difference: He is now 

municipal health officer (MHO) under the devolved setup. The CAP has 

won for Balilihan the Health and Management Information System 

(HAMIS) Gold Medal, which was handed out in 1994 with a P250,OOO 

cash prize by the DOH and the German Agency for Technical 

Cooperation (GTZ) to the municipality with the most outstanding health 

care management program. 

By virtue 0 f the new LocaI 

Government Code, Balilihan is 

now-at least by intent of the 

law-a full-fledged autonomous 

government unit. The functions 

and resources of the health, agriculture, 

and social welfare 

departments have been devolved 

to the LGU, putting to the 

test Chattos concept of the empowered 

community. 

In many ways, the devolution 

process has been 

smooth-or at least smoother 

than in many other places. "Because 

of the CAP, a strong 

linkage had existed between the 

LGU and the various sectors 

DEVOLUTION MATTERS 17 

..,

• 

faces severe financial constraints. The national government has taken on 

the responsibility of paying for the funding requirements of the first 

phase of the Magna Carta of Public Health Workers but the workers are 

not reassured. "Our LGU cannot afford the devolution," is MHO 

Dobias's succinct way of putting it. 

Corazon Danila, the town's budget officer, says the municipality 

allots about 10% of its budget to health. Of the 1994 total budget of more 

than P7 million, for example, about P750,000 is allocated forhealth. 

Much of the money is spent on salaries; only about P90,OOO goes to the 

purchase of medicines, repair of health centers and basic sanitation' 

services. It is barely enough to buy medicines and medical supplies, 

Danila concedes. 

At the frontline, the budget shortfall takes on a more human-and 

more urgent--

vice mayor, that decides, based on the mayor's 

budget proposal, how much would be allocated to 

each sector." 

And then there is always that ultimate check: the 

ballot. "I wish to see the day when the voting public 

raises its standards for its elected leaders," Chatto 

adds. It will take time, he concedes. "Right now, the 

positive effects of devolution have not been widely 

felt. Whatever benefits the community is getting 

from the devolution are not yet attributed to 

increased autonomy itself. Once the LGUs achieve 

real autonomy, the people who are running the 

system would have greater authority to decide what 

projects to push, but they would also be fully 

answerable to the people in their area of 

responsibility." 

But Chattos idea of autonomy extends beyond 

greater authority for local leaders to full participation 

in governance of the community itself. The CAP now 

appears to have become a calculated move toward 

what the Mayor calls "real autonomy". He explains, 

"With the clusters, people who may have had 

inhibitions about speaking out in the past now freely 

talk about their problems. And when the cluster 

speaks, it is a big voice because it represents a group 

of people." 

Self-help is thus considered a crucial component of the program. 

Each purok had to build a cluster house using their own resources. Says 

Chatto, "The people had to feel that they owned the cluster house, so 

they had to raise money for it, and they themselves had to build it. But 

more than the physical structure, we emphasized the idea, the meetings, 

the institution, the things that they talked about everytime they met." 

This is not to say that the CAP can work everywhere, every time. 

According to Chatto, places that are "politically hot" and those with 

ready access to government services are generally not as successful in 

the implementation of their self-help programs. "In fact, even in 

Balilihan, we found it easier to implement the CAP in areas that are far 

from the town center; the last barangays that got involved in this 

program were those in the poblacion area. The more economically stable 

the people are, and the nearer they are to government services, the less 

responsive they are to community-based initiatives," 

he adds. 

But the CAP is working just fine in Balilihan. Purok Talong of 

Barangay Del Carmen West is right in the center of the poblacion, across 

the public market. This cluster "of 114 members (25 families, 22 

households) has only recently completed its cluster house (or purok 


SAN LUIS, AURORA 

Classification : 4th 

Population : 16,740 

No. of Barangay : 18 

Land Area : 675.29 sqkms 

THE PEOPLE 

Most of the inhabitants are migrants 

from nearby provinces. Tagalog 

and nocano are the languages commonly 

used. There is also a substantialNegrito 

population, theDumagats. 


Aurora's basic economy is agricultural; 

copra and rice are the principal 

products. Weaving. especially of 

buntal hats, isan important cottage 

industry. 

Fishing production can be increased 

in Casiguran Sound and 

Dingalan Bay, but Baler Bay's is e,· 

pected to diminish due to over fishing 

and sedimentation. 

Aurora has maintained its forest 

cover but is under serious threat from 

logging. 

Isolation, inaccessibility and exposure 

to typhoons have hampered the 

province's development. 

Getting Things Done 

San Luis is hard to reach, It takes seven hours to get there by land. 

The road traversing the Sierra Madre is often winding, rough, and 

narrow. Sometimes, it is blocked by landslides-or even a stalled 

trailer truck. 

The town is in the central part of Aurora Province, seven kilometers 

away from the capital town of Baler. It is the largest (land area: about 675 

square kilometers) of the eight municipalities of the province. The 

population of 16,789, spread out in 18 barangays, is relatively small. 

Most live in the rural areas. 

Getting from the adjacent barangays to the poblacion is even harder. 

Dirt roads connect these barangays. "Mahirap kumuha I1g sasakuan," 

complains one resident. Transport is usually by tricycle. The coastal 

barangays are accessible only by sea transport, which has no regular 

schedule. 

But, for a fourth-class municipality, the town is thriving well under 

the conditions, thanks to the leadership of an energetic and hands-on 

mayor. "Field worker talaga aka," she describes herself. "Pumupunia aka 

kUl1g saall-saall. I believe in consultation. To govern well, I must be able 

to talk with the people. If they cannot come to the poblacion then I have 

to go to wherever they are. It's the best way for me to assess and address 

their needs." 

Among her constituents, Mayor Annabelle Tangson has a reputation 

for being responsive to the basic needs of the community. "Yallg health, 

priority talaga Iliya," is a common observation, one that the Mayor is 

quick to qualify: "Actually, my first priority is social services, but health 

is an integral part of any social welfare program," she points out. 

Something New 

A hands-on mayor who puts health near the top of his or her agenda 

would be expected to welcome the idea of having more control over the 

health sector, and this one is no exception. Tangson is a strong advocate of 

the devolution of health services to the local government units (LGUs) as 

provided in the Local Government Code of 1991 (Republic Act 7160). "I 

have always wanted to do more in the area of health," she says. "Before 

the devolution, I found it very frustrating that I could not do much in this 

regard. If I found the performance of a health worker wanting, there was 

not much I could do except complain. I would go to the rural physician, 

and he would tell me, sulat ka Ila tang." 


•

, 

• 

, • 

'. 

But-at least initially 

Mayor Tangson's positive views 

about the devolution were not 

shared by everyone, certainly not 

by the health workers, Many 

were apprehensive about what 

the new set-up might entail. This 

was especially true with Dr. 

Maria Pura Valenzuela, the municipal 

health officer (MHO), 

Fresh from taking the board 

exams, Valenzuela, 28, came 

into the job in 1992 at the same 

time as the newly elected 

officials assumed office, At that 

time, the devolution was 

already in the making. Aware that by 1993, she would be under the local 

government, she understandably felt more than the normal anxiety of a 

new graduate out on her first job. "It's as if I was entering two unknown 

terrains," she relates. "There were apprehensions talaga. Baka raw hindi 

kayanin. " 

Mayor Tangson herself says that everyone had to contend with 

head-splitting administrative problems in the beginning, or "growing 

pains," as she prefers to call them. And she was not just talking about 

the process, but also about herself, about having to cope under 

sometimes trying circumstances. The supplies from the region 

dwindled. Responsibilities and functions were transferred to the LGU 

even before the new system was fully in place. The centers were 

hampered by lack of medicines. People complained. "Minsan, kontilzg 

diperensiya lang, nagrereklamo na siln," midwife and field worker Aida 

Cabasug relates. 

Aware of the qualms among health personnel and the people in 

general, the Mayor called all devolved employees to several meetings. "I 

explained to them what the devolution means," she says. "I even gave 

the MHO a copy of the new Local Government Code so the health 

workers would know what to expect from it." 

She also consulted with the field workers. She relates, "I involved all 

concerned parties in the discussions because I knew that no matter how 

hard I worked I would not be able to accomplish much without their 

cooperation. My first question was, 'How do you work? What do you do 

in the barangay?' I'm the type of manager who wants to know how 

people do their jobs, so I will know how to assist them." 

Initially, poor discipline among health workers was a problem-s 

"saki! ng lila," is how the Mayor puts it-and even patients complained 

about it. 


[ulita Porbido of Barangay 

Ditumabo, a mother of seven, 

says she stopped going to the 

municipal health center a few 

years ago after being sent away 

when she was very sick. 

According to her, she was told 

to go to the barangay health 

center, but she found that there 

was no health worker manning 

the place. 

That was before the 

devolution, Tangson explains, 

"Ivuuanda 110 kasi allgdatillg 

doktor Ilg 5011 Luis. To be fair, he 

tried to cooperate with our 

office, but he was just not up to 

the job." She wanted a new 

health officer, she says, but it 

was difficult to get one because "I did not have the authority over health 

personnel, and all I could do was make representations with the DOH." 

In the end, she did manage to get a new doctor assigned to her town. 

The old doctor was transferred to a place where there were three 

physicians-"Hilldi kagaya sa aniin 110 klmg hindi siya mag-perform, patay 

allgserbisuo." But this, she stresses, would not have happened if she was 

not "very persistent." 

All that is in the past. Now that health programs are under the 

LCU's control, she can make sure that the people will get quality health 

service, Tangson promises. The Mayor describes herself as a 'strict 

manager'. "I expect everyone in my office to perform; if they don't, I 

don't hesitate to reprimand them. Umiiyak po Ilga allg mga'yall, pero aka 

Ilamall pcrjonnance tang, walallg persolla/all. I expect everyone to do his 

job, otherwise he has no business staying in government and being paid 

money from the people," she says. 

The tough boss isn't evident, at least not from the staff's 

pronouncements. "Si Mayor llamOlI talaga, allg support niqa, 

wholehearted," the MHO says. Even Cabasug, who, according to the 

Mayor, has been at the receiving end of one of her famous 'reprimands: 

declares, "Mabait 1101110'1 sa amill si Mayor." 

The health workers take special note of the fact that now "our 

salaries come on time, and we don't have to go to Baler to get them." 

Adds Michaela Catrnen, a midwife, "Even the procurement of supplies 

is now easier and faster. There is less red tape, and the Mayor always 

finds ways to provide us with the supplies that we need." 

Rationalizing the health budget has not been an easy task for 

Tangson. "In the beginning, I asked the devolved personnel, 'How much 

24 0 E VOL UTI 0 N MAT T E R S 

• 

., 

•

even compete with each other. Now we have only one nutrition program, 

administered by both the health and social welfare sectors. Sanitation and 

environment projects are a collaborative undertaking of the health sector, 

the environment department and the PNP." 

There are complaints about lack of medicines. "Noon, maraming 

gamot; ngayon, parang kokonti 'ata," remarks Milagros Simon, a housewife 

who regularly visits the health center for consultation. 

Dr. Valenzuela explains, "We have limited funds so we have to be 

selective about the kind of medicines that we buy." But, she adds, this is 

not necessarily a sign of weakness in health service delivery. She would 

much prefer it over the old set-up, which encouraged people to be very 

dependent on doleouts, "nagmumukhang[armacia tuloy kami dito." 

Now the emphasis is on preventive medicine. Most of the healthrelated 

projects in San Luis rely heavily on education: the maternal care 

program, for example, involves nutrition and preventive medicine, 

including immunization and good sanitation practices. Valenzuela 

wants to change the town's prevailing attitude on health. "People think 

that health care is all about curing diseases-you get sick.you go to a 

doctor, who will give you a pill that will cure you. But health care is 

really knowing how to take care of yourself. I believe in the health 

department's vision: Health in the hands of the people." 

Thus, San Luis residents are slowly being weaned from the idea that 

the rural health unit is their benevolent neighborhood drugstore. Today, 

each barangay health center has its own herbal garden, and every family 

is encouraged to grow medicinal plants for their own use. 

The campaign for self-reliance extends even to the municipal 

government. Tangson proudly speaks of her administration's success in 

renovating and expanding the rural health center with no outside 

financial assistance. "We now 

have a lying-in clinic, and we 

even improved the water 

supply system of the health 

center," she notes. "Before we 

took over, the center did not 

even have enough tables and 

chairs. Now it is equipped not 

only with desks and other 

furniture but also with electric 

fans, typewriters, and various 

office and medical equipment." 

All thanks, she adds, to sarilillg 

sikap. 


The Mayor is also actively 

promoting voluntarism in her 

town. Volunteers are 

•

• 

• 

everywhere-in blood typing programs, nutrifeeding, 

sanitation projects, even doing field work 

in the barangays. "High morale 'Wl/lIl1l siia," the 

Mayor observes. 'They work for no pay, and yet 

they work hard and well. But it's not all work. To 

motivate them, .we hold parties, picnics, parnl/g 

Volunteers Club." 

For Tangson, the ultimate goal is a self-paying 

health care system that will address the health care 

needs of San Luis. As an initial step to this objective, 

the municipality launched last May 12 the 

Medicare II program, an insurance scheme designed 

"to finance the health care need of every 

home." For an annual premium of P180 (Plan A), 

a member can avail of free consultation and annual 

check-up, diagnostic services at discounted 

rates, X-ray services under a co-payment scheme, 

and free admission of up to 30 days, among other 

benefits. A member who pays P300 annually (Plan 

B) gets even more privileges. 

With.the assistance of the Philippine Medicare Commission, San 

Luis has forged tie-ups with hospitals in many areas, as its lying-in clinic 

is not fully equipped to handle all medical cases. Even here, the people 

were consulted. Explains Tangson, "Residents in some barangays, 

especially those in the coastal areas, find it easier to go to adjacent 

municipalities than to come to San Luis, so we had to establish a scheme 

whereby they can be treated there and still enjoy their membership 

benefi ts." 

No Room for Apathy 

After a hard year of pushing her health programs, Tangson is 

understandably dismayed that lawmakers are now telling LGUs that the 

devolution of the health sector was a precipitate-if not an altogether 

unacceptable-move. "Ganadong-ganedo pa /1111111111 kanii, tapos IIgayolI 

ibabale-umlu allg pagod lIalllill, " she laments. 

She hopes that more support is forthcoming, not only from the 

DOH, but from the legislators as well. But even if there's none,"We'lI 

find a way. Ako /WIIl11l1, trabaho I/lll11a bago reklamo. I know that money will 

never be enough, so we have to make the best of whatever resources that 

'we have." 

They have made great strides, she says, and they intend to go the 

distance. As Dr. Pura Valenzuela, the young and won't-stop-at-anything 

MHO would put it, "I would try talaga." . 

Tangson is certain that greater autonomy is.exactly what.San Luis 

needs. "Let devolution stay" she appeals. "Give it time to work." '0 

D E VOL UTI 0 N MAT T E R S 27 

•., J oJ

LA UNION 

CAPITAL : San Fernando 

AREA : 1,493 sq km 

PCPULATION : 548,742 

CITIES : none 

NO. OF TOWNS : 20 

THE PEOPLE 

The majority ofthe population are 

llocanos. Some Pangasinenses are 

found in the southern part of the 

province, while a substantial group 

of Chinese Filipinos are in San 

Fernando, the commercial center. 

llocano is the predominant language 

ofthe people, 

COMMERCE ANO INDUSTRY 

The main sources oflivelihood are 

farming and fishing. The principal 

products are rice. corn, tobacco. garlic, 

sugarcane, and cassava. Grapes 

are extensively grown in Bauang. The 

rich Lingayen Gulf is the main fish· 

ing ground. 

Cottage industries include blenketweaving, 

basketry. shellcraft. pottery 

and furniture-making. La Union is 

also well·known for its basi-making 

industry. the nocano native wine 

made from fermented sugarcane 

juice. 

Visioning for Health in 

Every Home by the Year 2000 

Before the devolution of health services to local governments in 

1993, mortality statistics for the province of La Union suffered in 

comparison with national averages. For instance, 64.6% of cases 

resulting in death in La Union were not medically attended to 

compared to the national average of 58.7%. Although more infants were 

delivered by trained midwives, maternal, infant and fetal mortality rates 

were high. 

More people in the province died of communicable diseases of the 

respiratory system than the national averages although the number 

infected with these diseases was less. Again, deaths attributable to heart 

disease were almost twice as many as the national average, even if the 

number of heart disease and cancer cases was only slightly higher than 

the national figure. 

This mortality and morbidity profile of the province was a cause of 

deep concern for health authorities and local officials. The system that 

La Union inherited from the national government, however, was not one 

that could give the provincial government much confidence in tackling 

the health problems of its people. It consisted of the following facilities: 

the !locos Regional Hospital and the Provincial Hospital in the capital 

town of San Fernando; four District Hospitals located in the towns of 

Rosario, Naguilian, Bacnotan and Balaoan; and the Caba Community 

Hospital. The bed capacity of these hospitals totaled only 210 with an 

average bed to people ratio of one to 2,595. In the case of the Bacnotan 

District Hospital which served a bigger population, the ratio was even 

higher, at one bed per 5,520 persons. Twenty rural health units and 350 

barangay health stations were devolved to the municipalities. Since the 

province has a total of 576 barangays, 226 barangays, or close to 40 

percent, were without health stations. 

Like other local government units, the Provincial Government of La 

Union was at the start not keen on assuming responsibility for the 

devolved hospitals. Nor was it disposed to taking on the problems that 

were part of this responsibility. For example, before devolution, local 

officials were not all that aware of the damage to hospital facilities 

caused by the 1991 earthquake. But once health services had been 

devolved, they had to attend to the repair of damaged water supply 

systems and dilapidated wards. 

Some of these hospitals could not qualify for accreditation. They had 

no intensive care unit and lacked basic hospital equipment such as X-ray 

machines and ambulances. In each hospital, almost all the staff needed 


•

The province of 

La Union gamely 

faced the 

challenges of 

devolution in the 

health sector in 

spite of the 

enormous fiscal 

requirement and 

the Improvements 

It had to 

Immediately 

make In the 

hospital system. 

Sanggunian and develops programs for the provincial executive 

department. 

For purposes of recommending health legislation to the 

Sangguniang Panlalawigan, it has created eight committees - on 

bids, awards, and procurement; therapeutics (and quality control); 

personnel selection; grievance and discipline; budget review; 

continuing health education; medical missions and specialty support; 

and legal matters. 

The Local Health Board also sees itself as "a link between the 

Sangguniang Panlalawigan and the provincial executive", One 

member said it "stands in-between and acts asa go-between between 

these two departments." The Local Health Board recommends 

measures to the Sangguniang Panlalawigan which supports these 

through legislation. While the Sanggunian legislates, the Local 

Health Board implements; what the Local Health Board recommends, 

the provincial executive department executes. 

The Sangguniang Panlalawigan approves the Board's budget. In 

1993, when the "Health in Every Home" Program was launched, the 

Sanggunian approved a budget of 1'8 million. The budget in 1994 

was 1'2.25 million. 

The Local Health Board follows two rules in accomplishing its work. 

One, always get the approval of the Sangguniang Panlalawigan through 

legislation because "a law binds everyone". Two, get the authority and 

approval of the Governor because "no one dares break the King's 

order". 

An organized and well-supported LHB 

The support of Governor Justo O. Orros is crucial in the success of 

the Local Health Board. He presides over monthly meetings held in a 

special room beside his office. A secretariat composed of selected staff 

from the Sanggunian Committee on Health documents the meetings and 

processes the official communications of the Board. 

Four out of the five members of the Board are physicians - Dr. Jose 

C. Ostrea, the provincial health officer and vice-chairman of the Board; 

Dr. Conrado Galsim, the DOH director for Region I; Dr. Socorro B. 

Zarate, a member of the Sangguniang l'anlalawigan who chairs its 

Committee on Health; and. Dr. Fernando A. Astom, vice- president of 

the La Union Medical Society, director for Region I of the Philippine 

Medical Society, and training director of the !locos Regional Hospital. 

Together with the Governor, they make up a Board that earnestly 

addresses the health needs of the province. 

The Board is actively supported by 3,800 volunteer 

(meaning, unpaid) barangay health workers who provide front-line 

services under the supervision of midwives from the government sector. 


J 

• 

e.

'. 

Improving the hospital system 

The La Union Local Health Board was first convened in August 

1992. Within two months, it had laid out its work agenda. First item 

was the problem of budget deficits for devolved services and facilities. 

The provincial government agreed to cover the deficit that arose because 

the national government gave insufficient funds for the devolution 

process. 

After examining the bases for expenditures, the provincial 

government immediately realigned funds from other expense items to 

make sure there would be no interruption in the provision of hospital 

services to the people of La Union. 

The Board likewise attended to systems affecting hospital 

operations. It coordinated with the provincial offices on accounting, 

treasury, budget and audit to establish procedures for the release and 

utilization of funds. To make certain that every centavo in the health 

budget was well spent, the Local Health Board secured copies of 

Advises of Allotment. It monitored how the hospitals spent their budget 

by requiring all hospital department heads to submit their monthly 

performance report. Hospital officials were told: "No report, no 

additional appropriation. No liquidation, no cash advances." To 

improve services, the Board established a fast lane for hospital 

transactions in every hospital department. Even as it recognized the 

problems in hospital administration, the Board acknowledged command 

responsibility on the part of the Chiefs of Hospitals. 

The Flagship Program: "Health In Every Home" 

As mentioned earlier, the morbidity and mortality profile of 

the province was a cause of great concern for local officials. The 

Local Health Board understood that maintaining hospitals costs 

a lot of money. It had to find innovative approaches to health 

promotion and better and cheaper ways to manage medical care. 

In August 1992, the Board's recommended program to answer 

these concerns was formally passed by the Sangguniang 

Panlalawigan. SP Resolution No. 145,called the "Health in Every 

Home" Program, sought to address every aspect of health work 

in the province. It would be a "health promotive, sickness-preventive, 

curative and rehabilitative program". 

On July 13, 1993, a Memorandum of Agreement for the 

"Health in Every Home" Project was signed by participating institutions- 

the La Union provincial government, the provincial 

health board of the DOH proper, the DOH Regional Field Office, 

the La Union Chapter of the Integrated Midwives Association of 

the Philippines, and the llocos Regional Hospital. 

The "Health in Every Home" Program, in essence, aims to 

impart to people the neces.sary skills and knowledge they need 

"No report, no 

additional 

appropriation. 

No liquidation, 

no cash 

advances." To 

Improve serVice, 

the Board 

established a 

fast lane for 

hospital 

transactions In 

every hospital 

department. 

D E VOL UTI 0 N MAT T E R S 31

People are encouraged 

to take responsibility 

for their own health. 

For example, they are 

encouraged to grow 

plants for food and 

medicine. They learn 

that they can band 

together and form 

cooperatives and 

to diagnose and identify common ailments and do 

something about these. 

The program seeks to teach people to detect the presence 

of diseases before these can cause irreparable damage. The 

Board calls this "case finding instead of case waiting". Case 

finding is initially undertaken through the Barangay Health 

Census, after which the cases become part of the La Union 

Barangay Health Registry. The program aims to contain the 

spread of disease by identifying susceptible and sick 

household members and providing them with basic personal 

and medical information. These cases are then prioritized 

according to the necessity for and the kind of medical 

attention required. 

similar servlce-orlented 

All households are given basic health and medical knowl 

associations to solve edge corresponding to the health profile of their barangay to 

encourage personal health promotion and diagnosis at the 

common problems. 

household level. People are encouraged to take responsibility 

for their own health. For example, they are encouraged to grow 

plants for food and medicine. They learn that they can band together and 

form cooperatives and similar service-oriented associations to solve common 

problems. 

The rural midwives and 3,800 barangay health workers in the 

province's 576 barangays conducted a health survey which provided 

the baseline data for the design of the household education program. 

This health census revealed that of the 3,201 persons who died in La 

Union in 1992,only 22.9% were given medical attention and of the 394 

persons who died in the six devolved district hospitals, 225 or 76.51% 

died in less than 48 hours. The most common diseases were 

preventable ones. There were also a number of contagious diseases. A 

reduced incidence of degenerative diseases was noted. The top five 

causes of death were cerebro-vascular accidents, pneumonia, PTB, heart 

disease and cancer. Cancer cases brought to the hospital were in a fairly 

advanced stage. Such findings led to the training of midwives and 

barangay health workers in handling the principal causes of morbidity 

and mortality in their particular barangays. 

The health workers go to each and every household to educate people 

on health matters. For the year 1996, the program aims to teach a key 

member of every household how to approach and treat common preventable 

diseases in the person's own home and to recognize conditions where 

he or she will have to seek medical attention from outside the home. The 

person will learn how to take blood pressure with the use of a 

sphygmomanometer and how to measure pulse rate. He or she will also 

develop skills in the treatment of burns, dizziness and fainting spells, 

wounds and uncomplicated injuries. In addition to being taught how to 

prevent specific diseases, the person will be given such practical information 

as what foods to avoid to prevent hypertension and what to eat to 

prevent goiter. The Local Health Board believes that since the cost of hos- 


,

#. 

pitalization, care, and rehabilitation of patients is much 

higher than disease prevention, its goal is to promote health 

at the household level and contain disease where it begins. 

The preventive aspect of the program includes the,construction 

of potable water sources (shallow wells, deep wells 

and spring development) and sanitary toilets. Census findings 

showed that only 70% of the population had potable 

water supply. The LHB hoped to increase this figure to 81% 

but it exceeded its own goal and to date, 84% are assured of 

safe water, the largest such figure for a Region I province. 

Money for the potable water sources and sanitary 

toilets comes from the Local Health Board. A barangay or 

municipality may request for such a structure. The . 

request is validated by the Office of Provincial Planning 

and Development after the site has been inspected. As 

soon as the request is approved by the Board, the 

Provincial Engineering Office proceeds with the 

construction. 

The program's curative and rehabilitative aspects are 

not to be ignored. Projects on blood banking, harelip 

correction and cataract operations have been successfully 

implemented. 

The Local 

Health Board 

Initiated a ", 

blood banking' , 

program after 

a barangay 

census' 

showed that· 

many critical 

cases resulted 

In death 

because of 

Insufficient 

The Board initiated a blood banking program after a barangay 

census showed that many critical cases resulted in death because of 

insufficient blood supply. It promoted voluntary blood donation from 

30-50 walking blood donors in each barangay. The plan was for these 

donors to make themselves available when critical cases required blood 

transfusion. The donors' names, addresses and their blood types are 

required to be posted in visible places. Such a list may be found in 

barangay health stations, barangay halls, municipal halls and district 

hospitals, even in business establishments. Barangay residents who 

need blood are encouraged to locate these walking blood donors and 

bring them to the hospital for immediate blood transfer. 

blood supply. 

The Board wanted to extend the life span of donated blood by 

storing this in a refrigerator which costs P200 thousand. Money for the 

purchase was provided by Congressmen Ortega and Aspiras from their 

respective Countryside Development Funds while the Local Health 

Board allocated P150 thousand for the purchase of typing sera. The La 

Union Blood Center was put up by the provincial government to run the 

blood program. 

The barangay health census serves another purpose. Its 

documentation of harelip cases in the province caused suchcases to 

immediately receive reconstruction help. Plastic surgeons from Texas, 

USA called local officials to ask whether the province of La Union 

wanted to avail of their services. The Board instantly produced for them 


The Local Health 

the names, addresses and medical 

information on harelip cases, an 

average of 15 per municipality. The 

plastic surgeons from Texas decided 

to go to La Union soon after that 

call. 

With the help of the Rotary 

Club, cataract operations were also 

undertaken for the poorest of the 

poor in La Union, with the Club 

paying for the transportation 

expenses of the patient and a 

companion. 

The "Health in Every Home" 

Program has given the Board the 

vehicle by which it can improve the general health conditions of the 

province without limiting itself to the maintenance and support of 

hospitals. Partly because the Provincial Health Officer exercises general 

supervision over health officers in the different municipalities, and 

partly because of the unstinting support of the Provincial Government 

for the health boards at the municipal levels, mobilizing the entire health 

force of the province for the "Health in Every Home Program" has not 

been difficult. Since the health personnel are also mandated by the Local 

Government Code to support the programs of the DOH, it has been easy 

to convince them to be partners in the program. 

Board of La 

Union is 

confident that 

the health plan 

It has 

conceptualized 

and is currently 

implementing is 

one of the better 

organized 

programs in the 

country. 


Assuring quality health: the goal. 

The Local Health Board of La Union is confident that 

the health plans it has conceptualized and is currently 

implementing is one of the better organized programs in 

the country. The "Health in Every Home" program is not 

a piecemeal program. It is not targeted for a special 

disease or group. It means exactly what it says - that 

there should be health in every household in La Union. 

The agenda for a typical business meeting of the Local 

Health Board gives one a fair idea of the range of subjects 

with which it is concerned. For instance, its session on . 

September 4,1995 reviewed the update on the "Health in 

Every Home Monitor" which gives the latest statistics on 

the components of the program (number of potable water 

sources and sanitary toilets, the La Union Health Registry, 

hypertension prevention, voluntary blood donations, and 

a summary of appropriations and expenditures). 

The session took up a request of the Local 

Government Assistance and Monitoring Service (LGAMS) 

to document the LHB organization and accomplishments. 

It discussed ways to standardize procedures at the La

v 

, 

Union Blood Bank and thought out strategies for the recruitment of 

voluntary blood donors in different municipalities. It took up Sudipen 

Mayor Jose L. Macusi's request for assistance for goiter cases and 

malnourished patients in his municipality. It planned for the municipal 

launching of the "Health in Every Home" project and the turnover of the 

blood refrigerator by Congressman Ortega to the provincial government. 

Other matters discussed during this session was the Feeding 

Program for the second batch of beneficiaries of two towns, Bacnotan 

and Luna; and the purchase of materials for constructing an additional 

100 units of shallow wells. Sixty households in Barangay Ambangonan, 

Pugo would benefit from the construction of a water tank as 

recommended by the OPPDC. 

The Board fired off a memo to the different hospitals instructing 

them to provide preferential attention to barangay health workers 

seeking medical services. It also considered the request of La Union 

Medical Society President Dr. Fe Cayao-Lasam for the Board to assist in 

the purchase of a well pump for Sto. Rosario West where residents have 

to hike three kilometers just to fetch water. 

Indeed, the list of Board concerns is long but the energy level of members 

remains high. And politics does not get in the way of the work. Says 

Gov. Orros: "Health concerns in La Union are above partisan politics." 

Dr.Astom adds: "We work without remuneration." And why not? As 

representative of NGOs in the Board, he recognizes the results that partnership 

with the provincial government can yield. While the private sector 

may not make substantial financial contributions to the health programs, 

it lends its expertise in coordinating, organizing and networking, and sharing 

its technical proficiency in the medical field. 

It is a good thing that Gov. Orros 

does not believe in doing things by 

himself but in doing things with 

others. Guided by this philosophy, 

he has developed excellent rapport 

with NGOs by consulting with them 

at least once a month on problems 

he encounters. But while he seeks 

their advice, he is also clear on where 

the buck stops in La Union. He acknowledges 

that, as provincial 

administrator, he takes responsibility 

for the solution of problems. 

The Governor's philosophy of 

"doing things together" extends to 

Board operations. The Governor 

has asked Board members to act 

not only as his adviser on health 

D E VOL U .T ION MAT T E R S 35

It is a good 

matters but as his co-implementors. He believes that the 

special bodies provided for under the Local Government 

thing that Gov. Code were created precisely to assist the local government 

Orros does not executive in pursuing the policy of people empowerment. 

The people must be given the opportunity to take part in 

believe in doing local governance and this can be done, not just by thinking, 

things by but by doing. He tells the Board that by doing, by 

implementing, they get a quick grasp of what is happening 

himself but in 

and can react at once to events. 

doing things 

According to Gov. Orros, "good health cannot wait". 

with others. 

Health is crucial to people empowerment - people 

empowerment translates into sustainable development. 

That is why it was easy for him to choose a health program 

over the construction of barangay halls, auditoriums, or waiting sheds. 

Waiting sheds can wait, he says, but health cannot. When he explained 

to his constituents that he had to sacrifice these public works for hospital 

equipment and operations, they understood what he was trying to 

achieve. He in fact covered the deficit in the budget for devolution 

purposes with savings generated from the judicious use of supplies and 

materials and from leaving unimportant positions vacant. 

That Dr. Zarate represents the Sanggunian in the LHB has been no 

small matter. Without her, the Governor concedes, his work would have 

been more difficult. "Mas mahirap", he says. He also acknowledges the 

technical inputs to health programs provided by Board members who 

are all physicians. His concerns as an executive have thus become more 

focused. 

All told, without neglecting its role in the administration of hospitals 

and in providing corollary support through its selection, bids and other 

committees, the Local Health Board has done much more than what was 

expected of it. But it does not tire of thinking up ways to improve its 

work. For instance, the Board has already appropriated funds for the 

printing of a "Health in Every Home" Primer. All the knowledge that 

has been gathered in running a comprehensive program will now be in 

one manual that will give everyone information on basic health care and 

make them aware of health hazards in their respective barangays. Such 

a basic handbook for health technologies is only one of the many things 

for which every household in La Union can thank its Local Health 

Board. 0 


, 

..

, 

IROSIN, SORSOGON 

Classification 

Population 

No. of Barangays 

land area 

4lh 

37,887 

28 

158.8 sq. klns. 

THE PEOPLE 

Bicolano is the predominant dialect 

but because il is a gateway to the 

Visayas, their version is a unique 

mixture of vtsavan and Bicolano 

dialects. 

COMMERCE ANO INOUSTRY 

The fertile soil due 10 past volcanic 

eruptions and year round rainfall make 

Sorsogon a major producer of abaca. It 

is said the province produces the best 

hemp inall ofBlcol. Other crops widely 

grown are coconut and rice. 

The province also has a significant 

fishing industry as it is surrounded by 

rich fishing grounds. Raw materials 

abound lor cottage industries. Deposits 

of sulphur, kaolin, limestone and coal 

are largely untapped. 

ATown Helps Itself 

Amunicipality in the heart of Sorsogon, lrosin is the only inland 

town out of the 16 towns in the province. Irosinis bounded on 

the north by [uban, and on the south by Matnog and Sta. 

Magdalena. Facing it from the east is Bulan and from the west, 

Bulusan. It is the transit point to and from these opposite towns and is 

the gateway to the islands of Masbate and Samar. . 

The town ranks fifth in terms of population (37,887 in 1990) and 

seventh in termsof land area. Seventy-eight percent of Irosin's land 

area of 15,880 hectares is devoted to agriculture, while the remaining 

22% is made up of forest and water bodies. Due to its vast agricultural 

area, Irosin has the reputation of being the rice granary, citrus center and 

primary abaca producer of the province. 

In spite of its agricultural potential, Irosin has, for so long, suffered 

from poverty, neglect and helplessness. The town's wealth was 

concentrated in the hands of a few landowners and commercial 

entrepreneurs while the majority of the populace was mired in poverty. 

Health conditions were poor. Basic health services were inaccessible to 

majority of households, due to inadequate manpower and logistics as 

well as distance. There was high incidence of malnutrition and 

communicable but preventable diseases. Safe water supply was 

inadequate. Finally, there was low level of community participation in 

health concerns. There was exactly the order of things that would make 

up fertile ground for rural unrest. 

The communist insurgency was very much present. Indeed, in the 

late 80s, Irosin was placed on the nation's political map when NPA 

rebels laid siege to the municipal hall, the Presidcncia. 

Few professionals from Irosin opted to come back and serve their 

town. Among them was Dr. Eddie Dorotan. Exemplifying "service as its 

own reward", Dorotan served Irosin as Municipal Health Officer and 

Chief of the District Hospital. He now gives reality to his development 

vision after being elected mayor of the municipality in 1992. 

Evolving a Development Paradigm 

In Irosin, community participation in health concerns dates back to 

the 80s. Now it has provided the impetus for people's participation in 

other development endeavors like agrarian reform, livelihood 

promotion, cooperativism and environmental protection. 

o E VOL UTI 0 N MAT T E R S 37

Maximizing the 

opportunities for progress and 

social reform which the Local 

Government Code of 1991 

offers, the municipal 

government under Mayor 

Dorotan launched the 

Integrated Area Development 

Program (IADP) as its 

fundamental vehicle for 

development strategy. 

Founded on the three pillars of 

Livelihood Promotion, People 

Empowerment, and 

Improvement of Basic Services, 

. this integrated approach has 

addressed, with great success, 

the problem areas of poverty, 

people's powerlessness, and 

poor basic services. 

Health concerns became an 

immediate priority. Two 

months after the elections,in July 1992, Dorotan together with the NGOs 

and POs, launched the Irosin People's Health Program. Among the 

objectives of the program are: a) the establishment of links and a 

working relationship among the LGU, DOH, NGOs, POs and the 

communities to be able to deliver basic health services in a more 

effective, more equitable and sustainable way; b) testing and replication 

of appropriate health financing schemes; and c) strengthening of 

community health workers groups through federation building. The 

focus was on curbing the incidence of communicable diseases and 

malnutrition. 

Aware that agrarian reform is a must for rural development, the 

local government launched the Irosin Agrarian Reform Program in 

January 1993 "to emancipate Irosin's farmers from the bondage of the 

soil." Since the program started, 1,304 hectares of land were distributed 

to qualified farmer beneficiaries and 741 hectares out of the targetted 801 

hectares were converted from sharing to leasehold system. Nineteen 

agricultural cooperatives were organized, consolidated and reactivated. 

By using consultation and a win-win approach, the animosity between 

the farmers and landowners was effectively diffused. lrosin thus made 

a name for itself by being the first municipality to be declared an 

agrarian reform community. 

Spreading wide the process of empowerment, different sectors of 

the populace including people's organizations, non-government 

organizations and cooperatives were strengthened and linked up into 

networks. Irosin declared itself a peace zone and got rid of the gambling 

vice of jueteng. 


D 

,

• 

Multi-sectoral bodies were created to see to it that the strategies for 

local progress are working. Aside from those provided for in the 1991 

LGC, such as the Municipal Development Council, the Local Health 

Board and the Local School Board, there are also the Agrarian Reform 

Council and the Upland Development Council which are empowered to 

take a more direct part in local governance. Clearly, the mechanisms 

that enable the local government and the NGOs/POs to work together 

are in place. 

Using "NGO Technology" 

In barely three years after the IADP was launched, 

lrosin made the leap from a fifth-class to being a fourth class 

municipality. In 1995, lrosin won the coveted Asian 

Institute of Management's Galing-Pook Award for its 

innovations in the integrated area development approach. 

What was the key to Irosin's success? The fundamental 

principles of a community-based health program (CBHP) embodied 

in the lrosin People's Health Program, which are 

community participation, consultation and self-reliance, were 

adopted in providing solutions to other aspects of Irosin's development. 

As Mayor Dorotan puts it, "What we are doing 

here is basically an NGO planning technology, that of using 

the expertise of NGOs to influence local governance." The 

mayor and other local officials are confident that this "planning 

technology", perfected by Filipino pioneers of CBHPs in 

far-flung areas of the country, will bring Irosin far forward. 

During the public presentation of the Ateneo study on Irosin 

in which the town's planning process was compared to that of 

a promising municipality in Metro Manila whose mayor prac- 

As Mayor· 

Dorotan puts It, 

"What we are 

doing here Is 

basically an 

NGO planning 

-, 

technology, .that· 

of using the 

expertise of 

NGOs to 

tices a "benign strongman" style of leadership, a municipal councilor stood 

up and emphatically stated that in Irosin, it was a different case altogether. 

Even with these accomplishments, Mayor Dorotan finds there are 

problems with devolution. Although a staunch believer in local 

autonomy, he rues the fragmentation of municipalities into exclusive 

RHU domains. This, according to him, causes difficulties not only in the 

delivery of health services, but also in maximizing the use of public 

funds in the procurement of drugs and medicines. "Mas marami allgSOP 

("share of percentage," or grease money) Ilgayollg devolved Ila tayo." But 

Mayor Dorotan is quick to point out that "there is still a remedy for it." 

For example, following the initiative of the mayor of the neighboring 

town of Cubat, Mayor Dorotan, the mayor of Gubat and that of another 

town are now finalizing plans of coming out with a single list of 

accredited suppliers of drugs and medicines. In doing so, the 

municipalities are assured that they will get a more reliable, if not 

cheaper, supply of drugs and medicines. The municipalities will then 

be able to purchase cheaper drugs from reliable sources. 

Influence local 

governance... 


"\ 

Even after health services delivery was devolved, lrosin continued 

its close coordination with the Provincial Health Office, and this has 

worked for the municipality in a number of ways. Dr. Arturo Perdigon, 

the Provincial Health Officer, notes that the three municipalities in 

Sorsogon which are notable for their commitment to health (Sta. 

Magdalena, Gubat and (rosin) had maintained their links with the PHO. 

"They do consult us when they have problems concerning personnel, 

drugs and medicines, and the like. And we welcome this. We respond to 

their concerns (in a manner appropriate to) the Provincial Health 

Office's capabilities. Through constant (contact and discussion), we are 

able to know each other's capabilities and limitations." 

Sustaining the Process of Change 

There seems to be hope now for progress in lrosin. While poverty is 

still very much part of the landscape, unlike in the past, there now 

appear to be viable strategies to alleviate this problem - from equitable 

distribution of rural assets to agri-based industrialization and care for 

the environment. There are now local officials who have shown more 

responsibility. People empowerment is gaining ground and is replacing 

helplessness with dynamism and hope. 

The municipal government staff, composed mainly of young men 

and women, is energetic and enthusiastic about its work. Initiative and 

innovative "wild" ideas are welcomed here. Says Benjamin M. 

Gabionza, a young civil engineer who is the the Municipal Planning and 

Development Officer, "There is still much to be done, but we are happy 

serving Irosin. The people appreciate what we are doing." 

The achievements in the area of people's health continue 

to inspire, sustaining the process of development in what 

was once a "changeless land". Since the lrosin People's 

Health Program was implemented, various trainings were. 

conducted for all Barangay Health Workers (BHWs), 

midwives and nurses. These capability-building activities 

are also a factor in the dramatic increase in the number of 

population (50% as of last estimate) being served by health 

workers. For the past few years, there has been a dramatic 

decrease in the rate of schistosomiasis, diarrhea, parasitism 

and malnutrition. 

Aware that health is everyone's responsibility, households 

contribute to the local health fund by providing voluntary services 

(e.g.. helping in the construction of water and sanitation 

facilities), user-fees and pledges/donation from the income of 

cooperatives. Barangay Health Committees were formed composed 

of representatives of the barangay council, NGOs, P.O.s, 

cooperatives, RHU, CHWs, and BAWASAs (Barangay Water 

Associations) all of them having a direct part in the planning, 

implementation, monitoring and evaluation of health projects/ 

programs. 

The 

achievements 

In the area of 

people's health 

continues to 

Inspire, 

sustaining the 

process of 

development In 

what was once 

a "changeless 

land". 

D E VOL U.T ION MAT T E R 5 41

"The mayor has 

a good 

management 

tack, a good 

mix of vision 

and 

pragmatism. He 

believes In 

systematic 

planning and he 

Is results 

oriented. Most 

of all, he Is 

backed by 

NGOs." 

In both preventive and curative medicine, Irosin's 

accomplishments are every rural municipality's envy. In 

1995 alone, the municipal health office was able to install 

shallow wells in nine barangays; disinfected 52 of the 109 

water sources examined; examined/treated 10,000 people for 

various ailments; examined/treated 3351 TB symptomatic 

patients; immunized more than 19,000 persons with Oral 

Polio Vacine, anti-measles, Tetanus Toxoid and Vitamin A; 

rehabilitated 400 2nd and 3rd degree malnourished children, 

among others. 

Practicing self-reliance, Irosin now produces alternative 

supplementary foods for infants and pre-schoolers, known 

as MONRICO (mongo, rice and corn). Community Data 

Boards were set-up in all barangays so that the local 

populace would be able to keep track of their community's 

health condition. "It's the mayor's leadership, political will 

and the system that goes with it that generates the resources 

for health which Irosin needs" stresses Emma Frilles, a 

Public Health Nurse and the DOH Representative to the 

Local Health Board of Irosin. "The-mayor has a good 

management tack, a good mix of vision and pragmatism. He 

believes in systematic planning and he is results-oriented. 

Most of all, he is backed by NGOs." 

True enough, the resources for health generated by the mayor's 

innovative system of governance have earned for Irosin a number of 

distinctions, aside from those already mentioned, in the field of public 

health. It has consistently ranked No.1 among the towns in the 

province for immunization coverage and received an award for having 

the best family planning clinic in the province. It also placed first during 

the Regional Evaluation on Nutrition for 1995. CEBEMO, an agency 

based at the Netherlands that funds development projects, took notice of 

the innovations in Irosin and is presently preparing an assistance 

package for the municipality. 

Irosin is a fine example of people-empowered community 

development. With the will for change manifest among local elected 

officials and with the mechanism for people participation in place, Irosin 

seems to be on the road to progress. 0 


I 

•

" 

a 

NEGROS ORIENTAL 

Capital : Dumaguete City 

Area : 5,402 SQ. krn, 


Cities : Durnaguete, 

Bais, Canlaon 

No. oflown : 22 

THE PEOPLE 

Negros Oriental is culturally oriented 

towards Cebu: most ofthe people 

who inhabit the coastal lowns 

speak Cebuano. Other dialects spoken 

are Tagalog and 1I0nggo. 


Agriculture is the major activity of 

the people. The principal products 

grown are sugarcane. corn, coconut. 

and rice. The province has extensive 

marine resources, making fishing the 

main source of livelihood in the 

coastal areas. It also has cattle 

ranches and fish ponds. as well as a 

logging industry. Metallic minerals 

found in the province include gold, 

Silver, and copper. Among the popular 

cottage industries are woodceft. 

ceramics. shelleratt, and mat-weaving. 

Community Participation in 

Health Services Delivery 

"S weat 

is more binding than water mixed with cement." This 

remark from Gov. Emilio C. Macias of Negros Oriental sums up 

his appreciation of the fruit of his collaboration with the people 

of the province named the "Most Outstanding Province in 1994". 

Not that everything in his province's list of achievements was built with 

sand, gravel and lime, It is the infrastructure of development, and the 

sweat poured into the foundations that have made Negros Oriental 

what it is now: a progressive province with an unmistakable air of 

dignity and respect for its bounty. This year, the province again made 

waves when it was chosen for the Galing Pook Award by the Asian 

Institute of Management, thus prompting many people to ask, "What 

are they doing out there in hilly Negros Oriental?" Focusing on the key 

result areas and harnessing the goodwill of the people is what, the 

governor will tell you, 

People-powered innovations 

What has been Gov. Macias' winning formula? Owing to his 

background as a doctor and his knowledge of the relationship between 

health and development, Gov. Macias first put up safe water facilities in 

the mountain communities and pioneered the establishment of lO-bed 

Community Primary Hospitals in·these areas. Then, recognizing that 

human development in the hinterlands was sorely lacking due to the 

absence of any legislated high school, he built community high schools 

in the municipalities not far from his community hospitals. Next, he 

built roads interconnecting these municipalities to the highway. 

Realizing that "everything you do in the mountains eventually end up 

in the shore", he initiated watershed development by teaching the 

farmers contour farming and the importance of preserving the forested 

areas, All these initiatives were implemented and sustained with the 

active participation of the community. And, in all these, concern for the 

people's health provided the earliest lessons which the initiatives that 

followed built on. 

This case study focuses on the concept of Community Primary 

Hospital (CPH) which Gov. Macias started in 1988. 

Basis for innovation 

Prior to the establishment of the community primary hospitals, the 

province of Negros Oriental had a total of 10 hospitals (with only one 

added a few years later). Three of the hospitals are located in the capital 

city of Dumaguete, while the rest are in the outlying towns of Negros 


Oriental. Of the three 

hospitals in Dumaguete, two 

are privately-owned: the 

Silliman University Medical 

Center and the Holy Child 

Hospital. The Negros 

Oriental Provincial Hospital 

in Dumaguete, together wi th 

five district hospitals and 

one Medicare hospital in 

other areas form part of the 

government hospital 

network serving the whole 

province of Negros Oriental. 

All eight government 

hospitais were devolved to 

the Province of Negros 

Oriental in 1993. 

Of the 780 available 

hospital beds in the 

province, only ten are 

located in the hinterlands. As the hospitals' occupancy rate goes up to as 

high as 95 percent, the province falls conspicuously short of the World 

Health Organization-prescribed standard of one bed per 500 

population. 

Before the CPH concept was implemented, the province had a 

crude birth rate of 18.18 per 1000 people, while its crude death rate was 

3.42 per 1000 people, considered the highest in the region. The maternal 

mortality rate was ten per 1000 live births. The leadingcauses of 

morbidity and mortality were communicable and infectious diseases, 

like broncho-pneumonia and pulmonary tuberculosis, which are 

preventable. 

To complete the picture, the distance, difficult terrain, and poor road 

conditions, especially during the rainy months, make it next to 

impossible for the people to avail of hospital services in the poblacion. 

The Community Primary Hospitals 

Up to the late 80s, the countryside of Negros Oriental was torn apart 

by the NPA movement. The rebellion took much of its energy from 

neighboring Negros Occidental where the circumstances behind the 

collapse of the sugar industry provided argument for the supposed 

correctness of armed struggle. Health, refusing to be a fatality in the 

skirmishes, found an advocate in the person of the newly-elected 

governor. 

The shortage of hospital beds, the concentration of a greater 

proportion of the population in the mountain areas and the isolation of 


I

these areas from the cities and from among themselves prompted Macias 

to implement an idea he toyed with after he got elected as governor of 

the province. This was the idea of having Community Primary 

Hospitals in the mountains, serving not only as centers for primary 

hospital services in far-flung and isolated areas but also for 

comprehensive primary health care, giving attention to the control of 

diarrheal diseases and the expanded program on immunization. 

The concept was that of a lO-bed hospital of modest structure made 

of wood and nipa, but which can withstand the elements in a mountain 

area. More striking than the structure, however, was the mechanism by 

which the hospital would be managed and sustained by the community 

through an innovation called Community Hospital Board. After the 

community organizing component of the project had been handled 

successfully by Silliman University's Extension Service, the first 

Community Primary Hospital was established in 1988 in Kalumboyan, a 

mountain barangay at the center of the town of Bayawan, located 123 

kilometers from Dumaguete. 

Just what precisely Is the CPH for? 

First, explains Macias, "What you need in those mountain areas are 

primary hospitals where they can do primary hospital care as well as 

primary health care. Now kung hindi rna nakaya, pababain rna na sadistricta 

sa provincial hospital." 

"In fact, you don't need a doctor to administer primary health care. 

But we assigned a doctor there so the care would even be a little better. 

Now, we can do some kind of operation. Maka-tuli ang isadivan a incision 

. , . he can do that. Youdon't need a permanent structure or a doctor to 

give primary hospital care and primary health care." However, with 

presence of able doctors, the services offered by the CPH now include 

ones that are within the domain of secondary hospitals. 

Explains Macias, "Our CPH 

has become our first line of 

defense in our structure of hospitals. 

The district hospitals should 

be able to do operations below the 

navel: ectopic pregnancy; cesarean 

section, appendectomy .. whatever 

is involved in the opening of 

the abdomen and organs below. 

So from the primary, you have district 

hospitals that are secondary. 

Then we have the tertiary hospital 

which is our provincial 

hospital. There are times, though, 

when the CPHs render secondary 

hospital services, depending on 

the ability of the doctors." 


.\ 

• 

• 

rely mainly on rice and corn farming 

for their livelihood. Others 

raise poultry and livestock, while 

some operate 'habal-haba!', a motorcycle 

that can sit up to five 

passengers. In 1988, the average 

per capita income of the area was 

P816 per annum. 

The leading causes of morbidity 

are diarrhea, upper 

respiratory tract infection, intestinal 

parasitism, PTB, wounds and 

bronchitis, among others. The 

leading causes of mortality are 

broncho-pneumonia, PTB, stab 

and gunshot wounds, bleeding 

peptic ulcer, gastroenteritis and 

septicemia. 

Implementation phase 

The 20% development fund at the discretion of the governor 

provided the P350,000.00 needed to construct the community primary 

hospital. After talking with the local government leaders concerned, the 

community organizers were dispatched to Kalumboyan and the rest of 

the identified catchment areas to lay the groundwork for the community 

primary hospital, that is to conduct social investigation (51), baseline 

surveys and analysis and, most of all, ensure community support for the 

project. After the Barangay Council of Kalumboyan donated, through a 

resolution, two hectares of land for the establishment of the primary 

hospital, the construction started. 

The spirit of volunteerism came to life, as the residents of Bayawan 

rendered their share for its construction. "Instead of paying them the 

minimum wage, we paid them half. For they knew that the structure 

they were constructing was theirs.", says the governor. Recognizing that 

the process of empowerment will not be complete without helping the 

people find means to improve their lives, income-generating projects 

(lGPs) were set up, through the initiative of Silliman University, like the 

setting up in government land of market stalls in the poblacion where 

people can trade their produce and a Cooperative Corn Mill. Silliman 

only requires that it be paid back the capital used in the construction of 

the stalls, under an installment payment plan. Ten percent of the profit 

from these stalls and percentages from the corn mill are used to maintain 

the CPH. The community development expertise and funding assistance 

extended by Silliman University complements the meager resources of 

the provincial government earmarked for implementing the project. 

The hospital building has two (2) five-bed wards, one each for male 

and female patients, a doctor's office and quarters, an emergency/ 


treatment room, an operating/delivery room, 

two comfort rooms for male and female users 

and separate toilet and bathrooms for the 

doctors' and nurses' quarters. Except for the 

divider which separates the doctors' and 

nurses' quarters, all the walls are made from 

wood and nipa. Outside the building is the 

ambulance garage, a communal kitchen and 

comfort room, 3 small nipa huts which serve as 

sleeping quarters for relatives of patients and a 

herbal and vegetable garden in the backyard. 

Having water-sealed toilets in the (PH, as 

pointed out by Macias, teaches the mountain 

folks to observe proper hygiene in their own 

households. Electricity is provided through a 

solar panel at the rooftop of the building. 

After putting in the beds, the governor 

went on to scout for two doctors to man the (PH. "At that time, it was 

difficult to get doctors to go to the mountains and expose themselves to 

the dangers of the NPA. But there were some who accepted the 

challenge. I went to Cebu and told them that I am in need of doctors, 

even those who have not yet passed the board. I'll pay them. All I need 

of them is to try it out for six months. So I sent them there in the 

mountains, dalatoa silo. We pay them PI,OOO more than we are paying 

our doctors in the provincial hospital. Then I tell them that they don't 

have to work the whole week, that they can arrange for a 3 1/2 days 

work so that they can go down to the city for the rest of the week, for 

R&Rand also to visit the District Hospital in the catchment to report 

what they need up there." 

"In other words, we are trying to make going there an incentive. 

Besides, I tell them that sometime in your life you are asked to accept a 

challenge. Pumupunia aka sa bundok and I also get scared. Luckily, 

physicians were never a target of NPAs." 

Asked what it feels to work at the Kalumboyan (PH, Dr. Alexis 

Garabato, who is a native of Bayawan, was all smiles when he 

answered, "It's a good feeling to know that I can make a difference in 

the lives of the people here. It is challenging." At 36, the doctor with a 

boyish grin has been serving in Kalurnboyan for more than four years 

now. 

Aside from the two doctors, a complement made up of one hospital 

nurse, a rural health midwife, an ambulance driver and two utility 

workers man the hospital. Nine barangay health workers also work in 

rotation in Kalumboyan and the nearby areas. Does the (PH replace the 

Rural Health Unit? No, the (PH exists in partnership with the RHUs, 

concentrating more on the hinterlands and serving barangays in more 

than one RHU catchment area. Thus, with the (PH, there exists an 

actual opportunity for territorial integration in spite of the 

fragmentation caused by devolution. 


I 

• 

•

• 

• 

The CPH serves an average of 8 to 10 patients daily, mostly cases of 

ARt gastro-enteritis and pneumonia. There are also numerous typhoid 

cases as many residents in other catchment barangays still get their 

drinking water from open-dug wells. 

A native of Kalumboyan, Nita Lojera finds the Community Primary 

Hospital very useful. "Mammi IW dill allg Ilaipallgallak at ginamot diuan sa 

ospita/. KUllg wala iyall, paallo Ilamall kami dito." 

Operation and maintenance 

The CPH has no regular budget. except that which is given by the 

province for the salary of the doctors and the nurse. The budget 

shortfall is made up for by the goodwill of the people. 

The provincial government pays the salary of the two doctors (who 

receive a basic monthly pay of 1'8,845 each) and the nurse stationed at 

the CPH. The public health midwife, on the other hand, is taken care of 

by the DOH, and the services of the utility workers and ambulance 

driver are paid from the income of the CPH and from the donation of 

. the barangay council of Kalumboyan, respectively. Some of the drugs 

and medicines at the CPH also come from the provincial government. 

The CPH generates income from donations from individuals and sociocivic 

organizations, pledges from households, the catchment barangays 

and their officials and from associations of teachers, farmers and stall 

owners. In 1995, for example, the balance from donations to the 

Kalumboyan CPH stood at 1'20,000. This amount comes from: 10% of the 

yearly income of the market stall owners donated to the CPH; monthly 

contribution of 1'2.00 from each household in Kalumboyan; monthly contribution 

of 1'200 from the association of teachers; monthly contribution of 

1'100 from the major religious groups; monthly donation of 1'500 from the 

Barangay Council of Kal umboyan; 

monthly income of 1'800 

from donation of patients and fee 

charges whenever applicable. 

Examples of these fees are: 1'5.00 

for wound dressing, 1'50 for minor 

surgery, 1'100 for 

circumcision, 1'150 for delivery, 

P5.00/day for ward room and 

1'30.00 a day for a private room. 

Starting 1995, the amount of 

1'22,000is expected to come from 

the pledge of the catchment 

barangays to give 1.5.% of their 

individual IRA 1995 to the CPH. 

This decision was arrived at in a 

meeting of the Association of 

Barangay Captains (ABC). 

D E V a L UTI a N MAT T E R S 49

The CPH's modest 

structure also houses a 

pharmacy where the 

inventory of essential drugs 

like antibiotics, drugs for deworming, 

TB drugs and IV 

fluids are enough to last until 

the next procurement. 

Sustainability also depends 

on the people's appreciation 

of the importance of 

replenishing the drugs and 

medicines used in their 

treatment. 

How the CPH is managed 

The Community Primary 

Hospital is managed by a 

Development Board. The 

barangay captain of the 

barangay where the CPH is 

located chairs the board, while the Chief of the CPH (who is one of the 

doctors) serves as the vice-chairman. All the other barangay captains in 

the catchment area automatically serve as board members, together with 

the DECS representative, the Sangguniang Kabataan Chairman and a 

representative of the religious organizations. The board designates a 

treasurer to take care of the funds for the CPH and an Auditor to 

monitor disbursements. The Board prepares and approves an annual 

report, on which an annual procurement plan is based. 

During·the monthly meetings of the Board, matters related to 

hospital operations and maintenance like the purchase of drugs and 

medicines, fund drive, the repair of ambulance, or a new roofing for the 

hospital are discussed and decided upon and the decision is stated as a 

board resolution. The organization of support structures for the 

hospital and conduct of training for livelihood programs in the area are 

also matters close to the heart of the board members. The agenda for 

the meeting is sent to members days in advance, together with the 

minutes of the previous meeting. The Chief of Hospital recommends 

what drugs and medicines will be purchased and in what quantities. 

His recommendations are sent to the Board for approval. One can well 

see, therefore, that the interests of the community are well represented 

by the Board which manages and sustains the CPH. 

Significance of the CPH concept 

With the viability of the CPH shown in Kalurnboyan, a second 

community primary hospital was established in Barangay Amio in the 

town of Sta. Catalina. This was followed by two more in the south: 

Nabilog in Tayasan and Pacuan in La Libertad. Thus, there are now 


• 

•

"Instead of 

me alone 

managing all 

these 

hospitals, I 

further 

decentralized 

them (with the 

creation of 

hospital 

boards). With 

/' 

Devolution, Hospitals and the Community Hospital Board 

Drawing from the success of its Community Primary 

Hospital concept, the province of Negros Oriental has 

adopted a similar management mechanism for its provincial 

hospital and five district hospitals, The governor has issued 

an executive order creating a board for each of these 

hospitals. He chairs the board of the provincial hospital, 

while the 5angguniang Panlalawigan member assigned to 

the district chairs the board of the district hospitals. As in 

the case of the community primary hospitals, the chief of 

hospital serves as the vice-chairman. The members of the 

board include representatives from the NGOs, the private 

sector, religious organizations and socio-civic organizations. 

The mayors of the catchment municipalities also sit as board 

members of the district hospitals. 

devolution, our This organizational set-up seems to have generated as 

much goodwill as the CPHs. For instance, the city of 

hospitals even Dumaguete which, in the past, had not given a single 

improved." centavo for the operation of the provincial hospital (even 

though 45% of the in-patients and 55% of the out-patients are 

from the city) now gives a portion of its income to the 

hospital. Last year, the city of Bais gave P5 million for the expansion of 

the 25-bed district hospital into a 50-bed hospital. Pledges and 

donations from NGOs have also started to come in. As pointed out by 

Macias, "Instead of me alone managing all these hospitals, I further 

decentralized them (with the creation of hospital boards). With 

devolution, our hospitals even improved. This is one thing that 

devolution has done. Our provincial hospital earned P6 million last year 

while most provinces seek for augmentation, among others, for the 

operation and maintenance of their provincial hospitals." 

With decentralization of responsibilities has come decentralization 

of finances. Governor Macias explains: "These hospitals were earning 

even before (devolution), but none of these earnings went to the 

hospital. Everything went to the General Fund, to the National Treasury. 

With devolution, all their earnings now go to the province's General 

Fund. So I tell them, you earn it, you keep it, and you be the one to plan 

how to spend it. So there's autonomy, and yet there is a system of 

checks and balances as the 5.P. member sits in the Board. Whatever the 

hospital earns is kept in a trust fund and it is up to the discretion of the 

board how the money should be spent." 0 


•

PMCC is tasked to supervise the program and provide technical 

assistance to the local government unit. The government of Sampaloc, 

on the other hand, is charged with membership recruitment, collection 

and remittance of contributions, and information dissemination. The 

local government unit. providing a 1'10,000 seed fund, also undertakes 

to provide adequate manpower and other requirements to set in place 

the administrative infrastructure. The actual servicing of beneficiaries 

started January 1994. 

How the Program works 

Medicare Program II in Sampaloc is a simple operation. 

Membership is purely voluntary. The payment of premiums is the sole 

responsibility of the member. Unlike in other LGUs, there is no 

counterpart funding on the part of the local government. 

If members 

decide to avail 

of the services 

·of private 

hospitals, they 

may claim 

reimbursements 

from the 

program for 

costs Incurred. 

There are two policy plans, A and B, to provide some 

flexibility. A member pays P180.GO annual premium for Plan 

A or P120.00 for Plan B. Barangay health workers and 

municipal employees take care of recruiting members. 

Three hospitals service Sampaloc Program II members: 

the Sampaloc Medicare Hospital, the Quezon Memorial 

Hospital in Lucena, and the Unisan Medicare Hospital. If 

members decide to avail of the services of private hospitals, 

they may claim reimbursements from the program for costs 

incurred. 

Members enrolled are required to pay the total amount 

of premium to the system. If a member is unable to pay the 

total amount at once, deferred or staggered payments may 

be arranged. Barangay officials may collect premium 

payments which they can then turn over to the Municipal 

Treasurer. 

Benefits cover out-patient and in-patient services. The out-patient 

services are the same for both plans: consultations are free while 

laboratory fees are discounted. 

The in-patient benefits vary between the two plans, though both 

entitle members to 20-day free hospitalization. Medical benefits for 

common ailments amount to P600 for Plan A and P400 for Plan B. For 

serious illnesses, Plan A allows for benefits amounting to 1'1,000; for 

Plan B, 1'800. 

The benefits of Medicare I'll have a far-reaching and long-term 

impact on the general health status of the population and in instituting 

reforms in health care delivery systems. Program II has had a dramatic 

impact on the health status of the people of Sampaloc, especially since 

most of the people are poor and cannot afford to pay for medical 

services. A big percentage of the population belongs to the informally 


• 

•

• 

• 

employed sector and do not have steady sources of income. The 

insurance scheme allows them to set aside a small sum for sudden 

illnesses whose actual costs may be too much for on indigent citizen to 

assume. 

Since the health services are free, a member immediately seeks 

attention for his medical problems. This eliminates the widespread 

practice among the poor of delaying treatment when they are sick, 

hoping their illness will go away. Unfortunately, what frequently 

happens is that they end up getting even sicker, and their expenses may 

come up to staggering amounts. 

The program specifically answers the 

needs of indigents who can seek immediate 

medical assistance and avail of medicines 

they need. They no longer have to run for 

help and feel indebted to local officials. 

In Sampaloc fewer people now avail of 

the charity program of the DSWD, the"Bigay 

Kalingt:" or the"Aid to Individual Crisis Situations". 

The funds used for these programs 

are provided by the local government and 

therefore this translates into more savings for 

the municipality. 

More funds for the LGU 

With members' contributions now covering 

the cost of direct health services, the 

municipality is relieved from shouldering the 

direct costs of medical services for the indigent 

patient in the form of subsidy for the-hospitals 

that cater to them. This cost is now 

borne by the insurance fund. 

As the social insurance brings about general 

improvement of health among the 

population, the municipal government is in 

a better position to allocate more resources 

for public health concerns and innovative 

prevention measures that will complement 

the clinical and direct approach of the insurance 

program. 

In the light of devolution and the fiscal 

constraints of the municipalities, the local 

health insurance aids the local government 

unit overcome health costs. 

Hospitals are relieved from charity 

D E V a L UTI a N MAT T E R S 57

The life and 

sustainability of any 

social insurance 

program depends on 

the number of 

members enrolled. 

cases as the indigents can now pay for their services through 

insurance. This means more business and growth for 

hospitals which allow them to apply for reclassification of 

status from accrediting associations. Now that the 

Sampaloc Medicare Hospital is catering to more patients, it 

can now ask for an upgrading of its accreditation status. The 

savings could also mean more funds for better equipment 

and upgraded manpower resources. 

All things being 

equal. the more 

Recruitment and renewal 

The life and sustainability of any social insurance 

members. the program depends on the number of members enrolled. All 

better. things being equal, the more members, the better. For the 

Sampaloc Program, the PMCC prescribed a minimum 

membership base of 700 for it to become sustainable. 

Current membership is barely past this minimum 

requirement and represents less than 8 per cent of the total population. 

This means much still needs to be done in the area of recruitment. 

When the prc;gram was launched, the Senior Citizens' Group, which 

has a sizeable membership took an active part in the program promotion 

and active recruitment. Membership in the program was encouraged 

among their members. The Quezon Women's League is just as actively 

involved in promoting the program. QWL Chairperson Councilor 

Gladys Nantes says the organization has even set up a fund that would 

lend/grant money to its women members for premium payment. 

The Farmers' Association of Sampaloc has adopted the "turnuhan" 

scheme to help them pay their premiums. The "trmlUhan" involves an 

arrangement where a group of persons regularly pools its money and 

gives a certain percentage of this to a certain person at a chosen time. 

The purok leaders are also constantly being prodded to increase 

recruitment for the insurance program in their areas. Purok tally boards 

monitor the recruitment campaign. The number of those enrolled in the 

purok are indicated on the boards. Likewise, in the Activities Center of 

the municipality, a listing of all enrolled citizens are posted in blue, 

while those not enrolled are posted in red. 

The Mayor gives barangay and municipal officials a monthly quota 

of recruits. For instance, a councilor is required to enroll at least five 

new members every month. And the Mayor is very serious in imposing 

the quotas. She likewise makes it a point to attend local barangay or 

purok meetings to announce the benefits of enrollment. The Mayor sets 

aside P20.00 of her monthly salary to a "tl/rIll/llan" system to help those 

who.cannot afford to pay the premiums. 

The local DSWD office likewise helps in expanding membership. It 

has put in money to grant 100% subsidy for indigent citizens. Although 

it has only served 7 citizens, this is viewed as a start of something bigger. • 

58 D E v a L UTI a N MAT T E R S 

• 

•

• 

The non-renewal of membership, says Medicare Program 

Coordinator Aurea Catchuela, is prevalent among members who have 

not availed of the benefits in the previous year of membership. They 

decide to take the chance that they won't fall sick during the coming 

year and don't pay the premium. 

Many of them will be frustrated, says Catchuela, because they will 

not want to pay their premiums when they get sick in the hope that they 

can be accommodated in the program. Of course, they will not be 

allowed then to claim benefits. 

Ms. Catchuelasees this problem beyond the question of mere 

economics. There are some values that need to be inculcated among the 

members. Those who did not avail of the benefits should be taught to 

view their payment as help to others and not treat what happened 

merely as a "failed bet". Fortunately, this attitude is not so prevalent. 

A more intensive information drive may be necessary to help the people 

of Sampaloc better appreciate the value of a social health insurance 

program. Many residents, including those who have signed upas members, 

do not yet fully understand the mechanics of the program. The rules 

and regulations need to be explained. Knowing what health insurance is 

all about has a lot of bearing on the enrollment, renewal and the general 

attitude of the population to the program. 

For all the difficulties that Sampaloc is experiencing as far as local 

health insurance is concerned, it is a model worth emulating and one 

other LGUs can learn from. Sampaloc is the only municipality able to 

maintain an increasing number in members, albeit slowly, through 

creative recruitment approaches. In other municipalities in Quezon, 

membership dropped as fast as they were able to recruit. Moreover, it 

shows how valuable community participation and a determined 

leadership is in the establishment of a local health insurance scheme. 

Sampaloc is not a pioneer in health insurance but its experience 

represents a treasure chest of lessons from which other LGUs and local 

officials can learn. 0 


QUEZON 

Capital 

Area 

Population 

Cities 

No. ofTown 

Lucena City 

11.946.3 sq km 

1,372.000 

lucena 

40 

THE PEOPU: 

The inhabitants are mostly 

Iagalogs. The population isconcentrated 

in the flat south-central portion 

which includes Lucena. Sariaya, 

and Candelaria. Mer World War II. 

the Infanta area received migrants 

from Manila, Laguna, and Batangas. 

People from Bicol and Marfnduque 

moved to the southern part of the 

Tayabas Isthmus and the Bondoc 

Peninsula. 


Quezon is the country's leading 

coconut producer. Other major crops 

are rice. corn. banana. and coffee. 

Although the province has vast forest 

lands, timber and other forest 

products are now available only in 

very small quantities. 

Fishing isa year-round activity because 

of rich fishing grounds. especially 

in the many bays. 

Accessing Provincial Trust 

Funds for Devolved Hospitals 

Three years into the devolution process, the transition problems still 

plague local government units (LGUs). These problems cover a 

wide range including hospitals' financial difficulties, lack of drugs 

and medicines, unpaid benefits of health workers and the 

perceived deterioration in delivery of health services continue to plague 

local government units, The Department of Health (DOH) continues to 

facilitate direct intervention in addressing issues through executive 

action (e.g. EO 215, AO 170) and to provide technical assistance to LGUs 

but it can only accomplish so much. 

While local officials are slowly adapting to their new roles as health 

managers, their experiences provide one with a rich source of material 

for identifying effective mechanisms that can be replicated in LGUs 

which have not been as successful. Several LGUs, among them the 

province of Quezon, have made successful innovations in areas such as 

Local Health Board operations, hospital operations management, fiscal 

management and primary health care programs. Only a few months 

after health services were devolved in 1993, local health officials, 

members of the Sanggunian and the provincial governor had already 

instituted major health reforms through the passage of resolutions. One 

such innovation - accessing provincial trust funds for devolved 

hospitals-is documented in this paper. 

Hospital Operations Under Devolution 

The problems of many devolved hospitals have been attributed to 

disparities in the distribution of IRA shares among LGUs who absorb 

the burden of devolution. Both provinces and cities receive a 23% share 

from the total IRA. However, when the cost of devolution (the 

minimum fund requirement LGUs have to shell out to operate devolved 

facilities and personnel) is considered, provinces have to shoulder 58% 

of this burden while cities take on only 2.4% of the cost. This means 

that, on the average, provinces have to budget 30% of their total IRA 

income to fund devolved hospitals and the salaries of its health 

personnel while cities need to provide only 2% of its health budget. For 

hospitals, the financial difficulty of the provinces translates to slashed 

operating budgets, unavailable funds for health workers benefits and 

allowances, lack of local investments for upgrading and procurement of 

equipment, and lack of drugs and medicines. 

Bureaucratic red tape also constrains the operations of devolved hospitals 

which are subject to rules and regulations prescribed for all offices 

and departments in the local government unit. For a facility that depends 


• 

•

• 

relies on prompt delivery of drugs, 

medicines, and supplies to enable it to 

do its job well, a long process of procurement 

and fund release can be a 

nightmare. Consider this: a purchase 

request has to go through at least 14 

offices, with a minimum of three to four 

signatures required in every office. 

Hence, it is not surprising that it usually 

takes six weeks before requested 

supplies can be delivered. But emergency 

cases cannot wait and, more 

often than not, patients are made to buy 

their own medicines and supplies before 

any procedure, surgical or 

otherwise, can be done. 

Before devolution, hospitals had more control over their budgets. 

Funds were then directly released from the Department of Budget and 

Management. Fund utilization required a minimum of paperwork and 

most of the approving officials were within the hospital. Thus drugs 

and medicines were always available and when procurement was . 

necessary, these could be delivered without delay. Also, hospitals had 

their own trust accounts. Receipts from sales of drugs and medicines 

and professional fees of attending physicians remitted to these accounts 

could be used to replenish supplies. 

Trust funds under the Local Government Code 

The Local Government Code of 1991 allows LGUs to maintain two 

special funds to cover specific purposes: the Special Education Fund 

and the Trust Funds. Trust funds consist of private and public monies 

which have officially come into the possession of the local government 

or of a local government official as trustee, agent or administrator. It 

may also consist of funds received as a guaranty for the fulfillment of an 

obligation. Trust funds are used for specific purposes for which they are 

created or for which it came into the possession of the local government 

unit. An example of this are augmentation funds from the Department 

of Health to cover benefits and allowances of health workers. 

Before devolution, hospitals were authorized by the DOH to set up 

their own trust funds to which receipts from sales of drugs and 

medicines in the hospital pharmacies, sub-allotments from DOH 

Regional Offices and funds from other funding agencies are remitted. 

After devolution, most LGUs have not allowed hospitals to maintain 

trust funds to which they may remit income from their operations. 

Instead, hospitals are required to remit all receipts or incomes derived 

from the operation and provision of services in the facility to the 

Provincial Treasury where these funds become part of the General Fund. 

Once remitted to the General Fund, there is no certainty that such funds 

will be reinfused into the hospitals. 


This means that hospitals which depend • 

entirely on their regular appropriations are at the 

mercy of the local government units and how it 

allocates its available funds. Hospitals' approved • 

budgets do not usually reflect the actual needs of 

the facility. And even if they do, funds may be 

delayed or reallocated because of changing 

priorities. Under such a system, hospitals are not 

motivated to generate revenues or to cut costs since 

the income they derive from these innovations are 

remitted to the Treasury. 

When devolution came into being, the province 

of Quezon already had 169 health personnel under 

the supervision of the provincial government. It absorbed 

an additional 813 personnel from the Provincial Health Office and 

over 16 hospitals. Since then the Province has had total supervision over 

all health activities and programs in the province. 

Quezon province got a windfall in 1993 from the large increase in its 

IRA share, compared to the previous year. This incremental IRA was 

meant to cover the costs of devolution like salaries and benefits of 

devolved personnel and the operating expenses of devolved facilities. 

The province experienced financial difficulties when it assumed the cost 

of the devolved functions which is equivalent to P 68.7 M or roughly 30% 

of its total IRA in 1993. Despite additional IRA increases in 1994 and 

1995 the Department of Budget and Management has classified the 

province as one of those most in need of financial assistance as indicated 

by its Devolution Financing Burden (DFB Ratio) of 1.555. 

In 1995, the Province had a total budget of P 326.6 million. Out of this 

amount P93 million or 28% was appropriated for health. Of the P93 

million, P 77 million was appropriated for Personnel Services while P16 

million was earmarked for MOOE. 

Use of Trust Funds for a Revolving Fund System 

It is not an easy or a simple thing for a hospital to set up its own trust 

funds under the existing rules and regulations in the Local Government 

Code. It would have to set up the administrative requirements needed to 

implement such a system as well as gain authority to open separate 

books of accounts to record transactions - a procedure not allowed 

under the Local Government Code. Under the current set-up therefore, 

the only Trust Fund account that can be accessed by hospitals is the 

Provincial Trust Fund. 

The province of Quezon's innovation lies in its effort to include 

hospitals in the Provincial Trust Fund account. Under this system, it 

allows hospitals to remit to the Provincial Trust Fund income from 

medical and operating room supplies, x-ray, laboratory, ambulanceand 

other kinds of fees which would otherwise have to be remitted to the 


•

Table 2. 1995 Budget Appropriations for MOOE 

Quezon Memorial Hospital 

ITEM 

1.2 Maint. & Other Operating Expenses 

Traveling expenses 

Communication expenses 

Repair & Maint. of gov't facilities 

Repair & Maint. of govt vehicles 

Transportation services 

Supplies and materials 

Water, illumination & Power Services 

Retirement gratuity 

Property insurance 

Other services 

TOTAL MOOE 

AMOUNT 

200.000 

120.000 

200.000 

350.000 

12.000 

5.410.742 

1.020.000 

98.630 

78.335 

445.680 

7,935,387 

mentioned earlier, the Trust Fund account 

from the remittance of receipts from drugs 

and medicines are easily depleted. The 

allocations in the hospitals' regular allotments 

supplement the funds derived from the Trust 

Account. This arrangement assures that there 

are always available drugs and medicines sold 

in the hospital pharmacy. 

When the budget is being prepared, items 

expected to be covered by the trust funds are 

not included in the Work and Financial Plan. 

These, however, are included in the Annual 

Procurement Plan (APP) to comply with the 

LGC requirement that all procurements of 

supplies and materials be included in the API'. 

The QMH Hospital Cashiering System 

One of the support systems that has been 

helpful in accounting and classifying hospital receipts is the Hospital 

Cashiering System. This module is part of HAMlS' Information System 

for Hospitals being piloted in Quezon Memorial Hospital. It has been in 

operation since late 1994 and its use has been expanded to all hospitals 

within the province. 

The QMH cashiering system greatly facilitates the recording of 

QMH's daily transactions. All receipts are categorized according to fees 

classification and daily or monthly totals of fees per classification are 

generated. All fees and charges remitted to the Provincial Trust Fund 

are segregated from those to be remitted to the Trust Fund. Supporting 

papers which include the individual patient collection and receipt 

number are attached to the report to comply with COA regulations. The 

collection and the report generated by the system is then submitted to 

the Provincial Accountant's Office where they are remitted to their 

respective fund accounts. 

The system allows proper monitoring and evaluation of the sources 

of income over time. The PHO expects to improve the system to include 

modules on billing and inventory management, 

Trust Fund Utilization Processing 

Basically, the procurement processes involved in the utilization of 

monies in the Trust Fund are the same as when the funding source 

comes from the General Fund. The fund where payments are charged 

are identified in the Purchase Requests of the Hospitals concerned and 

recorded by the Provincial Accountant in the fund category - General or 

Trust Fund. When the remittance is entered in the Trust Fund it is 

recorded in the respective hospital's account and in the items where the 

corresponding fee were collected. Since funds are earmarked for specific 


• 

'. 

•

purposes - mainly drugs, medicines and medical supplies - and are not 

included in the Hospital's Work and Financial Plan, the purchase request 

does not have to pass through the Budget Office. 

Trust funds can be used for equipment purchases with the approval 

of the Sanggunian. All that needs to be done is for the Provincial Health 

Officer or the Head of Hospital to initiate the request and to identify the 

source item in the hospital remittance against which the fund outlay can 

be charged. The Sanggunian Chairman for Health, a member of the 

Local Health Board, then sponsors the resolution covering the request. 

With the Sanggunian approval the same procedures in the procurement 

process are observed. The following steps outline the procurement 

process using trust funds: 

• A Purchase Request (PR) is prepared and signed by the PHO or 

Hospital Head. It is then coursed through the offices of the provincial 

accountant, the provincial treasurer and the provincial governor, which 

approves the request. The approved purchase request is then submitted 

to the General Services Office. 

• Once the purchase request is approved, the General Services 

Office can call for bids. The bids and awards committee is convened and 

the winning bidder is identified. An abstract of bids is then prepared 

and signed by members of the committee. When an exclusive 

manufacturer is identified by the PHO/hospital the bidding process is 

omitted and the purchase order is prepared. 

• Now comes the payment processing stage. The PHO prepares 

the Disbursement Vouchers and certifies to the necessity of the items 

being requested. The Provincial Accountant attests as to the availability 

of funds. The Treasurer prepares the funding checks charged to the 

Trust Fund. The Governor signs the disbursement vouchers and the 

funding checks. Funding checks are released by the Cashier's Office 

Impact of the Instituted Reforms 

The most evident impact of hospitals' 

ability to access funds in the 

Province's Trust Account and the institution 

of a revolving fund system is the 

acquisition of new equipment - an xray 

machine, an ECG unit, an 

airconditioner and an ionotic enzyme 

analyzer. Under negotiation as well is 

the PHO's request to procure an operating 

microscope and a centrifuge. 

Budgets for Capital Outlay are rarely 

• included in hospital's appropriation. 

With unutilized remittances in the hospital's 

trust fund account, the Chief of 

• Hospital was able to get approval for 


..

Hospitals have 

a ready stand 

by fund where 

funding 

requirements 

for necessary 

supplies and 

materials can 

be accessed. 

the purchase of these equipments from the Sanggunian. With 

funds already identified, and approved for realignment to 

cover purchase of equipment, the hospital is able to upgrade 

its facilities and hence provide better service. 

This system assures that funds for emergency materials 

and life saving supplies are readily available and not subject 

to the changing priorities in the allocation of available 

financial resources. By generating their own financial 

requirements hospitals do not become overly dependent on 

their regular appropriations which may not reflect the actual 

needs of the facility. With the revolving fund system in place 

the Quezon Memorial Hospital expects to fund more than 

60% of its MOOE requirements from this source. This implies 

that only an estimated 40% of their MOOE requirements 

will actually be covered by their regular appropriations. 

Summary and Conclusion 

Before devolution, trust funds were considered the lifeline of 

hospitals in the sense that funds for necessary drugs, medicines and 

other medical supplies were easily accessible. Revolving fund systems 

were adopted where receipts from drugs and medicines were remitted 

and could be used to replenish supplies. But such an arrangement had , 

no legal basis under the Local Government Code so hospitals' trust 

funds and revolving fund systems had to be transferred to the provincial 

coffers. Coupled with budgetary allocations that are most often less 

than ideal the non-assurance of hospital's funding for replenishing vital 

supplies and materials and the lack of investments for upgrading and 

procuring equipment compromised the future for hospital services. 

Given these constraints, instituting the necessary reforms while 

retaining the same level of quality care became a formidable task. 

By allowing hospitals to have access to the Provincial Trust Account, 

the Province of Quezon has paved the way for the revival of a quasirevolving 

fund system. This in effect assures that hospitals have a 

ready stand-by fund where funding requirements for necessary supplies 

and materials can be accessed. 0 


• 

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•

, 

• 

PALAWAN 

Capital : Puerto Princesa 

Area : 14.896.3 sq km 

Population : 528.287 

Cites : Puerto Princesa 

No. ofTowns : 22 

THE PEOPLE 

The province has a cultural minoritypopulation 

0193.691 that includes 

the Tagbanuas. Pala'wans. Batacs, 

Catamianes, Ken·Uys, Jama-Mapuns, 

Molbogs. Cagayanos. Agutayanos. f 

and Tau't Batu. The Iagbanuas. scattered 

in the north, are short and slender. 

They are excellent basketweav 

ers and woodcarvers. The Pala'wans 

occupy the southern highlands. They 

traditionally hunt using spears. and 

bamboo blowguns. The Batacs are 

ofNegrito descent. The Calamianes \ 

or Kalamians are native to the 

Calarnien islands. The Ken-Uys. the 

. "vanishing tribe" ofPalawan. live in 

the mountains inthe south. 


The economy is basically agricul· 

tural. The three major crops are palay. 

corn and coconut. Mineral resources 

include nickel. copper, manganese. 

and chromite. Palawan has one of 

the richest fishing grounds in the 

country. 

ALAYKA: Leading Palawan 

to People-Powered Health 

The Local Government Code came into effect in January 1993, 

giving the Provincial Health Office of Palawan more autonomy 

and freedom to chart its own course. This opportunity for real 

change, however, would have been meaningless had the cast of 

characters led by Gov. Salvador Socrates and his tocayo Dr. Jose Antonio 

Socrates not converged in Palawan at that "magical moment of pregnant 

possibilities". 

By recruiting and mobilizing the private sector, particularly 

community-oriented organizations, to assist in improving health and 

medical care for the people of Palawan, devolution has given the 

'dynamic duo' the freedom to innovate towards the goal of "putting 

health and medical care in the hands of the people." 

Serving as anchor or foundation of these innovations is AlayKa 

Palatoan or Alay sa Kaiusugan Ilg Pulatoan. The first province-wide 

community-based health program in the Philippines, it is a magnified 

version of previous efforts of NGOs to "empower" the people through 

health by arming them with relevant knowledge about health and 

medicine and with organizing and analytical skills that ensure collective 

strength and voice. The main.difference here is coverage, for while 

before the NGOs could only organize a few villages, now every barrio 

and municipality in Palawan would be officially organized and trained 

by the PHO towards genuine community based health programs. 

As Gov. Socrates puts it: "The ultimate objective is to deliver to the 

people their own health concerns, such as nutrition, environmental 

sanitation, disease control, and potability of water systems. Allg palliwala 

Ilamill sa AlayKa, the hospital should focus on problems lla hindi kaya sa 

local level so they won't be cluttered with people lla minimallallg allg 

sakit. " 

Calling AlayKa Palawan the province's most innovative postdevolution 

program, Gov. Socrates has given the program all his support 

through the issuance of necessary laws, administrative requirements, 

and financial contributions which he claims is much more substantial 

than what the DOH has provided the program. 

ALAYKA Palawan: A GO Working as an NGO 

The concept of establishing community-based health programs in 

Palawan draws its inspiration from the twin goals set by the Department 

of Health: Health for All by the Year 2000 and Health in the Hands of the 

People by 2020. Devolution opened the way for LGUs to pursue health 

D E V a L UTI a N MAT T E R s· 67

programs which are community-based like AlayKa Palauxm. 

Thename AlayKa Palatoan is taken from the phrase "Alay sa 

Kaiusugan." Literally, it means an offering for health. Its goal is to 

make people take responsibility for their own health, not 

depending on dole-outs and relief for their medical needs. In 

essence, it puts health in the hands of the people. 

Community-based health programs (CBHP) are a unique 

innovation of NGOs. While the strategy of community 

organizing is borrowed from the NGOs, AlayKa Palawan is a 

program instituted and sustained by the Provincial government 

of Palawan. It is a GO working as an NGO. 

What makes AlayKa Palauian unique is that, unlike other 

CBHPs, particularly those undertaken by NGOs which have a 

limited target area. AlayKa Palaioan'e scope is province-wide. 

AlayKa Palawan: The Genesis 

AlayKa Palawan started through informal talks among Palawan's 

health leaders and health-oriented NGOs. 

Through the initiative and commitment of Dr. Socrates, Palawan's 

Provincial Health Officer, AlayKa Palatuan was formally presented to 

Governor Socrates as Palawan's own community-based health program. 

By virtue of Executive Order No.8, AlayKa Palawan was created. In 

July 13, 1993, the Sangguniang Panlalawigan of Palawan passed 

Resolution No. 280 endorsing the program, recognizing AlayKa 

Palawan as its own province-wide community-based health program, 

and encouraging all out support to the program. 

This legislation defined the legal structure for AlayKa Palawan. They 

also mandated it to create three essential working committees: training, 

field operations and administration. 

This legislation also created AlayKa Paunoan's Executive Staff and 

Board of Directors consisting of the Governor as Chairman of the Board, 

the Sanggunian Chairman on Health, the PHO, the Provincial Health 

Officer, the Assistant Provincial Health Officer for Field and Technical 

Services, two (2) members from the NGOs, two (2) members from the 

People's Organizations, one (1) from the AlayKa staff and the Program 

Director of AlayKa Palatoan as ex officio member. The composition of 

AlayKa Palatuan thus reflects its nature as a true CBHP. 

On August 13, 1993 AlayKa Palauian was formally launched in Puerto 

Princesa during a two day seminar workshop attended by then Health 

Secretary Juan M. Flavier. The event was attended by many of 

Palawan's key leaders, NGOs and People's Organizations. One 

significant output of the launching exercise was the signing of a 


•

.. 

• 

Memorandum of Agreement between the Provincial government, the 

NGOs and people's organizations to support AlayKa Palmoan. 

Thus, a true partnership between government and NGOs was 

forged, rallying the point to "Ibelltallg saalima allg mga tao allgkaavadan 

alldallg ltuoas" - to put health in the hands of the people. Thus began 

the work of AlayKa Paltnuan. 

CBHP: Definition and Mission 

Consistent with its ideals and principles, AlayKa Paunoan introduced 

the concept of community-based health programs province-wide. 

However, one question persisted:. Why not spend the government's 

limited resources on strengthening the already established health 

delivery system of the province? 

AlayKa Pnlatoan is not against the efficient delivery of health services 

to the people. On the contrary, AlayKa Palauutn's mission complements 

the efforts of the country's health delivery system. By concentrating on 

effecting primary health care in the community, CBHP helps doctors use 

their training more effectively, and enables hospitals to use their facilities 

more efficiently. 

What AlayKa Palatoan aims to do is to create a people-centered health 

program at the grassroots level where the people themselves, in 

coordination with health workers, address health and not medical 

concerns. There lies the difference and the responsiveness of community 

based health programs (CBHPs). 

In establishing CBHPs, AlayKa 

Palatoan should be able to define what a 

community-based health program is. 

This would however be contrary to the 

very nature of CBHP. It is the people 

themselves who must decide and define 

what CBHP is to their communities. As 

such, there would be different ways of 

defining CBHP relative to the needs and 

peculiarities of each community. 

'AlayKa Palawall does not set up 

CBHPs, the people do. AlayKa Palnumn 

merely presents the concept of CBHP 

to the people. The people then 

become aware of the circumstances surrounding their health problems. 

AlayKa steps in to facilitate the organization process, that the people 

may continue to organize and train themselves. Their end goal is to 

draw up solutions to their own community's health problems making 

them self-reliant. The community decides its own priorities and sets up 

its own health programs, in essence, setting up its own community 

based health program. 


It Is not however 

accountable to 

any political 

group. nor does it 

function for any 

other Interest 

than those of the 

health and 

medical concerns 

of the people of 

Palawan. 

As a facilitator, AlayKa Palaumn helps provide 

resources from government agencies or NGOs to fund the 

implementation of these community health projects. 

One lesson that AlayKa FalalVal1 learned from its work 

is that the status of a community's health is largely 

dependent on its socio-economic situation. Poverty, 

injustice, neglect and ignorance indubitably determine the 

landscape of a community's health. 

While AlayKa FalalVal1 is incapable of changing the 

whole socio-economic scenario of its communities by 

battling age-old problems like poverty and neglect, it is not 

incapable of making a difference in the lives of the people 

of Palawan. It is not however accountable to any political 

group, nor does it function for any other interest than 

those of the health and medical concerns of the people of 

Palawan. 

Strategies and Achievements 

AlayKa Palauian employs four major strategies to carry out its task. 

One is information dissemination. To introduce the concept of CBHP to 

the people of Palawan, it is imperative that they become aware of its 

significance to their communities and lives. Seminars are conducted, 

brochures and newsletters on AlayKa Palauian are distributed and radio 

broadcasts are aired as information dissemination tools. The people then 

decide for themselves whether they wish to adopt CBHP into their 

communities or not. 

In 1993 re-echo seminars on CBHP were conducted in 19 out of 22 

municipalities and 202 barangays in Palawan. This two-day seminar 

focused on the concept of CBHP, its vision, significance and strategies. 

Also discussed were topics on health and development, the formulation, 

functions and responsibilities of a Barangay Health Council, and the 

importance of teamwork. At the end of each re-echo seminar a 

Memorandum of Agreement between the various participants is signed, 

indicating their desire to implement and support AlayKa in their 

respective municipalities. A Pledge of Undertaking is also signed where 

the roles and functions of participating agencies are defined. 

Community organizing 

Community organizers from AlayKa then go to communities willing 

to adopt the program to help facilitate community organizing. AlayKa's 

strategy of community organizing is based on a simple yet effective 

concept- that of a multiplication process. 

Starting with a small core of committed community workers, 

barangays are organized into health communities. Each barangay then 

adopts another barangay where re-echo seminars on CBHP are 


• 

• 

,

• conducted. By organizing and strengthening the barangays, AlayKa then 

recruits more "foot soldiers" to help spread CBHP. Thus, the growth 

becomes exponential. 

• 

In 1993, 177 barangay health communities were established, way 

above the AlayKa's target of 68 barangays. This indicated the 

enthusiastic response of the people of Palawan towards CBHP. 

In 1994,AlayKa recruited 8 community organizers (Cas) while the 

municipalities employed another 10 cas. Ideally, each community must 

have a CO counterpart to which AlayKa's own CO can readily transfer 

its skills and knowledge. This encourages the early development of self 

reliance. 

Imperative to the success of community organizing is to equip the 

organizers with the proper skills, attitudes and know-how in 

implementing CBHP in the communities. This brings us to AlayKa's 

third strategy - training. 

In 1993, AIayKa targeted to 

recruit and train a total of 564 

community organizers. However, 

only 301 CO were trained 

or about 53 % of its total target. 

The reason for this low turn-out 

is traced to several factors: difficulty 

in travel specially among 

island barangays, personality or 

political conflicts, lack of budget, 

or conflicts in schedules. 

While conducting health-related 

training in collaboration 

with other government agencies 

was welcomed, it brought additional 

work to AlayKa's staff who 

did most of the legwork. As a result, 

AlayKa's training needs 

were sidetracked. This was rectified 

when two CBHP experts from Volunteer Service Overseas came to 

Palawan to assist in the evaluation and improvement of AlayKa's training 

modules. 

The final strategy is networking 

Consistent with the concept of partnership and because of limited 

finances and human resources, AlayKa has developed an effective 

network among various agencies which it can tap to help resolve issues 

and concerns related to its work. These agencies provide assistance in 

the form of financial support for food and travel expenses of cas, 

provision of training paraphernalia and equipment, manpower in the 

D E VOL U.T ION MAT T E R S 71

form of trainors and resource speakers. In those communities where 

acute medical attention is desperately required, medical missions are 

conducted through the generosity of health civic groups and institutions 

or by the LGU. However, AlayKa emphasized that the community 

should not solely depend on these medical mercy missions since its 

solutions are short-term and irregular. It does not enhance or sustain 

AlayKa's vision to bring health to the hands of the people. 

Working Together 

for the Common Good 

As community organizers have learned, the success of AlayKn 

Palawan and CBHP hinges upon the people's readiness to accept this 

innovation in health care. Acceptance, however, can only be given if 

more urgent priorities are satisfied. Where people are hungry, 

oppressed, neglected and poor, health takes a backseat to the battle of 

surviving life. It is during these 

"""'-'--.--------rw:= instances that compassion and 

commitment serves a CO in 

good stead. AlayKa does not 

propose to provide surefire 

solutions to the people's 

problems. It can only hope to 

ease their burden by utilizing 

its skills in networking to bring 

the people's problems to the 

attention of concerned agencies 

or institutions. 

72 D'E VOL UTI 0 N MAT T E R S 

AlayKn believes that it 

cannot isolate health from the 

rest of the people's concerns. 

Each concern affects all the 

others. 

other Innovations 

Another innovation, 

spearheaded no less by Palawan's usually publicityshy 

"governess", Ora. Naty Socrates, is the TANGAY 

Foundation which started as "Friends of Palawan's 

Provincial Hospital". This is a non-government 

organization seeking private sector support for 

improving the facilities of Palawan's provincial and 

peripheral hospitals. 

BAHATALA, which true to its namesake started it 

all, provides rehabilitation services and domicilliary 

care for the patients of the Palawan Provincial Hospital 

and is the pillar of the PHO's community-based 

rehabilitation program. 

•

• Infrastructure support for agriculture (such as post-harvest facilities 

and flood control) and safe water sources are sorely lacking. 

• 

• 

Money for hospitals 

In spite of the above socio-economic conditions in the 

province, the health care delivery system may be described as 

adequate. Its hospital system is interlinked with a good 

referral system and good networking. The province is being 

served by thirteen hospitals, six of which are governmentowned. 

Government hospitals now have. a total of 200 beds, 

which translates to a bed-to-population ratio of 1:2,524 

persons. Private hospitals provide another 76 beds. In 

addition, there is one Health Center for each municipality and 

104 Barangay Health Stations. 

Devolution brought about many changes in the province. 

One significant change was the improvement of the health 

facilities devolved to the province. Notable among these was 

the improvement of the Agusan del Sur Provincial Hospital 

which was given P2.5M augmentation assistance. Of the latter 

amount, P1.5M went to the completion of the Provincial 

Hospital Main Building. 

The provincial government also spent PO.5M per hospital for the 

following jobs: 

Devolution 

brought about 

many changes 

In the province. 

One significant 

change was the 

Improvement of 

the health 

facilities 

devolved to the 

province. 

• Esperanza Medicare Hospital: construction of a morgue and the 

building of a perimeter fence; 

• La Paz Municipal Hospital: purchase of a motorized banca for 

undertaking health work and construction of a perimeter fence; 

• Loreto Municipal Hospital: purchase of hospital equipment; and 

• Bunawan District Hospital: construction of medical staff 

quarters and purchase of hospital equipment. 

The provincial government also gave PO.5M for the construction of 

each of the following: the Veruela Main Health Center, Sta. [osefa Health 

Center, and the Esperanza Health Center. On the other hand, PlOO,OOO 

"was spent for the construction of the Mahayahay, Sibagat Health Center. 

San Francisco Health Center was given aid in the amount of P98,000. 

Assistance to barangay health workers in 1995 amounted to 

P1,283,600. P790,000 will be given in 1996. 

Devolution Chief 

Our person responsible for creating this goodwill on the part of the 

provincial government is Dr. Manuel M. Angeles, Provincial Head 

D E VOL UTI 0 N MAT T E R 5 75

He detailed the 

functions of each 

member and 

Officer and Chief of the Agusan del Sur Provincial Hospital. He was 

instrumental in making the local chief executives appreciate the 

magnitude of the health work to be done when the responsibility for 

health care delivery was transferred to the province. The local 

government, on the other hand, did not waste time in giving the support 

mandated by law. Those given for facilities and service delivery 

improvements are only examples of how the local government rose up 

to the challenge of being responsible for the health of their 

constituents. 

each one is 

made to 

understand his 

expected 

contributions to 

the success of 

Dr. Angeles, who happens to be pro-devolution, 

capitalized on the five-point program of the administration 

of the late Governor Democrito O. Plaza which listed health 

as a priority concern of the province along with education, 

social welfare, peace and order and economic development. 

He briefed the late Governor Plaza, the Vice Governor 

Alex G. Bascug who took over the provincial government 

when the former passed away, the Sangguniang 

Panlalawigan, the mayors and the Sangguniang Bayans, on 

the provincial health office: how it performed, its constraints, 

and the prescription for local government action. 

local health \Nork 

With authority from the governor, he immediately had 

in the province. the provincial health board organized. He detailed the 

functions of each member and made each one understand 

his expected contributions to the success of health work in the province. 

·He also opened the LHB meetings to other provincial officials whose line 

function, through non-health in nature, have bearings on health, like the 

environment and agriculture officials and engineer involved in 

development planning. 

Dr. Angeles also attends the mayors league meetings which are held 

monthly in different municipalities, marketing the health programs for 

the province and municipalities. Dr. Angeles comes to these meetings so 

that when health problems are discussed, he will be around to answer or 

to enlighten the mayors. 

In dealing with the municipalities, Dr. Angeles works on the same 

strategy he used in the provincial level: involves everyone in problem 

appreciation and solution. At both levels, it appears to be working. He 

conducts program review sessions from town to town for which he 

invites the local executives, the mayor, the Sanggunian, the budget 

officer, the treasurer and even the auditor to participate actively. And 

according to him, "The response has been very encouraging." 

Help from the Governor 

The health workers were one in saying that the local chief executives 

are doing their best in dispensing their responsibilities to them. Because 

they made it a point to communicate to them their concerns. But it is 


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, 

• 

•

• 

• 

also a quid pro quo situation. The local chief executives also have some 

expectations from them which they try to meet. The health workers are 

asked why they should be given the things they ask for. And they 

report their accomplishments to the local executives. The provincial 

health office, in particular, was given all that it asked for. In fact, what 

was given was more than was asked for, particularly during the time of 

Governor Democrito O. Plaza. 

The late Governor was especially happy with the Provincial Health 

Office and gave five awards to the office 

for work well done. 

Dr. Alex G. Bascug, now the Governor, 

was asked by the la te Governor 

Plaza to be his running mate because of 

his track record in medical care. The late 

Governor put health concerns very high 

in his administration's agenda. Dr. 

Bascug now continues the work and sees 

to it that what has been started will not 

come to waste. 

Being a doctor himself, he understands 

the problems of health. Before 

he became Vice-Governor, he was himself 

running a private hospital. It has 

been very easy for barangay health 

workers to approach Governor Bascug. 

When they cannot reach a place, for 

there are many inaccessible places in the 

province, and they have to go for emergency 

cases, he lends his Pajero to them. Barangay health workers get free 

medical care in the provincial hospital. 

Governor Bascug believes that health care is important because 

good health will ultimately redound to the wealth of the province and of 

the nation. He intends to put up as many barangay health centers, hire 

as many rural midwives as possible, and expand services of existing 

health centers as provincial funds will allow. 

Governor Bascug has received many awards for such activities as 

giving free medical/dental services, free circumcision, conducting 

lectures on anti-drug abuse and related health issues. He believes he 

won these awards not only because of the hard work he put into 

carrying out his vocation but also because of the good relationship he 

has had with his doctor colleagues and other health professionals. To 

this day, he maintains that cordial relationship. He believes that they are 

aware of his effort to improve the conditions of public health workers in 

the communities"bnstn nilOllg kabutihan", because he understands their 

unique situation. He knows they are underpaid and yet they take great 

risks in servicing far-flung areas of the province. 


Many have 

overcolTle their 

suspicion that 

the local 

governlTlent 

ITIlght crudely 

Interfere In the 

conduct of 

health _ork. 

Health workers' apprehensions and stoic commitment 

Aside from the financial support given by the provincial 

for health workers' salary and benefits and improvement of 

health facilities, the health workers are also appreciative of 

the efforts made by the local government units to augment 

their workforce. In the Provincial Hospital, for instance, they 

were given additional manpower like utility workers, 

nurses, nursing attendants, doctors, midwives, dentists even 

dietary personnel. The limitation of the MOOE, particularly 

on the 55:45 ratio in personnel services, did not deter the 

local government units from hiring casuals. The casuals 

were paid by the provincial governor's office but were 

assigned to the hospital. Before devolution, there were only 

nine doctors and over 20 nurses in the hospital. Now there 

are 16 doctors and 34 nurses. 

Inspite of the thorny issues like sustainability of salaries and benefits 

for health workers, health workers in the province, municipal and 

barangay levels, may be appropriately described as committed. Poverty, 

after all, has a way of instilling a sense of responsibility for one's fellows, 

a sense of solidarity that does not easily weaken during difficult times, 

as that in the immediate post-devolution. 

This sense of responsibility, which may be described as stoic, 

coupled with the somewhat unexpected willingness of the LGUs to 

absorb the health workers has generated a different sense of cynicism 

among the health workers, during the initial phase of devolution. The 

often asked question among themselves was "Why do they want to get 

us?" There was apprehension as to whether the local chief executives 

would understand and, therefore, implement the appropriate health 

programs and projects in the province. 

The devolved workers have undergone a series of briefings, 

seminars, conferences to help them get into the spirit and intent of 

devolution. This had to be done at the beginning of devolution. The 

municipal/provincial government and the devolved health workers did 

not see eye to eye. Frequently, health workers would not attend flagraising 

ceremonies at the capitol. Things had to be improved if the 

benefits of a proper work relationship with the local executives were to 

be realized. 

Over time, local health workers got used to approaching the mayor 

or the Sangguniang Bayan on matters ranging from drugs and medicine 

to janitors to clean health centers, or for supplies such as 

mimeographing paper. Many have overcome their suspicion that the 

local government might crudely interfere in the conduct of health work. 

Devolution improved the perspective of hospital personnel. A government 

hospital was an island by itself. Hospital personnel did not 

perform community work and confined the practice of their professions 

within the four walls of the hospital. They only did curative work and 


• 

, 

•

• none of preventive work. When their efforts were fused with local Under 

government intentions, hospitals improved their service packages devolution. 

by doing community work. This was also true at the municipality 

I level. however. there 

• 

• 

• 

Improvements in their working conditions started coming. 

They were given additional building space through expansion of 

facilities or even a new health center. Instruments and equipment 

were also coming in. Local government met all the supply needs. 

The health workers also saw that even lEC materials, equipmentand 

materials for documenting their activities in implementing 

their health programs such as video cameras and videotapes, were 

given by the local government units. Those who had doubts as to 

the sincere intentions of the local chief executives started to see 

that devolution was more advantageous in many respects. 

Local power 

Instead of being a formidable stumbling block, the depressed socioeconomic 

condition the province provided the spur for devolution effort 

in Agusan del Sur. The health workers always felt before that assistance 

from the national government was inadequate. They had the notion that 

they were in effect operating in a decentralized, independent set-up. 

They believe that whatever assistance was coming from SRA, UNICEF, 

UNFPA would only marginally support them in trying to catch up with 

less depressed provinces. With devolution, the LCEs have taken over, 

and risen up to the challenge, seeing that help from the national 

government, if it comes, will only be in trickles. 

Health workers believe that it is easier to secure funding now. 

Before, they were asked to defend their budget before the DBM. They 

had the experience of thinking they had justified their budget only to 

find out months later that they would not receive what they expected. 

Now, the LCE is easily persuaded to give financial support because 

being in the province himself, he immediately sees the results. 

Even planning with an area-based approach has improved. It is true 

that the same initial steps in the preparations of the plan were followed 

as before: namely, preparation at the barangay level, consolidation of 

barangay plans at the municipal level, and further at the provincial 

level. Under devolution, however, there is no need for the national 

office to concur with provincial health plans. These are therefore 

immediately implementable. 

Other devolved workers in agriculture, population management, 

and social services are further involved in the planning. This feature 

provides health plans with a wider perspective. Consultation with nongovernmental 

organizations also provides a non-government 

perspective in planning. 

Is no need for 

the national 

office to 

concur with 

provincial 

DEVOLUTION MATTERS 79 

health plans.

Consequently, collaboration and coordination were strengthened. 

Walls between departments have now been broken down. All devolved 

personnel such as in agriculture, social services, population office are 

now talking to each other on a "together in this" basis. A regular chiefof-office 

meeting is conducted every Wednesday, involving all provincial 

personnel, with the Governor or Provincial Administrator presiding. 

Now, they can be true to what they have always believed in - that 

they are in the best position to understand what occurs in their area and 

what need to be done. They feel they should not be dictated upon by the 

national office and are indeed doing freely what needs to be done, based 

on a program of services responsive to the observable needs of the 

community. 

They contend programming from the central office frequently does 

not match needs. There is general satisfaction in being able to assess 

plans without a generally uninvolved central office trying to look over 

their shoulders. 

They now have the power and authority, to plan, implement and 

improve the delivery of health services to their constituents. Local 

health personnel are one on this. 0 


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•

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, 

• 

• 

o. 

LA TRINIDAD, BENGUET 

Classification : 3rd 


No. of Barangays: 31 

Land Area : 90.91 sqkms 

THE PEOPLE 

Benguet isthe homeland ofthree 

tribes, collectively referred to as 

lgorots. The Ibaloi in the southeast. 

the Kankanai in the northwest, and 

the Kalanguya in the East. 

All three tribes share common beliefs, 

such as the existence of unseen 

beings who can harm or help mortals. 

They observe common rituals, especially 

the can80which involves animal 

sacrifice, feasting, and dancing. They 

live in single-room houses raised on 

posts and topped by a pyramidal 

thatched roof. They are skilled woodcarvers, 

basket makers, and weavers. 


Because ofits temperate climate. 

Benguet's leading agriculture activity 

isvegetable production. The province 

is known as the "Salad Bowl of the 

Philippines." Major crops include white 

potatoes, Baguio beans, peas, strawberries, 

cabbage, lettuce, and carrots. 

On their own: La Trinidad 

Literally and figuratively, La Trinidad has long lived in the shadow 

of Baguio, its more famous and affluent neighbor in the south. The 

smallest (90.91 square kilometers) among 13 towns in Benguet 

(total land area: 2,655 square kilometers), it is best known as the 

"Strawberry Fields of the Philippines," one that travelers may visit for .. 

some quick fruit-and-vegetable shopping on their way home to Manila 

or as a drive-through point going up to more exciting and 

adventuresome destinations further north in the Cordilleras. 

But not for long, and not since tourists of a different sort began 

turning La Trinidad into one of the best kept (now discovered) secrets 

this side of the world, Their main stop: the Mayor's Office, 'they' being 

mayors themselves, or otherwise just plain students of development 

from across the country. "We had quite a number of observers visiting 

our office in the last few months, They stayed a few days each time to 

see what we are doing in the area of development," says Edna Tabanda, 

the town's 50-year-old lady mayor. 

Readiness to blaze a new trail, La Trinidad in 1992 had just 

recovered from the big earthquake that hit Luzon two years earlier, 

Reclassified from fifth-class to fourth-class municipality just the year 

before, it was well on its way to being upgraded to third class after 

realizing an average annual income of more than P8.036 million between 

1989 and 1992, 

Yet as the implementation of the devolution under Republic Act 

7160 (Local Government Code of 1991) drew near, the town's 

administrators seriously doubted their capability to manage the 

devolved functions, particularly those of the Department of Health 

(DOH). The idea of greater autonomy in the delivery of basic health 

services appealed to the LGU, but the stark reality stared them in the 

face: They did not have the resources to efficiently ruh a health care 

system. 

But devolution was an idea whose time had come. The top-heavy, 

centrally run bureaucracy had become intolerably costly and inefficient. 

Programs were being mass-produced in Manila with little regard for the 

specific needs, culture, customs, preferences and peculiarities of 

individual communities. Change was in order, Despite its qualms, La 

Trinidad had to take up the challenge of making the new system work 

for the better. 

Just a little over a year since it took over the huge task of bringing 


health care closer to the people, the municipality 

looks back with pride at its success in affecting a 

transition that was not without birth pains. 

Shaky start 

Dr. Doris Jovellanos remembers clearly the 

uncertainty of the first few months after the 

devolution of health functions were to have been 

effected under the new Local Government Code. As 

municipal health officer, she knew that much 

depended on her to ensure the smooth transition of 

functions and authority from the national to the local 

government. 

But she had other concerns. She relates, "There 

were all sorts of rumors going around. According to 

these, some of our people would be given the ax. We 

would go back to the old political system-sabi Ilga, 

naritoIla Ilamall allg padrino; hahatoakan lahat. (Here 

again is the system of patronage; they will interfere in everything) So 

there was a lot of fear among health workers. We didn't know where we 

were going. My own attitude was, bahala Ila." 

Up to that point, [ovellanos had few dealings with the local 

government. She remembers being involved in environment-related 

programs that the Mayor's Office was also involved in. "We also worked • 

together in the Nutrition Council, which was chaired by the Mayor, but 

not very closely." 

The Mayor offers her own recollection of the pre-devolution days. 

"Back then, I knew precious little about what the health, agriculture and 

social welfare departments were doing in my town. We were all working 

in the same communities, serving the same people, but we did not know 

what each was doing. The Mayor's Office had long been subsidizing 

some health services, but even here we had little say in the identification 

of priorities. There was hardly any coordination. Kaliya-kaliya taloga." 

It was, she admits, a bit shaky at the start. "The functions and 

responsibilities were transferred to us long before we received our 

internal revenue allocation (IRA)," she relates. "We had no money to 

finance all the programs that were handed down to us, and yet we were 

expected to implement those programs as well as, if not better than, the 

national government." 

Still, Tabanda entertained few doubts that autonomy was the better 

way to go. She regards herself as a "consensus builder" and, in her view, 

a devolved system offers the best environment for building consensus. 0 

Indeed, this is the beauty of granting local governments greater 

autonomy, she says. "Central government policies that could neither be 

implemented realistically nor practically were a constant source of • 


• 

•

Having been 

thus assured, 

the devolved 

units began to 

plan their 

programs of 

action, fully 

In the manner of an avowed consensus builder, the 

Mayor began a series of consultations-ongoing to this 

day-on what programs would best meet La Trinidad's 

health needs. "1 always consult the health workers, and they 

consult me. This is our priority, this is the money we can use 

for this program, this is the program of the national 

government, this is what we need. We put everything 

together. We do not disregard the national program; we 

harmonize it with our own priorities and resources." 

realizing for the 

So far, so good 

first time that For the most part, the Mayor admits, "We have merely 

It was now up continued what the national government had been doing in 

the area of health. But our strategies are different. Knowing 

to them to our limited resources, we try to get the most out of every 

determine what program that we undertake. For example, we're using the 

schools to disseminate information, not just on health but on 

services were 

other matters as well. In anyone of these school forums, we 

most crucial In would have a population officer to talk about family 

their areas of planning, a nutritionist to talk about nutrition, a medical 

technologist to provide stool examination services. We 

jurisdiction. would show a film on the environment, and we would bring 

development workers to help. This, to me, has been one of 

the most positive effects of devolution. It has allowed us to 

bring together in our projects the education, health, agriculture, and 

social welfare departments, the Population Commission, the Philippine 

National Police (PNP) and other groups, including those from the 

private sector." 

Jovellanos herself is pleased with their progress so far. "Overall, I 

think we had a fairly good year. Maganda ang simula." 

She is particularly happy with the way her group has been able to 

respond to a recent outbreak of rabies. One death was reported, and 

with nine out of 10 dog bite victims testing positive for rabies, the group 

sprang into action. A single emergency meeting with the Mayor was all 

it took to mobilize the resources they needed to prevent a potential 

epidemic. The Department of Agriculture (DA) was brought in, and so 

were the PNP and the Department of Veterinary Medicine of the 

Benguet State University. In no time at all, the disease was contained. 

"Under the old set-up," [ovellanos says, "it would have taken us 

much longer to respond because we would have had to go through the 

channels-the Department of Health's (DOH) regional office and then 

the national office-for logistical support." 

Although the doctor had once worried over 'politicking' LCEs, she 

now sees some advantages in having the local officials involved in 

health programs. People sometimes respond positively to a program 

simply because the Mayor says so, she concedes. "One barangay once 


i 

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• 

• 

• 

."

f 

, 

refused to participate in our immunization program because it was 

against their religion. We went anyway, making sure that we had the 

Mayor with us. We had a good turnout, and everyone who came got 

their shots." 

The mayor is a nurse 

Still, Jovellanos is not completely sold on devolution. "The Mayor is 

a nurse," she observes. "She is supportive of our programs because she 

understands how important good health care is to the well-being of the 

community." 

Even Tabanda, now on her first term as mayor under the new Local 

Government Code, says that, yes, she is "health-oriented" because she is 

a nurse (GN/RN, St Luke's School of Nursing, 1966), although she holds 

two other degrees (BSCommerce, 1981 and Bachelor of Laws, 1986, both 

from the Baguio Colleges Foundation). 

[ovellanos frets that not everyone who will sit in the Mayor's Office 

will have health at or near the top of his or her agenda. And with 

everything so heavily dependent on the LeE, "Any progress we've 

made in health service will amount to nothing under an unresponsive 

administration," she says. "I heard that in some places today the budget 

for health is PSO,OOO-what can that buy?" 

Some of [ovellanos' biggest frustrations in her job are barangay 

.officials who 'forget' to put health services in their budget allocation. 

"Of the 16 barangay captains in La Trinidad, 1know of only one who 1 

can say fully supports our health programs." It is unfortunate, she adds, 

because the local government can do a lot, especially in mitigating 

health and environmental 

problems. "Sila allg nandiuan /la 

nakaba II lay, " she reasons. 

There are even more basicand 

immediate-concerns. To a 

limited extent, the benefits issuethat 

sore point of contention in 

almost all devolved health unitshas 

been resolved here, but the 

uncertainty remains. Says 

[ovellanos, "Even at this time, at 

Our level, there is still some disparity. 

Some health workers are not 

enjoying the benefits that we are 

now getting. With the law saying 

that the granting of benefits is subject 

to the availability of funds, we 

are apprehensive that the next 

mayor may not be as sympathetic 

as Mayor Tabanda is to our cause, 


•

There Is no 

high road to 

perfection, but 

those who will 

take the 

highways to La 

Trinidad next 

year are bound 

to take home a 

precious lesson 

from this 

hardworking 

community and 

ipil kanzi. Who do we turn to if the same issue crops up in the 

future?" 

Then there is, as always, the matter of drugs and medicines, 

a perennial-but not any less pressing-problem for the 

worker on the frontline. Says Edna Abalos, a public health 

nurse, "One good thing about the devolution is that the responsibility 

of requesting for medicines has been given to us, 

so we now get only those medicines that we truly need. Still, 

there are constraints. Sometimes we just don't have the medicines 

our patients need. We give them half of the required 

dosage and write a prescription for the other half." 

On yet another front, Councilor Adelina Dulnuan of 

Barangay Betag observes, "We tell people to go to the Rural 

Health Unit (RHU), and they come back to us complaining, 

'liuturo nyo sa anzin na pumun!a sa RHU-mayroon ngang 

doklor wala nalllang gamoi." 

their ne'er-saydie 

lady mayor. Something good Is happening here 

Understandably, Dulnuan, [ovellanos, and Abalos want 

some changes. Says Dulnuan, "I am against devolution if it 

means that health workers will be deprived of their benefits, and that 

medicines will remain scarce. If adequate funds are released on time, 

however, the devolution might just be the thing that we need at the 

barangay level." 

Adds Abalos, "We need to hire more people. Nag-iisa akong nurse 

dito. We only have two sanitary inspectors and nine midwives for the 16 

barangays." 

Suggests [ovellanos, "There should be a law that would ensure that 

health gets enough funding no matter who's in charge of the local 

government. This way, health service will not be compromised by the 

executive's so-called priorities." 

"Money," a resigned Tabanda concedes, "will always be short." 

And yet, everyone agrees: They've done well despite the odds. At 

the very least, the devolution has brought about some positive changes 

that promise unquantifiable-although perhaps not quickly evidentlong-term 

benefits. 

Dulnuan: "In the past, when people say they do not want to be 

bothered by all these health programs, there was nothing that anyone 

could do. NgaY011, pati bala inilalabas. Laluu nabibigyan." 

Abalos: "I would say the devolution has been successful in the sense 

that we are now involved in planning and decision-making." 


• 

;

• 

• 

[ovellanos: "People have become more aware of the benefits of good 

health, although they have not yet internalized the concept of health as 

something they can manage and must ultimately be responsible for. I am 

particularly encouraged by the response of the public to the immunization 

program which was initiated by the DOH and supported by NGOs 

and the local government units. Si Mayor, pumunta po so IIlgo liblib lin Iugor 

pornkumbinsihin long ong IIlgo loa. The response was heartening. Salin gallOOll 

pologi. " 

The Mayor admonishes, "There is no perfect system. The devolved 

set-up only means that a lot of things now depend on how much work 

we are willing to put into our respective jobs so we can accomplish the 

task that we set out to do. It will be up to us to innovate, to put our 

heads and hands together to remedy the perceived defects of this 

system. This is what we've got, let's make it work." 

Yet she refuses to entertain any suggestion of failure. The system 

will fail only if we want it to fail, she argues. "The national government 

can make things easy for us by providing us with the resources that we 

need to do what is expected of us. I wish they would, and I wish they 

would come to our aid every time we need them. But I don't want 

anyone tying the noose around our necks. I'd rather we solved our 

problems on our own, in our own way, even if it would mean we would 

have to make do with the limited resources that we have. My attitude is, 

we can cope with any situation. It will take time, but we'll make this 

work." 

There is no high road to perfection, but those who will take the 

highways to La Trinidad next year are bound to take home a precious 

lesson from this hardworking community and their ne'er-say-die lady 

mayor: He who is free to chart his own course can choose to travel as 

fast and as far as he wants. 0 

La Trinidad lVas reclassified from [ourth-class 10 third-class municipalitu 011 [une 

16,1993 by uirtueof Finance Department Order No. 35-93. 


, Figure 1 is an example of an RFOs organizational 

structure, in this case, the RFO VII. There are four major 

divisions: Technical Service Division; Health Manpower 

• Development and Training Division; Finance Division; 

and Administrative Service Division. 

• 

• 

The re-structuring of RFO VII 

In October 1992, the first Local Government 

Assistance and Monitoring Division (LGAMD) was 

established in RFO VII in Cebu City, with Dr. Rosario 

Benabaye as officer-in-charge. Certain DIRFO-VII 

personnel were reassigned to this division in order to 

perform the different functions of the five sections under 

it, namely: a) LGU/NGO/Community Link with four, 

staffers including the head;b) Local Health Board, with 

two personnel; c) Health Information Exchange, with 

five staffers; d) Monitoring and Assistance, with three; 

and e) Disease Sentinel Surveillance, also with three 

staffers. 

These personnel were relieved of their previous 

functions and responsibilities. However, because of 

administrative dilemmas that characterized the changeover 

phase (and which persists in the transition phase) 

and because the division is a copy of a central office 

body envisioned to be just ad hoc in existence, they still 

had to perform most of their previous duties and responsibilities. 

Often, due to work assignment overload, 

some important activities were not given the necessary 

attention. With openness and organizational vigor, RFO VII conducted 

regular evaluation and review of the existing structure. with the end in 

view of developing a structure more responsive to a decentralized set-up. 

Over time, manpower allocation for the different sections and the parameters 

of concerns for each section evolved, but the five concerns remained 

essentially the same. 

A Manual for the New Set·Up 

Fully aware that much remained to be done in translating the general 

functions of the DOH into specific tasks and responsibilities, Director 

Consuelo Aranas assisted by then Assistant Regional Director Dr. Jose 

Rodriguez proposed the conduct of two studies, namely: Field Testing of 

Mechanisms for Regional Health Coordination; and Monitoring the 

Progress of Devolution in a Province. The proposals were submitted to 

the Health Policy Development Project-UPEcon for funding support in 

January 1993. The studies were conducted in July to December 1993. 

The result of the studies is the Manual for Regional Health Coordination. 

Applying the field perspective, this manual discusses the functions 

of the DOH in a decentralized set-up, such as the Field Health Service 


Information System (FHSIS), disease surveillance and outbreak management, 

training and provision of technical assistance, and performance 

monitoring. 

The chapter on Area-Based Planning gives insights to this feature of 

. health empowerment tried and tested even before the LGC and 

challenges the reader to try it in his/her area. The manual was first 

used in January 1995 in the province of Bohol, and shortly in the other 

provinces of Region VII. Its institutionalization was done through the 

Comprehensive Health Care Agreement (CHCA). In this partnership 

contract between the DOH and the province, the former gives resources 

for the health package proposed for the area while the latter provides 

counterpart resources and undertakes, supports or assists the 

implementation of the health programs. Copies of the manual were 

disseminated to all DIRFOs and some LGUs. 

Today, the five concerns of LGAMD are ably handled by five 

sections, now with new names: 

A. Public Information and Health Education 

B. Health Information Exchange 

C. LGU/LHB Assistance and Monitoring 

D. Community/LGU/NGO/I'O Link 

E. Disaster and Epidemic Management 

The rationale for lodging the Public Information and Health 

Education Section with the LGAMD is to ensure that health campaigns 

are properly focused on the communities and mobilize public/private 

sector support. A health campaign formulated by people who are 

familiar with the local culture, a trait LGAMD staff possessed by virtue 

of their work, is expectedly more effective. 

The Health Information Exchange Section 

takes care of preparing the consolidated 

regional health report or the Health Information 

System (modified FHSIS), a regular undertaking 

which was made problematic after health 

services delivery was devolved to LGUs. 

Considering the importance of maintaining the 

health database in a decentralized set up (so the 

DOH can keep track of developments in the 

LGUs), the effort must be taken to ensure that 

LGUs continue to prepare and submit their 

FHSIS forms in time. Aside from having the 

people to prepare the report, the creation of a 

separate section to handle this job telIs the LGUs 

that the national agency is serious about its new 

role as "servicer of servicers." , 

The LGU/LHB Assistance and Monitoring Section focuses on providing 

LGUs the technical assistance they need. Through the DOH 

representative in the Local Health Board, this section keeps track of the 


•• 

••

'1 

, 

.. 

the anomalous: a midwife leaving her area time and again to attend 

trainings that are very much related, and in the process using up 

precious time and resources. An Integrated Course for Public Health 

Nurses is also being prepared. 

Standing on its own 

"The organizational re-structuring of RFO-VII can be credited as the 

main contributing factor that has maintained, sustained and to some 

extent even strengthened the link between the LGUs and the RFO:' says 

Dr. Benabaye. "The creation of the Local Government Assistance and 

Monitoring Division (LGAMD) has improved the relationship of the 

local health offices and LGUs because there is a special or specific group 

of people who can be tapped and provide assistance when needed." 

The efforts of RFO VII have borne fruit, and there are enough 

benefits to share with other DIRFOs. Because of adequate groundwork, 

the mechanisms that were introduced to cope with devolution, 

particularly the LHB and the CHCA, were instituted without much of 

the expected difficulties. The first Municipal Local Health Board to 

become operational was established in Region VII, in Cordova and 

Cebu, Almost all the LHBs in the region that followed are now 

operational. Ask a DOH representative to the Local Health Board how 

she is doing and you will be impressed with how well she understands 

her role as being both the DOH representative and the critical link 

between the department and the LGU. 

Says Dr. Lakshmi Legaspi, the present OIC of LGAMD-RFO VII, 

"We ensure that the DOH representatives exude the air of knowledge, 

authority and goodwill in relating with the local chief executive and 

health officials." Knowledge and authority counts a lot when one is in 

the field and dealing with local chief executives and local health officials, 

a big number of whom still have hang-ups from a centralized politicoadministrative 

system. Even in a place like Cordova, Cebu where the 

Mayor is a devolution advocate, the DOH representative, Mrs. Sitoy, 

regularly visits RFO VII and makes it a point to attend seminars and 

workshops conducted by the Department whether in Manila or the 

region. She says that these are where she.updates herself on the 

programs, policies and goings-on in the Department. 

Another example of the dynamism of RFO VII is its achievement in 

negotiating the CHCAs in the region without any assistance from the 

central office, a feat rarely duplicated by other field offices. 

RFO-VII has shown how an organization rises before the challenge 

of decentralization: adapt and be relevant. Its example invites others to 

follow suit. 0 

Tilepresent Regiona! Director ill Regioll VII, Or. Marietta Fl/entes, hascOlltilll/ed 

witil tiletrClldsettillg policies of Or. Aranasalld Or. Rodriguez.

devolution matters - DOH Central Library - Department of Health

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