THE DEVOLUTION OF THE

DOH
 VISION-MISSION OF DOH
• Vision – To be the leader of health for all in
the Philippines

• Mission - Guarantee  equitable, sustainable

and quality health for all Filipinos, especially
the poor, and to lead the quest for
excellence in health. 
 HISTORY OF THE DOH
• In 1947, under Executive Order No. 94, series
of 1947, the Bureau of Public Welfare to the
Office of the President and the Department
was renamed Department of Health (DOH)
 HISTORY OF THE DOH
• In 1987, the re-organization under Executive
Order No. 119, which placed under the
Secretary of Health five offices headed by an
undersecretary and an assistant secretary
– These offices are:
• Chief of Staff, Public Health Services,
Hospital and Facilities Services,
Standard and Regulations, and
Management Service
 HISTORY OF THE DOH
• In 1992, the full implementation of Republic
Act No. 7160 or Local Government Code. The
DOH changed its role from one of
implementation to one of governance.

• In 1999, the functions and operations of the

DOH was directed to become consistent with
the provisions of Administrative Code 1987
and RA 7160 through Executive Order 102
LOCAL GOVERNMENT CODE OF
1991 (LGC)

• DEVOLUTION refers to the act by which the

national government confers power and
authority upon the various LGUs to perform
specific functions and responsibilities.
LOCAL GOVERNMENT CODE OF
1991 (LGC)
• The main feature of the LGC is the
relinquishing of responsibilities of the
national government in favor of local
government units in the provision of
public goods and social services.

• To efficiently deliver the devolved tasks,

the LGUs were given increased powers to
mobilize their own resources.
LOCAL GOVERNMENT CODE OF
1991 (LGC)
• AIM: To improve the health status of the
Filipino people through greater and more
effective coverage of national and local
public health programs, increase access to
health services especially for the poor, and
reduce financial burden on individual
families.
 OFFICES IN THE DOH
• The DOH is composed of:
– about 17 central offices
– 16 Centers for Health Development
located in various regions
– 70 hospitals and 4 attached
agencies.
The central office is composed of the Office of
the Secretary and five major function clusters

• Office of the Secretary

– Health Emergency Management Staff; Internal
Audit Staff, the Media Relations Group and the
Public Assistance Group including 3 major Zonal
Offices of the DOH located in Luzon, Visayas and
Mindanao.
– These offices are mandated to coordinate and
monitor the implementation the Health Sector
Reform Agenda, the National Health Objectives
and the Local Government Code with the
various Centers for Health Development
• Sectoral Management Support Cluster
– composed of Health Human Resource
Development Bureau and the Health Policy
Development and Planning Bureau

• Internal Management Support Cluster

– composed of the Administrative Service,
Information Management Service, Finance Service
and the Procurement and Logistics Service
• Health Regulation Cluster
– composed of the Bureau of Health Facilities and
Services, Bureau of Food and Drugs and Bureau of
Health Devices and Technology

• External Affairs Cluster

– composed of the Bureau of Quarantine and
International Health Surveillance, Bureau of
International Health Cooperation and Bureau of
Local Development
• Health Program Development Cluster
– composed of the National Center for Disease
Prevention and Control, National Epidemiology
Center, National Center for Health Promotion and
National Center for Health Facilities Development
 THE CENTER FOR HEALTH
DEVELOPMENT
• Responsible for field operations of the Department
in its administrative region

• Providing catchment area with efficient and

effective medical services

• It is tasked to implement laws, regulation, policies

and programs.

• It is also tasked to coordinate with regional offices

of the other Departments, offices and agencies as
well as with the local governments.
 DOH HOSPITALS
• Provides hospital-based care
• Provides specialized or general services
• Some conduct research on clinical
priorities and training hospitals for
medical specialization.
ATTACHED AGENCIES
• The Philippine Health
Insurance Corporation
– is implementing the
national health
insurance law
– administers the
medicare program for
both public and private
sectors.
 ATTACHED AGENCIES

• The Dangerous Drugs

Board
– coordinates and
manages the dangerous
drugs control  program
ATTACHED AGENCIES

• Philippine Institute of
Traditional and
Alternative Health
Care

• The Philippine
National AIDS Council
DISTRIBUTION OF TASKS
BETWEEN LGUs
 DOH Structure (Pre-devolution)
Office of the Secretary of Health

Executive Committee for

National Field Operations

15 Regional
Field Offices
Regional Hosp.
Medical Centers
Sanitaria
Provincial Health
Offices
Provincial
Hospitals District
Health
Offices

City Health District Municipal

Offices Medicare & Health
Municipal Offices
Hospitals
BHSs
 Health Structure (1993, Post-devolution)
Office of the Secretary of Health

Executive Committee for

National Field Operations

15 Regional
Field Offices
Regional Hosp.
Medical Centers
Sanitaria
Provincial Health
Offices
Provincial
Hospitals
A District
Health
Offices

City Health District Municipal

Offices Medicare & Health
Municipal Offices
B Hospitals
C BHSs

A Devolved to Prov’l Gov’t B Devolved to City Gov’t C Devolved to Municipal Gov’t

 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
• ROLES:
– lead agency in articulating national objectives for
health to guide the development of local health
systems, programs and services
– direct service provider for specific programs that
affect larger segments of the population
– lead agency in health emergency response
services, including referral and networking
systems for trauma, injuries and catastrophic
events
 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
– technical authority in disease control and
prevention
– lead agency in ensuring equity, access and
quality of health care services through
policy formulation, standards development
and regulations
 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
– technical oversight agency in charge of
monitoring and evaluating the
implementation of health programs,
projects, research, training and services

– administrator of selected health facilities

at sub national levels that act as referral
centers for local health systems
 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
– innovator of new strategies for responding
to emerging health needs

– advocate for health promotion and healthy

life styles for the general population
 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
- capacity-builder of local government units,
the private sector, non-government
organizations, people's organizations, national
government agencies, in implementing health
programs and services through technical
collaborations, logistical support, provision of
grant and allocations and other
partnership mechanisms
 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
- lead agency in health and
medical research

- facilitator of the
development of health
industrial complex in
partnership with the private
sector to ensure self-
sufficiency in the production
of biologicals, vaccines and
drugs and medicines

- lead agency in health

emergency preparedness
and response
 ROLES AND FUNCTION and
POWERS OF DOH (E.O. #102)
• protector of standards of
excellence in the training
and education of health care
providers at all levels of the
health care system
• implementor of the National
Health Insurance Law;
providing administrative and
technical leadership in
health care financing
POWERS AND FUNCTIONS OF DOH
• Formulate national policies and standards for
health
• Prevent and control leading causes of health
and disability
• Develop disease surveillance and health
information systems
• Maintain national health facilities and
hospitals with modern and advanced
capabilities to support local services
POWERS AND FUNCTIONS OF DOH
• Promote health and well-being through
public information
• To provide the public with timely and
relevant information on health risks and
hazards
• The resource allocation shift, specifying the
effects of the streamlined set-up on the
agency budgetary allocation and indicating
where possible savings have been generated
 POWERS AND FUNCTIONS OF DOH
• Develop and implement strategies to
achieve appropriate expenditure
patterns in health as recommended
by international agencies
• Development of sub-national centers
and facilities for health promotion,
disease control and prevention,
standards regulations and technical
assistance
• Promote and maintain international
linkages for technical collaboration
POWERS AND FUNCTIONS OF DOH
• Create the environment for development of
a health industrial complex
• Assume leadership in health in times of
emergencies, calamities and disasters;
system fails
• Ensure quality of training and health human
resource development at all levels or the
health care system
 POWERS AND FUNCTIONS OF DOH
• Oversee financing or the
health sector and ensure
equity and accessibility to
health services
• Articulate the national
health research agenda and
ensure the provision of
sufficient resources and
logistics to attain excellence
in evidenced-based
interventions for health
Impacts of Devolution
 Introduction
• 7100 islands
• Political local government units – local
chief executive
• 18 administrative regions
• Approximate population: 78 million
– 52% urbanized
• “High functional literacy rates”
• Life expectancy at birth – 68 years
• Poverty – 37.5%
 Introduction

• Health profile – “generally typical of

a middle developing country”
• Persistent high fertility rates
• Declining mortality rates
– CVD & cancer
– TB – 5th leading cause
• High infant & maternal mortality
• “Double burden”
 Aims
• Provide background to the
introduction of devolution to the
health system in the Philippines
• Describe the impact of devolution on
the health system, services, &
selected health status in 2 selected
provinces in the Philippines
– Surigao del Norte & South Cotabato
 Methods
• Decentralization – delegation of powers
from central towards provincial or district
departments of health
• Rapid appraisals of health management
systems
– Objectives:
– Baseline data for project monitoring &
evaluation
– Analysis of the health situation for the
provincial health office
 Methods
• Methods used for appraisal:
– Field observation
– Interviews
– Health managers & staff, local chief executive, community
members
– Group discussions
– Health managers & staff, local chief executive, community
members
– Review of health information data & socioeconomic
profile
– Survey questionnaires
– Circulated to all district hospitals & rural health units
• Facility response rate - >90%
 Methods
• Data analysis through: Field
Health Information System
• According to health
management system
themes:
– Health financing
– Human resource development
– Health referral systems
– Health planning
– Community participation
 Results
• Aims of decentralization
& devolution: improve
the efficiency &
effectiveness of health-
service provision through
reallocation of decision-
making & resources to
peripheral areas
 Results
• Negative effects:
– Under- prepared middle level
management
– Increased local political influence
& control over technical
management
– Decline in quality of
infrastructure & service delivery
• Sharp decline in the
accessibility & availability of
rural health services
 Human Resources Impacts

• No strategic plan for the

introduction of devolution
• No prior development of
health staff or local
government executives &
officials for their new roles
• Insufficiently prepared to
cope with the wide sweeping
changes of devolution
 Human Resources Impacts
• LGAMS (Local Government Assistance
& Monitoring Services)
– Represent DOH in legislative bodies &
inter- agency concerns related to
devolution
– To assist & support DOH representatives at
the peripheral level
– Limited resources & adequately prepared
staff
 Human Resources Impacts
1st year post devolution resulted into:
– Decreased hospital occupancy & health center
utilization rates
– Untimely or decreased procurement of drugs,
medicines, and supplies
– Decreased maintenance & operating expenses
for health facilities
– Loss of managerial & fiscal control of hospitals
– Resignation of key personnel
– Low staff morale
 Human Resources Impacts
• Perceived loss of regulatory control by
the DOH
• Perceived political recruitment &
retention of health staff at the LGU
level
• Loss of national bureaucracy
– Rapidly filled by local government
political power
 Health Administration
Impacts
• Difficulty in managing referral systems
• Operations of the referral systems are
hindered by the limits of jurisdiction
– retrains the cooperative health activities
of the devolution
Financing and Utilization of
Health Services Impacts
 Financing and Utilization of
Health Services Impacts
• Since the advent of
devolution, the under
financing of public health
services had resulted in
their slow decay.
• Decay measured in terms of:

under staffing
low utilization rates
un-maintained infrastructure
unrepaired or unreplaced equipment
 Financing and Utilization of
Health Services Impacts
• Provincial health
expenditure statistics
indicate very high
expenditure on personnel,
but contrastingly very low
expenditure on resources
to deliver services and
virtually no funding for
capital investment.
 Financing and Utilization of
Health Services Impacts
• Lack of investment in
public infrastructure
and operational cost
-> under utilization of
services and the high
out of pocket expenses
by those who access
the services
Table 1: Indicators of Provincial expenditure on health,
Surigao del Norte and South Cotabato, the Philippines,
1998†
http://rrh.deakin.edu.au/publishedarticles/article220_1.gif
 Health Referral System
Impacts
• Due to understaffing, lack of
operating expenses and decaying
infrastructure -> distinction
between levels of service was
being lost

• Primary and secondary hospitals

-> sited next to rural health units
but were performing same basic
outpatient health center function
 Health Referral System
Impacts
• Under financing and under resourcing
-> primary and secondary hospitals
incapable of providing referral services
to the health centers
• Access to essential surgical and
obstetric services in the primary and
secondary hospital was reduced
 Health Referral System
Impacts
• National health system -> lines of
authority and reporting are clear from
central to peripheral level.
• Devolved system -> relationships of
power and authority between health
managers at different levels are more
complex (primary accountability is to
political authority)
Responding to the effects of reform
1998 by making devolution work
• “disintegration” of
systems - most obvious
feature of early
implementation of
devolution in the
Philippines

• Two options remained:

reintegration of systems through

re-nationalization
reintegration of systems through
“making devolution work”
Responding to the effects of reform
1998 by making devolution work
• Third Philippines National Health
assembly -> a concept for for an inter LGU
health system based on Inter Local Health
Zone was proposed to foster greater
collaboration and coordination for health
between LGUs
Responding to the effects of reform
1998 by making devolution work

• In early 1999, League of

governors, with DOH and
DILG entered into health
covenant to achieve a
unified integrated health
care delivery system
based on Inter LGU
approach.
Responding to the effects of reform
1998 by making devolution work
• To encourage and facilitate
inter-LGU cooperation and
innovative strategies and
approaches for basic
health service delivery,
President Estrada issued
Presidential Executive
Order 205 in January 2000
mandating establishment
of ILHZ and Integrated
(inter-LGU) Health
Planning.
 Responding to the effects of reform 1998
by making devolution work
• In mid-2000, the then Hon. Secretary of Health, Alberto
Romualdez launched the Health Sector Reform Agenda
(HSRA) to guide the DOH in its support of LGUs in their
efforts to 'make devolution work'. The HSRA outlines
reforms in three key areas:

Health services delivery reforms for local health systems,

government hospitals and public health programs.

   Health regulatory reform to fill gaps post-devolution and since the

advent of the ILHS.

Health financing reforms for the National Health Insurance Program and
creation of mechanisms for complementation with community health
insurance schemes.
 Discussion and conclusions
• A primary aim of decentralization is to
increase the resource base for primary
care, by shifting as many resources as
possible from central to peripheral
locations.
 Discussion and conclusions
• A second aim is expand the ‘decision
making space’ of middle and lower
level managers, in order to increase
the responsiveness of sub national
authorities to local health needs and
situations.
 Discussion and Conclusions
• A third aim of decentralization is to
enhance the efficiency and
effectiveness of health services
management through prompt and
appropriate middle level management
decision-making.
 Issues in the process of devolution

Underspending in the health sector:

• Health sector accounts for almost

half of the devolved fxns to LGUs.
• Nat’l healthcare spending continued
to increase in nominal terms for the
past years
• Decline in percentage share of total
gov’t spending on health
 Issues in the process of devolution

• Share of local gov’t in healthcare spending

continued to increase in nominal terms after the
devolution, in 1993.

• Local gov’t expenditures increased in

nominal terms from 7% of total gov’t
expenditures in the 1985-1991 period,
to 14.7% in the 1992-1997 period
• LGU’s health expenditure has fallen
short of the cost of devolved health fxns
(CDHF).
• Due to devolution, the share of local gov’ts in health
expenditures has increased, but the LGUs are spending
less than what the nat’l gov’t used to spend for local
health services before devolution.

• Reduction in spending in health was actually

accompanied by a marked decline in the quality of
health services----proving that there was indeed
underspending in the health sector.
Unfunded devolution:
• Ironically, after the devolution, the
national agencies continued to receive
increasing budget allocations.
• These budgets do not even reflect devolutions as a
priority.
• Central office of the DOH accounts for almost 37% of
the budget for administration and support. The regional
offices share the rest which are the coordinating arms
of the national agencies to the LGUs in the
implementation of their task.
• In health sector- regional offices is limited to managing
the regional hospitals and assisting the nat’l agency in
the implentation of public health programs.
• Regional agencies are
expected to provide
technical assistance to LGUs

• They are not able to

provide the LGUs with
enough technical support to
allow these LGUs to deliver
effectively on devolved
services due to inadequate
finding and utilization of
funds.
 Mixed feedback on quality

• DOH has achieved a certain degree of

devolution with respect to functions

• Quality of healthcare delivery after

devolving the major task to LGUs should also
be examined
 Mixed feedback on quality
• Poor availability of drugs in
comparison with the period
prior to devolution

- experts expressed concern

over the deterioration of
technical quality, while
most of the people
expressed more views
- technical performance –
no significant change in the
volume of in-patients
treated or outpatient
consultations
 Mixed feedback on quality
- quality of care deteriorated in terms of supplies
equipment, and infrastructure because of decreased
funds for maintenance and other operating expenses
(MOOE) and almost non-existent funds for capital outlay
(USAID n.d.)
In the management of devolved hospitals and
availability of facilities, the ff were observed:

• Devolved hospitals have deteriorated, since

it cost more in 1998 to deliver the same
volume of services delivered in 1992
• Philippine government hospitals, especially
those at the provincial and district levels,
have become poorly equipped and
undernamed
• Regional and national hospitals, owing to the
unmet health demands at the local level, are
congested
In the management of devolved hospitals and
availability of facilities, the ff were observed:

• Networking and patient referral

systems between national and
local, and between public and
private, hospitals are inadequate

• Gov’t hospitals still rely heavily

on direct subsidies from national
and local gov’ts

• There is inadequate and

uncoordinated implementation of
public health programs in
hospitals
 In the management of devolved hospitals and
availability of facilities, the ff were observed:

• Only 1/3 of the total number of hospitals

and about ½ of hospital beds are public

• Out of the country’s 41,000 barangays,

only ¼ have barangay health stations.
These gov’t facilities have regained
notoriety as sorely lacking in equipment,
medicines, and staff

A number of researches support the

observation that there has been
deterioration of health services after
devolution
 Demoralization among rank and file

• Significant deterioration of employment

conditions of developed personnel, causing
demoralization
• Health sectors - salaries of devolved workers
decrease relative to central gov’t employees
(by 1/5 to 1/3 on avg), and civil servant
vertical career mobility was interrupted by the
fragmentation of the public health system
 Demoralization among rank and file

• Strong objections from

health care workers brought
about the passing of Magna
Carta of health workers,
which resulted in further
disarray
• Affected or devolved
personnel have little or no
chance of availing
themselves of any training
or scholarships, both local
and foreign coz national
employees are prioritized.
 Re-nationalization of some hospitals

• DOH continues to retain 48 hospitals, 35 of

which are classified as tertiary. The re-
nationalization of these hospitals resulted in
the DOH putting 52% of its budget into the
maintenance of these hospitals
• Explains the continuous increase in the budget
of DOH, despite the devolution of almost 70% of
its personnel
Lack of coordination

• Free riding and negative

externalities
• Quality of health of individuals
in a municipality influences the
health of adjacent
municipalities
• The delineation of
responsibilities and functional
relationships between nat’l
gov’t agencies, including the
DA, LGUs and other
stakeholders, remain unclear
and the linkages among
research, training and extension
remain weak.
 What Went Wrong?
• Dependency on the IRA

– Failure to maintain developed

hospitals
– Decline in quality of healthcare
services
– Inability to sustain technical
personnel
– Inability to shoulder the required
costs
– Lack of funds by the LGUs
 What Went Wrong?
– IRA is not enough to cover the cost of devolution
– Purpose of IRA is not to fully cover the cost but to
augment the budget
– Recommendation: IRA should be formatted to
factor in a mechanism that will encourage LGUs
to source their own funds
– Dependency on IRA is not compatible with fiscal
autonomy
What Went Wrong?
1. Lack of Technical
Resources

– LGUs cannot maintain

their technical personnel
due to insufficient
financial resources
– LGUs should administer
their localities and act as
economic managers
– Lack of appreciation of
developed tasks
 What Went Wrong?
1. Plain Politics

– Re-nationalization of some hospitals is a result

of lack of budget of LGUs to maintain these
medical centers
– Due to fiscal incapacity and result of politics
– The provision of social services depends not on
what is needed but on what activities will get
greater mileage for the political career of
government officials
 What Went Wrong?
– Most appointments for position
are based not on merit and
credibility, but on personal
relationship of individuals to
lead local leaders

– As a result, individuals without

enough competence and skills
are made to manage the
delivery of social services
Congressional initiatives to address the
problem of devolution

• A number of initiatives seek to

address the problem in healthcare
delivery

• Bills that aim to provide incentives

and additional benefits to barangay
heath care workers and rural health
doctors

• Bills that suggest the formulation of

a National Health Code and a
comprehensive national health
facilities program
 Congressional initiatives to address the
problem of devolution

• A bill that tries to address lack of operational

budget

• 2 possible reasons in attempting to re-nationalize

hospitals:

– LGUs lack the capability to maintain the hospitals

– Politics
 Conclusion
• The obligation of LGUs to
their constituencies has
become a tool for politics

• The effectivity and efficiency

of decentralized governance is
compromised

• Decentralizing the provision of

basic services will help people
identify the kind and amount
of services they want to
receive
 Conclusion
• The problems with the IRA formula have to be
addressed

• Period of transition and adjustment for the LGUs,

the national government, and the constituents

• Premature to prescribe re-nationalization as the

solution to improve the current state of social
services delivery
THANK YOU!!!