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HEALTH POLICY AND PLANNING; 16(Suppl 2): 61–69
© Oxford University Press 2001
Community participation in local health boards in a decentralized setting: cases from the Philippines LAURIE S RAMIRO,1 FATIMA A CASTILLO,1 TESSA TAN-TORRES,2 CRISTINA E TORRES,1 JOSEFINA G TAYAG,1 ROLANDO G TALAMPAS1 AND LAURA HAWKEN3 1Department of Social Sciences, College of Arts and Sciences, 2Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila, Philippines and 3WHO Humanitarian Mission, Albania Decentralization has been associated traditionally with participation and empowerment in local decisionmaking. This study of four cases analyzed the role of local health boards in enhancing community participation and empowerment under a decentralized system in the Philippines. Local government units (LGUs) with functioning local health boards were compared with LGUs whose health boards were not meeting regularly as mandated by law. The study found that there were more consultations with the community, fundraising activities, health initiatives and higher per capita health expenditure in LGUs with functioning local health boards. Only the mayors and municipal health officers felt empowered by devolution. In general, awareness of devolution and their potential roles in health decision-making was low among members of the community. These findings can be attributed to the socio-cultural and historical traditions of centralized governance with little popular participation, overall attitudes of the community and board members, perceptions of health as primarily a medical matter, economic circumstances of LGUs, and insufficient preparation for devolution. Recommendations are suggested in response to these findings.
Introduction The concept of decentralization has been traditionally associated with increased community participation and empowerment.1,2 Despite its theoretical potential in achieving the broader objectives of political and financial reform,3 studies on decentralization indicate that achieving enhanced community participation in decision-making can be a complex task.4–6 The Philippine government embarked upon a decentralized system of governance by enacting Republic Act No. 7160, known as the Local Government Code (hereafter the Code) of 1991. Dubbed as ‘the most ambitious decentralization initiative ever in Asia’,7 devolution in the Philippines was a political reform involving five major government sectors. The Department of Health was most affected in scale and scope of resources, powers and responsibilities devolved.8 With the passage of the Code, local health boards (LHBs) were meant to become the main mechanisms for broader community participation and involvement in local health development. LHB members include the mayor as chairman, municipal health officer as vice-chairman, local councillor for health, a representative of the Department of Health and a member of a health non-governmental organization (NGO) who represents the community in the LHB. There were no explicit provisions in the Code, nor in the Department of Health’s implementing rules and regulations,9 on the selection of the NGO representative. The Department of Health’s representative is appointed by the Secretary of Health. Others become members by virtue of their positions. As advisory bodies, LHBs were tasked to propose annual budgetary allocations for the operation of health services, serve as advisory committees to the
legislative council, and create advisory committees on personnel selection, promotion and discipline, bids and awards, budget review, etc. The Code stipulates that ‘the board shall meet at least once a month or as often as necessary’ to carry out its functions. The central Department of Health retains the functions of policy making, standard setting, surveillance and monitoring, control of foreign-assisted projects, and the planning and funding of nine core health programmes: child health, nutrition, women’s health and safe motherhood, tuberculosis control, safe water and sanitation, hospital management, institution building, support programmes and regional core programmes such as schistosomiasis and malaria.10 Implementation of these programmes was maintained at the local level. An ad hoc structure, the Local Government Assistance and Monitoring Service (LGAMS), was created by the Department of Health to ‘ensure the smooth transition of responsibility over the devolved functions . . . and, to redefine the national–local government relations under the decentralized framework’.8 Funds for local health activities are derived from local income and the Internal Revenue Allotment. Additional funds can be derived through the Comprehensive Health Care Agreement of the Department of Health and/or Health Development Fund for 22 provinces under the Social Reform Agenda of the national government.11 Initial studies on devolution in health in the Philippines focused on stakeholder perceptions and financial sufficiency. Local officials favoured devolution; health workers and NGOs opposed it. Devolution was regarded as ineffective in improving access, efficiency and quality of health services.12–14 Fiscal deficits were common in areas that became responsible for extensive services including hospitals.15–17
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There is a scarcity of local literature that analyzes decentralization mechanisms intended to achieve community participation. This present study aims to analyze the role of the LHB as the government’s intended mechanism for broader community participation in health decision-making in the Philippines.
Conceptual framework Figure 1 shows the analytic framework for this study. A good understanding of the rationale behind devolution, an appreciation of the LHB as a mechanism to broaden community participation in health decision-making, and social factors such as smooth interpersonal relationships among LHB members, are some of the essential elements leading to the functionality of LHBs. It is hypothesized that functioning LHBs result in broadened community participation in health decision-making. In this study, ‘community participation’ was defined in terms of the following indicators: democratic selection of community representative, members’ high involvement in health decisionmaking, full attendance of members in LHB meetings, and presence of regular community consultation and information-dissemination activities. However, the extent of community participation can be affected by the political dynamics within the LHB and the community, as well as stakeholders’ sense of empowerment. If there is broadened community participation, there should be more local health initiatives, adequate health budget and perceived satisfaction of health services by the community. These desired outcomes, however, are affected by the income level of the LGU.
Figure 1.
Methodology Selection of study areas The study used a multi-stage sampling scheme. One region in Central Philippines was chosen based on the assurance of cooperation from the regional office of the Department of Health. From this region, two provinces where municipalities had organized LHBs were recommended. Four municipalities or local government units (LGUs) from these two provinces were purposively chosen based on income and functionality of the LHB. In selecting the income adequate/inadequate LGUs, the government’s classification of municipalities was used. The government classification was based on the annual income of municipalities for the past 3 calendar years. In this study, Classes 1 to 3, with income levels above 12 million pesos, were considered ‘income-adequate’, and Classes 4 to 6, with income levels of 12 million pesos and below, were regarded as ‘income-inadequate’ municipalities. Based on a census of LGUs conducted by the research team in both provinces in 1997, not one had an LHB that met the Department of Health requirement of meeting ‘at least once a month’. Hence, in this study, LGUs with health boards that met regularly at least once every quarter in 1997 were classified as having functioning LHBs, while those with health boards that met irregularly or did not meet at all in 1997, were considered LGUs with non-functioning LHBs. To be included, comparison LGUs should: (1) belong in the same region;i (2) have the same mayor and municipal health officer at least one year before and one year after the establishment of the LHB; (3) have records available for review;
Framework showing the link between functionality of local health boards, community participation, income levels and outcomes
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Community participation in local health boards and (4) be willing to participate in the study. As exclusion criteria, the LGU should not have: (1) a mayor who is a health professional; (2) a fully devolved hospital; (3) experienced a major epidemic or disaster during the study period; and (4) received extraordinary funds during the study period. Table 1 provides the characteristics of the four study areas. The names of the study areas are fictitiousii to comply with a confidentiality agreement made earlier with the study participants. A detailed description of each municipality was done to provide insights of the types of settings studied and hence strengthen the generalizability of the findings. From 1995 to 1997, Iris and Kamia municipalities had average incomes of 49 million and 20 million pesos, respectively; hence, they were classified as Class 1 and 2 (‘income adequate’) municipalities. Sampaguita and Talahib had average incomes of 12 million and 10 million pesos, respectively and were considered Class 4 (‘income-inadequate’) municipalities. Iris and Talahib were the sample LGUs with functioning LHBs, while Kamia and Sampaguita were the LGUs with non-functioning LHBs. Based on similar fieldwork experiences, the four study areas can be said to be typical communities in the Philippines in terms of political culture and delivery of health services. Only Kamia had a 10-bed community hospital. The other three LGUs operated with outpatient and non-curative primary health services. Data-collection procedures This study was carried out in 1997–98. Data were obtained from primary and secondary sources. From the municipal records, information relating to health budget before and after LHB organization was documented. The minutes of the LHB and health staff meetings provided the health plans and activities of the LGU. Using semi-structured interview guides, 30 key informant interviews were undertaken with the head of LGAMS, regional director of the Department of Health, regional and provincial LGAMS coordinators, members of the LHBs, mayors, health staff, barangay (village) health workers and general population. As more themes and linkages of meanings began to emerge, other informants were included (e.g. budget officer, vice mayor). Nine focus group discussions with health staff, barangay
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health workers and mothers were conducted in the health centres and private houses. A 24-item community survey questionnaire using a 5-point Likert scale was developed to assess level of awareness of devolution, feelings of empowerment, involvement in health decision-making, extent of participation in health activities, and overall satisfaction with local health services. Similarly, a 24-item questionnaire for LHB members assessed their perceptions of devolution, the LHB and its roles and responsibilities, extent of involvement and level of influence in health decisions. The community survey was administered to 400 household heads or spouses in each of the four LGUs or a total of 1600. Central and remote barangays were equally represented. Twenty LHB members or five members from each LGU participated in the LHB survey. The response rates were 100% for the community and LHB surveys. Data collection was undertaken simultaneously in the four study areas. Research team meetings were regularly held to assess the validity and reliability of observations and insights. Four feedback roundtable discussions with LHB members and local government officials were organized to disseminate and validate initial results, and to obtain stakeholder recommendations to improve health decision-making in the LGUs. Data analysis The qualitative interviews were transcribed and emerging themes and patterns were identified with the use of coding schemes. This procedure was conducted continuously throughout the duration of the fieldwork. For each variable, the data were placed in a matrix to facilitate comparison. Qualitative data were presented in narrative forms using summative and verbatim quotes. The survey data were checked and edited immediately after fieldwork, and encoded for data processing using dBASE-4. Both survey data and secondary data were analyzed using descriptive statistics. Frequencies and proportions were
Table 1. Characteristics of sample local government units (LGUs), Philippines, 1996–97 LGUa
Total land area (hectares)
No. of villages (Barangay)
Total population
Socioeconomic classification
Type of LGU (year of LHB organization)
Class 1 Income-adequate Class 4 Income-inadequate Class 2 Income-adequate Class 4 Income-inadequate
With functioning LHB (1995) With functioning LHB (1993) With non-functioning LHB (1994) With non-functioning LHB (1994)
Iris
6 286
24
37 005 (l996)
Talahib
8 500
29
12 677 (1997)
Kamia
18 467
23
39 721 (1997)
Sampaguita
19 585
29
19 622 (1996)
a Names of LGUs are fictitious. LHB = local health board.
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computed for each item. Mean ratings were also calculated for each domain with each item weighted equally. The results of the community survey were presented in table form. The results of the LHB survey were triangulated with the findings in the key informant interviews and focus group discussions and were presented in matrix form.
Results Perceptions of devolution Only a few members of the LHB had a positive attitude towards the devolution of health services to LGUs (Table 2). The key informant interviews revealed that mayors in three areas considered devolution in general as ‘good’, but complained about the lack of funds to implement the devolved health services and salary law. The mayor in Kamia wanted re-centralization of health services because of the ‘intransigence’ of the municipal health officer. The municipal health officers, in general, did not like devolution, mainly because of the inability of LGUs to provide salary increases and benefits as mandated by law. The municipal
health officers of Sampaguita and Kamia resisted being supervised by the mayor. However, the dependence of the local executives on their expertise made the municipal health officers of Talahib and Iris feel ‘good’ about the new set-up. The Department of Health representatives were also quite resistant of devolution due to the LGUs’ insufficient support for local health workers, though they felt less personally affected because their positions were not devolved. It was only in Talahib that the NGO representative appreciated the potentials of devolution. An interview with her revealed that she was happy over the increase in the number of barangay health workers, the higher benefits and incentives given them, and the increased opportunities for their involvement in health activities. The NGO representative in Sampaguita claimed that: “devolution is good if the mayor is a good leader . . . because medicines will be more available”. In general, the local councillors for health had lower regard for devolution and their role in the LHB. The interviews with health workers revealed that the local councillors for health in Talahib and Sampaguita were political opponents of the mayor, which may have affected their perceptions of
Table 2. Perceptions of local health board members toward devolution and their roles in the board, by study area, Philippines, 1997 Members’ attitudes
Mayor Appreciation of devolution Appreciation of LHB Appreciation of role in the LHB Perceived involvement in health decision-making Perceived influence in health decision-making Municipal health officer Appreciation of devolution Appreciation of LHB Appreciation of role in the LHB Perceived involvement in health decision-making Perceived influence in health decision-making DOH representative Appreciation of devolution Appreciation of LHB Appreciation of role in the LHB Perceived involvement in health decision-making Perceived influence in health decision-making NGO representative Appreciation of devolution Appreciation of LHB Appreciation of role in the LHB Perceived involvement in health decision-making Perceived influence in health decision-making Local councillor for health Appreciation of devolution Appreciation of LHB Appreciation of role in the LHB Perceived involvement in health decision-making Perceived influence in health decision-making
Functioning LHB
Non-functioning LHB
Iris
Talahib
Kamia
Sampaguita
0
0
0 0 0
0
0 0 0 0 0
0
0
= most of the time; = sometimes; = rarely; 0 = not at all. LHB = local health board; DOH = Department of Health. Sources: Synthesized from survey, key informant interviews and focus group discussions.
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Community participation in local health boards devolution and local health development. The councillor for health in Iris appeared totally unconcerned about the change in the system of governance as gauged from the faceto-face interviews with her.
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somewhat less influential in the making of final decisions (Table 2). The survey and interviews revealed that the mayors, municipal health officers and Department of Health representatives (in this order) were the most influential persons in local health decision-making.
Perceptions of the LHB and members’ roles There were variable perceptions of the LHB as an important mechanism for broader participation in local health decisionmaking. Of the LGUs with functioning LHBs, only the mayor of Talahib fully supported the LHB (Table 2). The mayor of Iris thought that LHB meetings were not necessary because “there was no money to talk about anyway . . .”. In Sampaguita, the mayor had low appreciation of the LHB, saying “there is no need for board meetings; the public health nurse tells me what is needed and I support her”. In Kamia, the Mayor wanted to convene the LHB but was restricted by his conflicts with the municipal health officer. In LGUs with functioning LHBs, the municipal health officers and Department of Health representatives appreciated the LHB. They felt highly involved and influential in health decision-making. An interview with the municipal health officer of Talahib, however, revealed that she considered her role as vice chairman and secretary of the LHB as an “added burden”, but she expressed this only after the LGU failed to provide salary adjustments to the health staff. The municipal health officer in Kamia did not at all value his role in the LHB, presumably because of his conflicts with the mayor. The role that local councillors for health play within the LHB was not fully appreciated. The Iris councillor for health claimed that she was “not informed about the meetings”, “busy with her business and other work” or “out of town”. Although they recognized their roles in the approval of the health budget and as legislators of health policies and ordinances, the councillors for health, in general, did not feel involved or influential in the making of the health plans. Moreover, only the NGO representative in Talahib perceived herself to be highly involved in LHB meetings, although
Community representation in the LHB In all the four cases, there was no democratic consultation in the selection of the NGO representatives. Except in Talahib, where the NGO representative was recommended by the municipal health officer, the mayors appointed NGO representatives of their choice. In Kamia, the NGO representative was a senior citizen; in Iris, a member of a women’s organization; in Sampaguita, an officer of a consumer cooperative; and in Talahib, the president of the association of barangay health workers. At the time of their appointments, only the Talahib NGO representative was active in community health affairs as required by law. Moreover, only the NGO representative of Talahib belonged to the lower socioeconomic class. Interviews with the mayors and NGO representatives indicated that the selection of the NGO representatives was somewhat arbitrary. In Kamia, the mayor made an instantaneous appointment of a person with whom he had one prior meeting. The Sampaguita NGO representative, against the mayor’s will, was selected because his group was the biggest NGO in the community. The Iris mayor did not appoint a member of an NGO engaged in health because this person was a political enemy. According to the records of the Talahib LGU, the Barangay Health Workers Association was not an accredited NGO in the community. Attendance in LHB meetings From the minutes of LHB meetings, it is apparent that the NGO representatives did not attend all meetings during 1997 (Table 3). In Iris, the NGO representative was present in only two of the four meetings. The Talahib NGO representative attended 6 of the 8 LHB meetings. The NGO representative in Iris claimed her absences were caused by “the demand on my time by business and professional work”.
Table 3. Local health board meetings and attendance of members, by study area, Philippines, 1997 Functioning LHB
No. of LHB meetings Attendance Mayor Municipal health officer DOH representative Local councillor for health NGO representative
Non-functioning LHB
Iris
Talahib
Kamia
Sampaguita
4
8
0
2
0 4 4 2 2
6 8 6 1 6
NA NA NA NA NA
0 2a 1 1 1
a When the doctor resigned from the LGU, the public health nurse took over. LGU = local government unit; LHB = local health board; DOH = Department of Health.
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However, the municipal health officers in LGUs with functioning LHBs and the Department of Health representative in Talahib were present in all their respective LHB meetings. The mayor in Iris never attended, but sent his representative instead. The local councillors for health were generally absent, either because they were “not informed about the meetings”, were “busy” with other activities or were not in the area at the time the meeting was set. This could also be attributed to their low regard for devolution, and in the case of Talahib and Sampaguita, their political competition with the mayor. Community consultations and negotiations in health decision-making It appeared that faster and less bureaucracy in decisionmaking were the gains of devolution. However, direct and regular consultations with the people were not very common, although in LGUs with functioning LHBs, more consultative assemblies were reported. In Iris, consultations with the people were made during the few medical missions in the barangays. In Talahib, the LHB consulted the barangay leaders regarding the activities of barangay health workers and the establishing of health stations. It also conducted health information campaigns (bandillo) with the support of the church. In the other areas, consultations with the people were done through the barangay councils. The NGO representatives did not conduct systematic consultations or feedback to the community except through informal mechanisms. Negotiating health decision options were frequently done through informal channels. The municipal health officers made direct negotiations with the mayor for routine and emergency matters. In Kamia and Sampaguita, negotiations took place in informal venues such as outside office hours, in corridors etc. Talahib is the only case in which the annual health plan and budget were deliberated upon by the LHB. Feelings of empowerment Except for the mayors and municipal health officers, empowerment was not in the consciousness of the other LHB respondents. The mayors felt empowered by devolution
because they make the final decisions in all LGU matters including health. Key informant interviews with the health staff revealed that the mayor had the final discretion on personnel recruitment and promotion, establishment of health facilities and purchase of drugs, mainly because “he controls the funds”. The municipal health officers in Iris and Talahib felt empowered because the mayor relied on them for all health matters in the community. Only the NGO representative in Talahib felt empowered because of her deeper involvement in community health matters. Community feelings of empowerment were generally low but were slightly higher in LGUs with functioning LHBs (Table 4). The interviews revealed that some people were not even aware of the change in the system of local governance. Only in Talahib were there “somewhat high” perceptions of participation and involvement in health activities, perhaps as a result of the active involvement of barangay health workers. Outcomes of LHB decisions In the four cases, the health plans focused primarily on the implementation of the Department of Health core programmes. However, in LGUs with functioning LHBs, there were more fund-raising activities and more health initiatives (e.g. herbal medicine project). In terms of budget, there were no definitive trends in the proportion of total LGU budget allocated to health in 1997 (Figure 2). In income-adequate LGUs of Iris and Kamia, there were substantial health budget increases after the LHB was established; however, most of these funds went to the upgrading of personnel salaries. Per capita expenditure on health was higher in LGUs with functioning LHBs, whatever their income designation. In 1997, per capita expenditure was P75 in income-inadequate Talahib and P71 in incomeadequate Iris compared to P49 in income-adequate Kamia and income-inadequate Sampaguita, both of which have nonfunctioning LHBs. Overall, satisfaction with government health services was generally higher in LGUs with functioning LHBs (Table 4). However, concerns about polluting industrial firms were
Table 4. Community awareness of devolution, participation, empowerment and satisfaction with health services (in mean ratingsa), by study area, Philippines, 1997 Variables
Functioning LHB Iris Talahib (n = 400) (n = 400)
Non-functioning LHB Kamia Sampaguita (n = 400) (n = 400)
Overall n = 1600
Awareness of devolution Perceptions of empowerment Perceived extent of participation in health activities Feelings of involvement in health Overall satisfaction with health services
2.0 1.6
2.6 1.9
1.5 1.4
1.3 1.1
1.85 1.50
3.9 3.7 4.0
4.1 4.0 4.3
3.7 3.5 3.8
3.3 3.3 3.5
3.75 3.62 3.90
a Where a score of 1 to 1.7 means ‘very low’, 1.8 to 2.6 is ‘somewhat low’, 2.7 to 3.5 is ‘average’, 3.6 to 4.4 means ‘somewhat high’ and 4.5 and above is ‘very high’ ; ‘n’ refers to number of respondents in each study area. LHB = local health board.
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Community participation in local health boards
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Figure 2. Percentage of total local government unit (LGU) budget allocated to health (1994–1997) by study area, the Philippines, 1997. Note: data for LGUs with functioning local health boards (LHBs) are solid lines; for LGUs with non-functioning LHBs are dashed lines. The @ symbol indicates a year when LHBs were organized.
expressed in Iris. In Sampaguita, the absence of a community doctor was a major complaint, but residents were quite happy with the free medicines distributed by the LGU.
Discussion This study confirmed the hypothesis that functioning LHBs facilitate community participation in health decision-making, although to a greater extent in Talahib compared to Iris. Clear distinctions were found between LGUs whose LHBs met regularly (functioning LHB) and LGUs with non-functioning LHBs. The former undertook more consultations with the community, more fundraising for health, and initiated health activities beyond the Department of Health core health programmes. The per capita expenditure on health was higher in LGUs with functioning LHBs, irrespective of community income status. The results also showed that mayors and municipal health officers felt empowered by devolution. Only the NGO representative in one community felt empowered because she was often consulted on community health matters. Community members in general were not aware of devolution and their potential roles in health decision-making. Devolution was viewed as the transfer of power from the national to the local government, specifically the mayor, rather than empowerment of the community. This study was limited by the research design used, the number of sample areas involved and the inability to find LGUs with LHBs that met monthly, resulting in less distinction in definition between functioning and non-functioning boards in the cases studied. Nevertheless, the results of the study raise legitimate questions regarding LHBs as the primary mechanism for community participation and empowerment in health decision-making. Firstly, the LHB is only an advisory body and the final decision on whether to implement LHB recommendations comes from the mayor. Secondly, there is only one community representative on the board, and the arbitrary method
of selection has resulted in lack of representativeness for their respective communities. Thirdly, except for one, neither the NGO representatives themselves nor the communities actually understood their role as voice of the people in LHB meetings, and there was little feedback by the NGO representatives to the community on LHB discussions and decisions. Finally, the opportunity for community participation was further reduced when the boards did not meet regularly, where informal negotiations predominated, where the mayors and the LHB members did not see the value of broader participation in decision-making, and where there was open hostility between the mayor and other board members. A further aspect of broader participation is the involvement of other sectors in wider health considerations. In the cases studied, the Department of Health representatives and municipal health officers played active roles in decisionmaking both in and out of LHB meetings, raising concerns that health was viewed primarily as a medical matter best handled by health personnel. The opportunities provided by a broad-ranging devolution (including agriculture, social welfare, environment and sanitation) for health were not exploited. A major factor that challenges the true operationalization of decentralization in the Philippines is the historical tradition of centralized governance with little popular participation, and the paternalistic attitude of old-time politicians.18 In general, mayors approved of devolution because it gave them more ‘power’ or ‘control’ over health services. But if control is seen as the most important dimension of devolution, rather than democratization, this is problematic for community participation, because it can lead to paternalism and political patronage. Popular participation and empowerment are influenced by: (1) awareness of the importance of the issue; (2) perceptions about capacity to influence decisions; and (3) opportunities available for participation.19 In three of the four cases studied, these factors were not sufficiently high
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among LHB members to facilitate active community participation. However, in Talahib, substantial progress had been made. Can a structure like the LHB enable communities to participate in countries where most people are poor and a narrow class has monopolized public decision-making19 for many years? The results from Talahib, and to some extent Iris, demonstrate that an LHB can be an arena for initiating community participation and empowerment. Al-Mazroa and alShammari,5 in their study of the decentralized health system in Saudi Arabia, also showed that community participation and intersectoral collaboration increased through the setting up of regional committees. However, the study’s findings indicate that, in general, insufficient attention was given to factors that would enhance community participation and empowerment. These include building community consciousness toward participation, democratic selection of the community representatives, providing a sufficiently purposeful role for the local health board, and ensuring that board members fully understand their roles and responsibilities with clear mechanisms for accountability.
Conclusions In conclusion, the results of this study corroborate past observations that the process of devolution is long and complex,20,21 especially in countries with fragile democracies like the Philippines. They show that the objectives of decentralization cannot be achieved by simply changing the system of governance. A more thoughtful groundwork for devolution is necessary before broadened participation and empowerment of the community can be attained. Thus, a number of policy changes are recommended to strengthen the LHB as a mechanism to broaden community participation. First, the importance of the LHB as a vehicle for community participation should be vigorously advocated to LGU leaders, health workers and other stakeholders by the combined efforts of the Department of Health and the Department of Local Government. A key influential person, whether from government, NGOs or unorganized groups, with high commitments to health, could be tapped to lead the initiative. Part of the advocacy should be a thorough discussion of the roles, responsibilities, expectations, accountability and benefits that could be derived from being an active LHB member. Orientation and appreciation seminars, skills training (e.g. negotiation strategies, strategic planning methods) and group enhancement activities can be conducted among these groups. Second, local activities to raise the consciousness of the community should be conducted by the LHB and NGOs to strengthen the appreciation of a holistic and democratic system of governance.22 The methods should be participatory, innovative and sensitive to the cultural and psychological sentiments of the people. They must ensure that community members understand their rights and the processes to participate in health decisions.
Third, there should be more community representatives on the LHB, selected by consensus by the community during village assemblies to balance the influence of the local government officials. These community representatives could come from NGOs engaged in activities other than health (e.g. environment, social services, agriculture), people’s organizations and unorganized community members. Although the law mandates that mayors appoint NGO representatives, guidelines can be made to ensure that only people who were recommended during the village assemblies can qualify as the community representative in the LHB. The Department of Health should also reassess the criteria used for defining a functioning LHB. More substantive indicators, such as number of local health initiatives, amount of money allocated to health as well as achievement of desired health outcomes, could substitute for regularity of LHB meetings as the criteria for functionality. The Philippines has had 7 years of valuable experience from which lessons can be drawn for devolution to work more effectively. Although systemic problems such as class structure and political traditions can make strategies to improve community participation a more complex task, the participatory traditions and values of the community can be used to capitalize on the initial steps that have been taken for greater community participation and empowerment in local government.23 Countries planning to decentralize their health systems to broaden community participation should, therefore, seriously consider the political, sociocultural, psychological and financial constraints that may impede the achievement of the desired outcomes of decentralization.
Endnotes i The Philippines has 16 regions classified according to geographical proximity and ethnolinguistic similarities. The sample areas belong to Region VIII. ii The actual names of the sample areas can be requested from the researchers. Our contact address is incorporated in this article.
References 1
Singer MA. Community participation in health care decisionmaking: is it feasible? Canadian Medical Association Journal 1995; 153: 421–4. 2 Milewa T, Valentine J, Calnan M. Managerialism and active citizenship in Britain’s reformed health service: power and community in an era of decentralisation. Social Science and Medicine 1998; 47: 507–17. 3 Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Social Science and Medicine 1998; 47: 1513–27. 4 Lomas J, Woods J, Veenstra G. Devolving authority for health care in Canada’s provinces: An introduction to the issues. Canadian Medical Association Journal 1997; 156: 371–7. 5 Al-Mazroa Y, al-Shammari S. Community participation and attitudes of decision-makers: towards community involvement in health development in Saudi Arabia. Bulletin of the World Health Organization 1991; 69: 43–50. 6 Elstad JI. Health services and decentralized government: the case of primary health services in Norway. International Journal of Health Services 1990; 20: 545–59.
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Community participation in local health boards 7 Chamberlin C, Saadah F, Scheyer S et al. Philippines devolution and
health services: Managing risks and opportunities. Washington, DC: The World Bank, May 1994. 8 Perez JP. Decentralization and health systems change: managing transition dilemmas in the early years of devolution in the Philippines, Manila, 1995. 9 Department of Health. Rules and regulations implementing the Local Government Code of 1991. Manila: Department of Health, 1993. 10 Department of Health. Responding to questions on devolution of health services: the Local Health Boards. Guidebook for governors, mayors and members of the Local Health Boards. Manila: Department of Health, 1993. 11 DOH/LGAMS. Guidelines for the utilization, disbursement and reporting of the Health Development Fund. Manila: Department of Health, 1996. 12 Field Epidemiology Training Program. Project report on the survey on municipal health officers on issues and concerns after devolution, 1994. 13 DOH-Senate. Project report on the national survey of health sector and local government officials on the impact of devolution of health services on the health system of the Philippines. Manila: Department of Health, 1994. 14 WHO-DOH/LGAMS. Project report on a follow-up survey on devolution, 1995. Manila: Department of Health. 15 Diokno BE. A policymakers’ guide for the use of central-local transfers: the Philippine case. Manila, 1996. 16 Capuno JJ. Project report on the devolution and local health expenditures in the Philippines: central transfers, spillovers and rents. 1996. 17 Capuno J, Solon O. Project report on the impact of devolution on local health expenditures: anecdotes and preliminary estimates from the Philippines. 1996. 18 Carino L. The land and the people. In: de Guzman R, Reforma M (eds). Government and politics of the Philippines. Oxford: Oxford University Press, 1988: p.145. 19 Meyer W. The political experience: a preface to the study of politics. University of Michigan Press, 1978. 20 Mills A. Decentralization concepts and issues: a review. In: Mills A, Vaughan P, Smith D, Tabibzadeh I (eds). Health system decentralization: concepts and issues. Geneva: World Health Organization, 1996. 21 Vaughan JP. Lessons from experience. In: Mills A, Vaughan P, Smith D, Tabibzadeh I (eds). Health system decentralization: concepts and issues. Geneva: World Health Organization, 1996. 22 Romero S. Local governance for local empowerment. Diliman Quezon City, The Philippines: SALINLAKAS, Institute for Strategic and Development Studies, 1995. 23 Seedat M. Science, resilience and implications for prevention. Paper presented at the International Conference on Safe Communities, Johannesburg, South Africa, October 1997.
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Acknowledgements This project was supported by the WHO/TDR Initiatives on Health Sector Reform (Project ID 960999) and the DOH-LGAMS. We wish to thank Juan A Perez III and Alex Herrin for their important inputs to this project. To David Evans, Anne Mills and Max Price for their invaluable contributions to the development of the project protocol; Norman Hearst, Erik Blas, Ruairi Brugha and colleagues in the Surabaya workshop for their comments on the manuscript; and the mayors, LHB members, health staff, community respondents, our research assistants, Neil Liwanag and Romy Marcaida and field interviewers, our many thanks.
Biographies Laurie S Ramiro is Associate Professor of Psychology and Health Social Science in the Department of Social Sciences, College of Arts and Sciences, and Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila. Fatima A Castillo is Professor of Political Science in the Department of Social Sciences, College of Arts and Sciences, University of the Philippines, Manila. Tessa Tan-Torres, MD, is Associate Professor in the Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila. Cristina E Torres is Professor of History in the Department of Social Sciences, College of Arts and Sciences, University of the Philippines, Manila. Josefina G Tayag is Professor of Political Science in the Department of Social Sciences, College of Arts and Sciences, University of the Philippines, Manila. Rolando G Talampas is Assistant Professor of History in the Department of Social Sciences, College of Arts and Sciences, University of the Philippines, Manila. Laura Hawken is a Consultant with the WHO Humanitarian Mission, Albania. Correspondence: Prof. Laurie S Ramiro, Department of Social Sciences, College of Arts and Sciences, University of the Philippines Manila, Padre Faura st. Ermita, Manila, Philippines. Fax No. (632) 526-4265. Email:
[email protected]
