Philippine Institute for Development Studies
Policy Notes December 1998
Health Management Strategies of Selected Cities
ure of health workers under a decentralized regime, the financial and management capability of local governments, and the ensuing politicization of health services. There were scores of gripes, too, ranging from insufficient or delayed release of funds and supplies to health not being a priority of local executives. Many local officials complain that their internal revenue allotment (IRA) is inadequate to finance devolved functions. There is evidence for this complaint. Manasan reports that provinces shoulder 60 percent of the total cost of devolution of health services while cities shoulder only 2.5 percent. Both receive the same proportion of IRA.
he number of people living in cities continues to grow unabated. This growth, further swelled by rural folks lured by bright lights and jobs, puts an increasing strain on city health services and sanitation facilities. The devolution of government functions to local governments has given local officials greater autonomy to face, head on, the challenge of urbanization. Whether local officials resort to being "cry babies" or rise up to the call of duty depends on how they perceive the situation. Some see devolution as a threat, others as an opportunity.
Pros and cons The health sector was particularly opposed to devolution. There were concerns regarding the security of ten-
Advocates of devolution were more optimistic. They counter that devolution can, in fact, improve health service delivery. With health workers under the jurisdiction of local governments, so the argument goes, decisionmaking is faster thus allowing for immediate action on health needs. Greater accountability to and closer association with the people also put local officials in the best position to undertake relevant health programs.
PIDS Policy Notes are observations/analyses written by PIDS researchers on certain policy issues. The treatise is wholistic in approach, and like the PIDS Executive Memo, it aims to provide useful inputs for decisionmaking. This Notes was recast and repackaged by Wilbert R. San Pedro based on PIDS Discussion Paper No. 98-36 of the same title authored by Virginia S. Pineda, Research Associate at the Institute. The views expressed are those of the author and do not necessarily reflect those of PIDS or any of the study's sponsors.
According to the Department of Healths Local Government Assistance and Monitoring Service (LGAMS), there was better overall primary health care management in places where the health sector and the local government have succeeded in forging a working relationship.
Galing Pook and Health and Management Information System (HAMIS) awards.
Passing the buck to local governments
Coping with insufficient health stations
Under devolution, city governments are mandated by law to provide primary health care and to support government health facilities from barangay health stations to city hospitals. It is no understatement to say that with one fell swoop, a great deal of responsibility has been shifted from the national government to the local governments.
Reaching out. Gingoog City delivers basic services to people who live far from government facilities through an outreach program. The Gingoog Total Integrated Development Approach or G-TIDA was initiated in December 1988 as an outreach program to rural barangays. It provides health, medical, infrastructure and other services.
These cities are Lapu-Lapu, Olongapo, Naga, Cotabato, Butuan, Surigao, Gingoog and Puerto Princesa.
A core group, organized by the mayor, plans and Primary health care includes health education, conimplements the program. It is composed of several coortrol and treatment of diseases, immunization, motherdinators and a secretariat. Outreach activities are done child health and family planning, environmental sanitation and provision of safe water supply, nutrition, and "The responsibility of providing primary health care is now supply of essential drugs. effectively in the hands of city governments. While many local Midwives and health workgovernments have still to get a grip of the situation, some city ers supply these essential governments have already started turning adversity into services at the barangay opportunity." level while physicians provide secondary health care in infirmaries, clinics and hospitals. Tertiary care is rendered by specialists in hosonce or twice a month. The G-TIDA team meets directly pitals with advanced facilities. with the people and their leaders to discuss the problems of the barangay. If problems cannot be given immeThe responsibility of providing primary health care diate attention, they are referred to higher authorities. is now effectively in the hands of city governments. While The team informs people about the services provided by many local governments have still to get a grip of the agencies in the city so they would know which to approach situation, some city governments have already started for their specific needs. turning adversity into opportunity.
Eight who made the grade We focus on eight exemplary cities whose health management strategiescharacterized by imagination and practicalitycould help other cities cope with the demands of devolution and urbanization. All eight have been winners of prestigious competitions such as the
Through the G-TIDA approach, people in some of the far-flung barangays were able to install water pipes connected to a spring using local resources and relying on the bayanihan system. Gingoogs outreach program is now on its tenth year and has provided a means for delivering health services
in areas without health stations. At present, all 50 rural barangays have health stations manned by a midwife and volunteer health workers. During the programs early years, the G-TIDA team stayed for two days and one night in a barangay. However, outreach is now limited to one day per barangay due to increased demand for outreach services. Expenses for outreach activities by participating agencies are taken from their regular agency budgets. There are no additional appropriations except for overhead expenses such as gasoline, transportation and food. In 1996, Gingoog City appropriated P189,400 for the program. Tapping private homes for public needs. To solve its lack of barangay health stations, Cotabato City tried a different approach. Since building costs for a concrete barangay health station is about P100,000, the city can, at most, only afford to build three structures a year. Unable to build more of these structures due to its limited funds, Cotabato City opted to use barangay halls and private homes as venues for health services. These alternative venues are free of charge. Today, Cotabato City has at least one health station for its 37 barangays and seven more extensions. Of these, 23 are permanent structures constructed by the city while the rest are lodged in barangay halls or private homes.
When health workers are scarce Volunteers for the common good. Another major problem when providing health care is the lack of personnel. The common approach to beef up manpower is to mobilize volunteers. Cotabato City activated 100 volunteers, mostly trained hilots, to assist midwives in barangay health stations. Olongapo City has some 300 health volunteers. For its rescue and emergency medical assistance program, Naga City has 400 trained first responders and emergency medical technicians, all of whom are volunteers. Since volunteers render free services, the city is able to save on salaries. In return, the cities reward them
through other means. For instance, Cotabato City gives a P500 Christmas gift to each volunteer while Olongapo City provides them hospitalization benefits. Naga City volunteers receive uniforms, group insurance, and food while on duty. Women power. Womens groups are valuable partners of city governments. Olongapos Balikatan Ladies of Olongapo Movement (BLOOM) has 6,000 members, many of them housewives. Aside from cleanliness projects, members volunteer as nursing aides in the city hospital, assist health workers in immunization drives and conduct health classes. Lapu-lapu City has mothers support groups consisting of 410 members. The city taps this group in its advocacy activities such as feeding children during nutrition month. In Surigao City, the Primary Health Care Federated Womens Club (PHC) laid claim to over 12,000 members in 1996, over 63 percent of households in the city at the time. As volunteers, PHC members operate and maintain barangay health stations and feeding centers. They record and follow up the immunization of children, assist pregnant women to obtain pre-natal check-up and conduct health education activities. They also learned to treat common illnesses through herbs and liniments. Involving private companies and medical practitioners. Lapu-lapu City requested private companies and institutions to assist in the health needs of specific barangays. Companies donate supplies and facilities as well as the services of doctors (retainers) who provide free clinics in adopted barangays on a monthly basis. At present, ten companies and five educational institutions have adopted eight barangays. Lapu-lapu Citys Health Office has also involved doctors affiliated with the Mactan Doctors Organization and nurses from the Mactan Community Hospital in its immunization program. The city provides the vaccines while the volunteers provide their services. Currently, 50 doctors and 100 nurses offer free services to different barangays. Maximizing available health practitioners. Cotabato
CityÂ’s Office of Health Services initially targeted at least one midwife stationed to each barangay. However, limited funds again hampered this goal, so the city shifted strategy and hired casual, instead of permanent, midwives. Salaries were sourced from the 20 percent development fund. Starting 1993, the city was able to provide one midwife, employed on a casual basis, to all 37 barangays. More casuals were hired to beef up manpower in its main health center. Salaries for casuals total P2.5 million yearly. Puerto Princesa CityÂ’s satellite clinics, another project financed by the 20 percent development fund, hired five doctors on a part-time basis. The city has five strategically located satellite clinics. A doctor provides medical services in his assigned clinic for two days per week. The remainder of the week, he works in hospitals or engages in private practice. The city pays its doctors P10,000 a month each. The schedules of doctors in satellite clinics are synchronized to maximize their availability. For instance, in one satellite clinic, the doctor's schedule is Monday and Tuesday. In the other nearest satellite clinic, the doctor's schedule is Thursday and Friday. This way, during those days when the doctor assigned to a satellite clinic is not scheduled to come, the patient can instead go to the nearest satellite clinic and avail of another doctorÂ’s services.
Meeting medical emergencies
barangays some 17 kilometers away. Emergency calls come not only from within Naga City but also from neighboring towns. ERN has an extensive radio network linking the offices of the mayor, the ambulances, police and fire stations within Metro Naga. Key personnel of the 14 LGUs comprising Metro Naga were also provided with hand-held radios.
"The Emergency Rescue Naga (ERN) is a quick response unit led by the Naga City Hospital...whose average response time is three to five minutes within the city proper and 30 minutes for the farthest mountain barangays some 17 kilometers away."
ERN has one paramedic, a driver, and 400 trained first responders and emergency medical technician volunteers. Regular hospital staff, numbering 40, are on call. Assistance is rendered by the Philippine National Police, Bureau of Fire Protection, City Disaster Coordinating Council, Task Force COMET (for calls involving peace and order problems) and other civic organizations. Facilities consist of three ambulances, one all-terrain rescue vehicle, one rubber boat, and a trauma van.
Quick response saves lives. Naga City initiated Emergency Rescue Naga (ERN) under its disaster preparedness program in April 1991. The ERN is a quick response unit led by the Naga City Hospital. It provides emergency medical assistance, rescue services, and transport to a hospital. It also gives medical back-up assistance to particular events.
In 1996 alone, ERN responded to 2,257 emergency and transport cases or an average of six trips per day. It has provided valuable rescue services during calamities such as super typhoon Rosing which caused floods of more than five feet in Naga in 1996. ERN evacuated more than 1,700 persons during that operation. The city spent P150,000 on ERN operations in 1997.
The ERN has two telephone hotlines and two VHF controls. Its volunteers are equipped with beepers. Average ERN response time is three to five minutes within the city proper and 30 minutes for the farthest mountain
Emergency Rescue Naga won the Galing Pook Award (top 20) in 1994, the Disaster Management Award for the regional level in 1995 and 1996, the national level in 1995, and the DOH Alay Buhay Award in 1996.
Saving lives in the boondocks. Puerto Princesa City has five strategically located satellite clinics to serve farflung barangays with no access to health services. The clinics handle emergency cases as well as simple illnesses. For more serious cases, ambulances bring patients to hospitals within the city. All barangays and tribal communities are provided with hand-held radios (VHF transceivers). Emergencies are reported to the barangay chairman who relay the information to the nearest satellite clinic which fields an ambulance and health personnel. If patients require hospitalization, the satellite clinic makes an advance call to the receiving hospital. A satellite clinic is manned by two midwives, a radio operator, a driver, and a utilityman. A doctor provides medical services for two days a week and a dentist comes every two weeks. A clinic is equipped with four or five beds. Between 1993 and 1997, the clinics have served an average of 47,000 patients per year. Most cases were simple illnesses such as respiratory infections. The clinics serve as a vital link to the citys referral system. They resulted in the increase in emergency cases and the decline in the number of patients with simple illnesses clogging hospital docks. Puerto Princesa Citys satellite clinics had a budget of P6.2 million in 1997 and are among the top 20 Galing Pook winners in 1996.
Augmenting finances Mandatory barangay allocations for health. Olongapo City requires its barangays to allocate five percent of their internal revenue allotment (IRA) to health and welfare. Drugs allocated to the barangays are sourced from this fund. In Cotabato City, barangays also finance their own medicines. Lapu-lapu City requires its barangays to provide allowance for barangay health workers ranging from P400 to P1,500 per month. Twenty percent development fund. Cotabato City
and Puerto Princesa City both use their 20 percent development fund for projects, salaries of temporary health personnel and satellite clinics. Contributions. In Surigao City, the Barangay Environmental and Sanitation Implementation Group (BESIG) members contribute their labor while the government provides the funds for infrastructure projects such as health stations and feeding centers. The citys PHC Federated Womens Club obtained P1.5 million for the construction of its training center from a senators Countrywide Development Fund. Under the share-food project of a Butuan City barangay, well-to-do families sponsor malnourished children for three months. In Lapu-lapu City, companies and
"In Lapu-lapu City, the city health officer toured all the barangays for one month to identify the people's needs and ways of improving health service delivery."
congressmen contribute to a milk feeding program for school children while a food manufacturer regularly gives noodles. They also donate facilities and supplies to the barangays.
Identifying health needs: knowing the problem gets you half the way there Tour of duty. In Lapu-lapu City, the city health officer toured all the barangays for one month to identify the people's needs and ways of improving health service delivery. He traced the city's low performance in the Expanded Program of Immunization (EPI) to the absence of a specific schedule for immunization and doctors visits and peoples lack of interest. A permanent schedule was set and people were encouraged to go to their barangay health stations. As a result, Lapu-lapu was awarded the Most Accelerated City in EPI in 1991.
Currently, the city health officer goes to the barangays three to four times a week to check on the status of programs. The mayor goes visiting with him three to four times a month. The health officer also conducts a barangay assembly every quarter. He presents current government health projects and solicits comments from the community on their health priorities. The community participates in coming up with solutions to address its problems.
rounds and issue citation tickets (fines) to violators of sanitation ordinances (such as unclean premises and putting out garbage outside of the scheduled collection time). This combination of health and environmental management resulted in the reduction of sanitationrelated diseases such as typhoid fever and paratyphoid infections. The occurrence of these diseases declined from 75 percent in 1988 to 9 percent in 1995 per 100,000 population.
Going down to the grassroots level. In Olongapo City, the mayor goes to the barangays accompanied by his department heads to see the actual situation at the grassroots. The mayor visits all 17 barangays within a quarter. During barangay consultations, the people air their problems to the mayor. The department head who has jurisdiction over the problem is tasked to take action and start with the solution the following day. People report to the mayor in case the problem remains unsolved.
Clustering of barangays: a new meaning for hamletting
"Gingoog City opted for an integrated approach for its outreach program, well aware that there are problems which cannot be solved by one agency alone but by several agencies working together."
Integrated approach: The sum is greater than its parts Gingoog City opted for an integrated approach for its outreach program, well aware that there are problems which cannot be solved by one agency alone but by several agencies working together. Olongapo City strengthened the linkage between health and sanitation by integrating its environmental management program with health activities. The Community Health Office plays a major role in solid waste management. Its sanitar y inspectors conduct regular
For more effective super vision and monitoring, Cotabatos Office of Health Services grouped its 37 barangays into seven clusters. Each cluster is supervised by a coordinator who monitors the activities of his respective cluster. Dividing the 37 barangays among seven coordinators simplified the task of supervision and monitoring since it enabled the coordinators to immediately respond to the problems of the barangays within their respective clusters.
Planning, monitoring and evaluation: dont expect what you dont inspect Seminars. Butuan Citys nutrition personnel together with the Department of the Interior and Local Government conducts planning seminars with barangay leaders. They compare the nutritional status of puroks in the barangay and guide leaders in making their quarterly action plans. The Cotabato Office of Health Services conducts semi-annual and annual review of programs. Regular feedback through meetings. In Surigao City, the PHC chapter monthly meetings provide the means for identifying community problems at the purok level. Monthly staff meetings, in addition to reports, are also conducted in Olongapo City to monitor and evaluate performance in the barangays. Health workers in each of Lapu-lapus eight districts and nutrition workers in each of Butuans ten barangay clusters hold monthly meetings for the same purpose. Community data board. Surigao Citys community
data board posts the health status of households. Each household is represented in the board by a small hut. The hut shows the house number, the name of the family head, the health concerns, and the period covered (first to fourth quarter). For comparison purposes, the previous years quarterly performance is included as baseline. The community data board is updated every quarter through a survey of all households. The survey inquires on health concerns such as pregnancies, immunization and nutrition status of children, garbage disposal, water source, occurrence of diseases, PHC health insurance membership, and availability of toilet. For each health concern, the health worker assigns a colored circle to indicate health status (below is an example).
barangays are evaluated using various criteria such as primary health care activities, food production and livelihood programs. Prizes range from P50,000 to P100,000. The city also ranks barangays according to prevalence of health problems such as the rate of malnutrition, and announces the poor performers in ABC (Association of Barangay Captains) meetings. Recognition of best and worst performers motivates the barangays to give programs and projects their best shot.
More improvements in the current set-up
Gingoog Citys outreach method is useful as a temporary measure for coping with insufficient barangay health stations. However, the long-term solution is to provide additional health stations to reach all the barangays. While people benefit from the curative and preventive health services provided during Color Meaning Example outreach activities, other health services have Blue Not applicable Nobody is pregnant in the household to be done on a regular basis. The G-TIDA Yellow Improving Degree of malnutrition changed from severe to mild approach may be adopted by cities while they Green Safe Children are fully immunized are in the process of setting up additional Red Danger No PHC health insurance health structures. To sustain outreach activities, local governments could train people from within the area as health workers and nutrition scholBy looking at the red circles, the health personnel ars. In addition, they could mobilize peoples organizations. is alerted on the most pressing health need of the households. The concerns of the purok can also be prioritized according to the number of red circles. It follows that the Cotabato Citys use of barangay halls and private health concern with the most number of red circles is the homes as additional health stations is a progression from most pressing health need of a purok. Comparison with the G-TIDA approach. This enables regular provision of the previous quarter shows where performance has imhealth ser vices rather than being just a one-shot approved or deteriorated. proach. Another alternative is to rent a space for the
The best and the worst: appealing to the Filipino ego In Surigao City, the PHC recognizes outstanding performance based on a set of criteria such as the number of babies immunized and the number of sanitary toilets constructed. Awards are given to ten outstanding PHC chapters, five outstanding workers, and outstanding couple during the PHC annual convention. Butuan City conducts an annual contest for outstanding barangay. Ever y quarter, the per formance of the
barangay health station. Equally important is the availability of health workers. Mobilizing volunteers and mothers, in particular, is a good way of supplementing manpower without paying salaries. Likewise costless is Lapu-lapu Citys channeling of the services of medical practitioners who are retained by private companies. The hiring of par t-time doctors, as practiced by Puerto Princesa, enables curative services to reach remote barangays. The availability of doctors in satellite
clinics reduce the number of patients going to hospitals for minor illnesses. The citys strategy can be extended to dentists and medical technologists. To sustain this activity, barangays may contribute for the salaries of parttime doctors and other health personnel. The latter may serve the barangays on a rotation basis. Naga and Puer to Princesa can learn from each others experience in emergency medical assistance. Puerto Princesa could follow Nagas mobilization of volunteers for handling emergencies while Naga may consider the stationing of ambulances in strategically located barangays as done in Puerto Princesas satellite clinics. This way, the ambulance need not come from the city proper but any ambulance nearest to the place of emergency can respond immediately, thus saving travel time. Cities provide free services and medicines in public health facilities including the use of ambulances. In some cases, they are able to obtain financial and in-kind contributions from individuals or companies. One possible source of funds is cost-recovery, specifically, charging fees for medicines, use of ambulances, and medical services. Only the really indigent may be exempted from payment. This, of course, requires a system for determining peoples capability to pay.
Health in the hands of the people: in conclusion The Department of Health (DOH) sees health in the hands of the people by 2020. Devolution was a major step towards this vision. The government has set mechanisms to soften the impact of devolution. To advise local governments on health plan and budget, the 1991 Local Government Code mandated local governments to create Local Health Boards (LHBs) composed of local executives, health officers and representatives from the DOH and the private sector or nongovernmental organizations. To ensure the speedy resolution of problems brought about by devolu-
tion, Transition Action Teams (TATs) at provincial and regional levels were created. The DOH added another office to its structurethe Local Government Assistance and Monitoring Service (LGAMS)to attend to local government concerns. It also provided for Comprehensive Health Care Agreements (CHCAs) between the DOH and local governments to implement priority health programs. A few more kinks, of course, need to be ironed out. Specific studies have identified these concerns, namely, the resolution of the issue of the inequitable distribution of IRA shares vis-à-vis devolution burdens (IRA reallocation bills are currently pending in Congress), technical assistance to LGUs in exploring other schemes for raising financial resources and in improving the management capability of devolved hospitals, greater participation of nongovernment organizations and peoples organizations in local special bodies, and development of alternative modes of inter-governmental cooperation to deal with issues of service delivery and monitoring that cut across jurisdictional boundaries. On the part of the DOH, it can jointly undertake revenue enhancement projects in devolved hospitals with local governments just as it has done in hospitals that continue to stay in its aegis (such as the Rizal Medical Center in Pasig City and the Ilocos Regional Hospital in La Union). It can provide technical assistance in improving pricing, billing and collection systems of devolved facilities. Lastly, the DOH can help local governments gain competence in managing devolved facilities through continued trainings. 4 For further information, please contact The Research Information Staff Philippine Institute for Development Studies NEDA sa Makati Building, 106 Amorsolo Street Legaspi Village, Makati City Telephone Nos: 8924059 and 8935705; Fax Nos: 8939589 and 8161091 E-mail: email@example.com, firstname.lastname@example.org