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Abstract

The decentralization of basic social services in 1992 prompted local chief executives to
assume the responsibility of providing these services, including health, to their constituents.
It aims to improve the delivery of services by empowering local leaders and giving them
the mandate to undertake decision-making to immediately respond to local needs.
The decentralization was envisioned to bring governance closer to the people.
The Local Government Code (LGC) of 1991 set up various mechanisms to ensure
support for the decentralization and responsiveness of the local health system. This included
institutionalization of local health boards (LHB) at every level of the local government unit
(LGU). The LHB is regarded as an avenue for wider community participation at the local
level. Community-based organizations can become members of the LHB and take part in
the decision-making process. The LHB
also assists the LGU, particularly the
Sangguniang Bayan, in crafting health
ordinances and resolutions, as well as in
preparing health budgets.
However, after almost two decades
of implementation, not all LGUs have
been able to institutionalize their LHBs.
Evidence shows varying outcomes of
decentralization, with some LGUs faring
better and being more responsive than
others. Some had no organized LHBs, while
others had functional and effective LHBs.
Still, there were others that organized
Datu Paglas municipal health officer, Dr. Tina
their LHBs, but only on paper. The study1
Almirante (in white shirt) leads the LHB members
during the municipal health summit.
on the status of LHBs supported positive
correlation between the functionality
of local health boards and some indicators of LGU responsiveness such as community
consultations, health initiatives, and the allotment of budget for health, among others.
This study is part of the situational analysis for an intervention that intends to ensure the
presence of a supportive policy environment in the local health system. The analysis examines
the functionality of LHBs in the Zuellig Family Foundations (ZFF) Cohorts 1 and 2 partnermunicipalities at the onset of the partnership. The Foundation envisions the LHBs as a critical
institution to support the reforms that can be instituted in the municipalities and as a catalyst
of a more responsive policy environment. The analysis also explores the difference in the
possible outcomes between municipalities with functional and non-functional LHBs in terms
of percentage of budget allocated for health, adequacy of health workers, and the provision
and amount of barangay health worker honorarium.

1
Ramiro, Laurie S., Fatima A. Castillo, Tessa Tan-Torres, Cristina E. Torres, Josefina G. Tayag,
Rolando G. Talampas, and Laura Hawken (2001). Community participation in local health boards in a
decentralized setting: Cases from the Philippines. Oxford University Press.

Local Health Board

Decentralization
The decentralization of basic social services in 1992 intends to empower both the LGUs
and the community. It gives local leaders the mandate to undertake local decision-making
and respond according to local health needs. Devolved functions of LGUs, including provision
and financing of basic health services, are intended to ensure a responsive local health
delivery system as well as community participation and accountability. For the community,
various mechanisms are enshrined in the LGC to ensure greater participation, including the
institutionalization of the LHB. The table below enumerates the basic functions devolved to
various institutions of the LGU.

Devolved Health Functions based on the Implementing Rules and


Regulations of the Local Government Code of 19912
Functions

Local Government Units (LGUs)

Provision

1. Barangays Health services through the maintenance of


barangay health stations


2. Municipalities Implementation of programs and projects such as:

primary healthcare

maternal and child care

communicable and non-communicable disease control services

access to secondary and tertiary health services

purchase of medicines, medical supplies, and equipment

construction and maintenance of clinics, health centers, and other

health facilities


3. Provinces Health services through hospitals and other

tertiary health services


4. Cities All health services and facilities provided by
municipalities and provinces

Financing

1. Funds for basic services and facilities shall come from the share
of LGUs in the proceeds of national taxes (IRA and national
wealth), other local revenues, and transfers from the national
government, national government agencies (NGAs) and
government owned & controlled corporations (GOCC).


2. NGAs affected by devolution or the next higher LGU may
augment basic services and facilities assigned to a lower LGU

Participation
and
Accountability

Local Health Board


A LHB is established in each LGU composed of the local chief executive
as chair, the local health officer as vice chair, the Sangguniang Panlalawigan/
Sangguniang Bayan chair of the committee on health, a representative from
Non-Government Organizations or the private sector, and the Department
of Health-Representative. The LHB shall propose to the local Sangguniang
Bayan an annual health budget, and serve as an advisory committee on health
matters to the local Sanggunian and other local health agencies.

Bautista, A. B. (1993). Rules and regulations implementing the Local Government Code of 1991 with
related laws and concept of decentralization. Mandaluyong City: National Bookstore.

Zuellig Family Foundation

With the authority given to local government units comes greater accountability, as
embodied in the concept of closer governance. Local governments now have the responsibility
of providing health services to their respective communities. Through decentralization, the
Rural Health Unit (RHU) is administratively and financially under the Municipal Mayor while
government provincial and district hospitals are under the Provincial Governor. The Department
of Health (DOH), however, maintains specialty hospitals, regional hospitals and medical centers.
It also operates regional field offices known as Centers for Health Development (CHD) in every
region, which has a provincial health team made up of representatives to the local health
boards and retained personnel involved in managing selected priority health problems. 3
At the local level, citizens can more easily learn of the activities and programs that their
local leaders have promoted and supported, discern how much effort they have devoted to
improving public services, and confirm whether they have delivered on campaign promises. In
other words, the information that citizens need to make judgments is more readily accessible
under decentralization. 4
The responsibilities devolved to LGUs demand greater leadership and management
competencies. This poses imperatives for local chief executives to exercise good
governance to ensure efficiency and efficacy. They are expected to optimize the various
support mechanisms provided by the LGC to ensure smooth transition of authority and
responsibility from the national to the local governments. These support mechanisms
are intended to complement the skills and expertise of local chief executives in
carrying out devolved functions. A case in point is an LHB intended to guide and
provide technical support on health to the local chief executive and other local
decision-making authorities.

Autonomous Region in Muslim Mindanao


The case is relatively different in the Autonomous Region in Muslim Mindanao (ARMM).
Functions of the DOH-National are devolved to the Autonomous Regional Government
(ARG) through Executive Order 133 series of 1993. The ARG finances the operations of the
Department of Health-ARMM (DOH-ARMM) where health service provision is centralized.
DOH-ARMM administers, manages and implements the public sector health programs. The
Integrated Provincial Health Office (IPHO) and Rural Health Units, as well as health personnel,
are all under the DOH-ARMM. However, there are no clear guidelines on the role of LGUs in
the delivery of health programs and services.
While there is EO 133, there also exists the Muslim Mindanao Autonomy Act
(MMA) No. 25 that mandates LGUs to provide basic health services, which is similar
to the provision in the LGC of 1991. EO 133 and MMA 25 have conflicting provisions
made worse by the absence of implementing rules and regulations that define the ARMM
health system. 5 This situation impedes the efficient delivery of health services in ARMM.
The centralized structure of the delivery of public sector health programs has resulted to the
growing indifference and lack of ownership of health challenges among LGUs in the ARMM.
Some LGUs tend to depend solely on the DOH-ARMM for health service delivery. While some
consider health as their last priority, there are also LGUs that played critical roles in
effective health service delivery.
Ronquillo, Kenneth, Fely Marilyn Elegado-Lorenzo, Rodel Nodora (2005). Human Resources for Health
Migration in the Philippines: A Case Study and Policy Directions. Paper for ASEAN Learning Networks
for Human Resources for Health (August 2-5, 2005) Bangkok, Thailand.
4
Campos, J. E. and J. S. Hellman (2005). Governance gone local: Does decentralization improve
accountability? R.White and P. Smoke (eds.) East Asia Decentralizes: Making Local Government Work.
Washington, DC: The World Bank. pp. 237-252.
5
Department of Health; Autonomous Region of Muslim Mindanao and Department of Health-ARMM (2008).
ARMM-Wide Investment Plan for Health (AIPH).
3

Local Health Board

Mayor Datu Abdulkarim Langkuno addressing his constituents during Paglats community health summit.

The Role of the Local Health Board


One of the mechanisms enshrined in the LGC to ensure the effective implementation
of decentralization is the establishment of the Local Health Board in every province, city or
municipality. 6 The LHB is envisioned to provide technical expertise and guidance to the LGUs.
Composed of representatives from the public and non-government sectors, the LHB serves as
a venue for greater stakeholder participation.
The LHB is regarded as the governments intended mechanism for broader community
participation in health decision-making in the country. 7 The LHB is composed of the local chief
executive as the chairman, the local health officer as the vice-chairman, with the Sanggunian
Committee on Health chairman, a representative from the DOH, and a representative from the
private sector or non-governmental organizations as members.
Section 102-105 of the LGC specifically mandates the LHB to propose to the
Sanggunian concerned the annual budgetary allocations for the operation and
maintenance of health facilities and services; to serve as an advisory committee to
the Sanggunian; and to create committees which shall advise local health agencies
on personnel selection and promotion, bids and awards, grievances and constraints,
personnel discipline, and budget review, among others. (Local Government Code,
Section 102-105) .
Local Government Code (1991). Section 102-105.
Ramiro, Laurie S., Fatima A. Castillo, Tessa Tan-Torres, Cristina E. Torres, Josefina G. Tayag, Rolando G. Talampas,
and Laura Hawken (2001). Community participation in local health boards in a decentralized setting: cases from
the Philippines. Oxford University Press.

6
7

Zuellig Family Foundation

The LGC also set provisions for conducting regular meetings and quorums.
The provision requires at least one meeting a month, or as often as necessary.
The quorum is constituted by the majority of the members while the affirmative vote of the
majority of the members is necessary to approve proposals. Regular meetings ensure that
members are up-to-date and informed of the health situation, issues, and current status of
programs and projects.
The abovementioned functions of the LHB are critical in local health system
development. The LHB serves as an avenue where the LGU and local health officers can
sit together to discuss and address health concerns of their constituents. Local health officers and
community representatives are given the opportunity to air out health issues and consequently,
provide feedback to the community. The LHB also serves as an accountability mechanism that
ensures checks and balances on the local chief executives decision-making power.
In a comparative study conducted in 2001, there were more community participation,
fund-raising activities, health initiatives and higher per capita health expenditure in LGUs
with functioning LHBs than in LGUs with non-functional LHBs. (Ramiro et. al. 2001)
Moreover, in the case of ARMM, the LHB serves as the link between the DOH-ARMM and
its institutions on one hand and the local governments on the other (refer to Figure 1).
The LHB serves as a venue to get LGUs involved in discussing and addressing local health
needs of the community.

Figure 1. ARMM Public Health System

Assessment of Functionality
The study assessed the functionality of LHBs in the Zuellig Family Foundation Cohorts
1 and 2 partner-municipalities at the onset of the partnership. The research is part of the
situational analysis for an intervention to create a supportive policy environment in the local
health system where the LHB shall serve as the critical mass that will advocate and support
health reforms initiated by health leaders.

Local Health Board

The assessment is based on the Local Governance Performance Management


System, which was developed by the Department of the Interior and Local
Government (DILG) to self-assess LGU performance. The performance indicators of
functionality include:

Performance Indicators
Composition is in accordance with Sec. 102 of RA No. 7160, or the Local

Government Code of ARMM, in the case of ARMM LGUs
the LHB has submitted an annual health plan and budget to the Sanggunian
the LHB has served as the advisory committee to the Sanggunian on health matters
the LHB has created committees that would advise local health offices or units on
personnel selection, promotion and discipline, grievance and complaints, bids and
awards, budget review and other related matters
the LHB holds meetings at least once a month

The analysis showed that 11 out of the 22 local health boards can be considered functional.
These include two from Cohort 1 and nine from Cohort 2. Functionality is measured based on
the averaged rating of the municipality on the performance indicators mentioned above. Of
the five criteria, most of the functional LHBs were able to get high ratings on composition and
regular meetings. Only three, however, were able to submit annual health plans and budgets
to their Sanggunian. Eight LHBs were able to serve as advisory committees to the Sanggunian
on health matters, while eight others were able to create functional committees. The findings
indicate that despite their functionality, areas for improvement remain, particularly in terms
of performing their functions.
LHBs in eleven of the municipalities were rated as non-functional. Ten had formal
documents stating their composition based on the LGC, yet were rated low based on
compliance to its mandate and functions. Their LHBs existed merely on paper.

Only 11 of the 22 LHBs


were found to be functional.

Functionality and Outcome


Part of the analysis also explores the possible outcome of functional local health boards
particularly in terms of the percentage of budget allocated to health, the adequacy of rural
health workers, and the provision of BHW honorarium. In general, functional LHBs showed
positive impacts on local health system development. LGUs with functional LHBs tended to
have relatively higher percentage of budget allocated for health. There was also positive
correlation between functioning LHBs on one hand, and the adequacy of rural health workers
and provision of higher honorarium among BHWs, on the other.

Zuellig Family Foundation

The results reveal that generally, the average percentage of health budget of LGUs with
functional LHBs are higher than those with non-functional LHBs. The average percentage of
budget allocated for health of LGUs with functional LHBs was 10.27% of the total budget
compared to 8.73% in LGUs with non-functional LHBs. Municipal health officers said that
LHB meetings and budget deliberations in the LHBs enable the mayors and SB on health
chairmen to recognize the importance and implications of addressing health concerns. It also
builds their awareness on the need for health programs that will be implemented in the
municipalities; thus, they provide relatively higher financial support for health. Moreover, LHB
meetings discussing budget allocations for health enable MHOs to lobby for the support of
other LHB members.

The average percentage of health budget


of municipalities with functional LHBs are
higher than those with non-functional LHBs.
Aside from its impact on budget allocation, LHBs also play a vital role in addressing
various issues at the local level. The LHB is mandated by the LGC to create committees that
can provide advice on issues such as health personnel selection, promotions and disciplinary
action, grievances and complaints. Through this mechanism, rural health workers are given the
opportunity to air their concerns about their work conditions, such as the inadequacy in the
number of providers and the lack of BHW honorarium.
The research showed that municipalities with functional LHBs tended to have more
rural health workers computed based on provider-to-population ratio. Figure 2 illustrates
that average healthcare provider index 8 increases as LHB rating for functionality increases.
A statistical test on the correlation validated the significant interaction (sig=0.017) of the
two variables at the 0.05 level. Disaggregating the data, midwife-to-population ratio and
BHW-to-household ratio indicate the same correlation. It is observed that municipalities
with functional LHBs have relatively adequate number of midwives and BHWs compared
to municipalities with non-functional LHBs (see Figure 3). A statistical test showed that
the cumulative average of midwives, BHWs and average provider in municipalities with
functional LHBs were significantly higher than those in LGUs with non-functional LHBs.

Municipalities with Functional LHBs have


relatively adequate number of providers than
those with non-functional LHBs.

Average healthcare provider index calculates the adequacy of selected rural health workers (doctors, nurses,
midwives and BHWs) computed based on the provider to population/household ratio. Index closer to one
indicates more adequate number of selected rural health workers compared to index closer to zero.

Local Health Board

Figure 2.

Figure 3.

Indicators


Adequacy of selected
rural health workers

Significance

Municipalities with Municipalities with


Functional LHBs
Non-functional LHBs

Midwife to population
BHW to household
Average provider
to population/
household index

0.7396
0.8582
0.7203

0.5279
0.6069
0.5650

0.015
0.043
0.013

The study also indicated a positive correlation between the frequency of regular meetings
of the LHB and the average amount of BHW monthly honorarium. Statistical analysis revealed
that on the average, the BHW monthly honorarium is relatively higher in municipalities with
more frequent LHB meetings 9 (See Figure 4). This particular test excludes four municipalities

Statistical test shows that correlation is significant (0.031) at 0.05 level.

Zuellig Family Foundation

from ARMM since incentives and compensation of health personnel come from the
DOH-ARMM. Municipal health officers acknowledge the value of regular meetings as a venue
to raise and address contentious issues that would have been neglected. Commonly neglected
issues include rural health worker benefits and incentives. In this case, frequent meetings
enable the BHWs to voice out their needs and sentiments to the local chief executives and
other authorities.

Figure 4. 10

Crucial Enabling Factors for


Functional LHBs
The research also revealed various insights on the functionality and dynamics of
the local health board in their respective municipalities. Based on the situational analysis,
crucial enabling factors for the LHB were found to include shared mission, vision and
commitment; presence of local champions; holding of regular meetings; individual
perception of the LHB and each members roles; and the interpersonal relationships
of members.

Shared Mission, Vision and Commitment


Based on the key informant interview conducted with LHB members, the recognition of
shared vision and mission among LHB members helped in setting their commitment and
passion for work. In areas where the LHB is inactive, there seemed to be no clear vision and
mission, or it existed only on paper or on some plaque at the Municipal Health Office.
Also, the MHO seemed detached from the LGU, as if it was an entirely independent entity.
As a consequence, the LGU lacked ownership of health issues and simply left these to the
MHO. These were visible in most of the cases in this study where the MHO and his/her staff
carried the burden of responding to the health needs of the community.

10

LHBs are rated 1, 3, 5 according to frequency of regular meeting. (1-less than quarterly; 3-Semi-monthly/
Quarterly; 5- Monthly)

Local Health Board

Perception of the LHB and Members Roles


The LHB members perception of their roles and the LHB itself is crucial in ensuring active
participation in the LHB. Predictably, mayors with functional LHBs perceive it as an important
mechanism to gain support from his constituents. As a venue for greater participation, the LHB
established their credibility as empowering the community and encouraging the participation
of other stakeholders. In the same way, the MHO and the DOH-Rep felt empowered with
the ability to provide technical support, as they were frequently consulted on health issues.
The other members appreciated their perceived high involvement in decision-making. On the
other hand, members of non-functional LHB regarded it as another layer of bureaucracy with
mandated functions but no police power.
Local Champions
The presence of local champions also drives a responsive health system where leaders
push for improvements in health service delivery. Often, these local health leaders are the
mayors and/or the municipal health officers who are committed to provide better health
services. In the case of a functional LHB, the mayor and/or the MHO initiated the meetings
and the establishment of programs. Among inactive LHBs, the mayors lack of awareness and
ownership and the MHOs lack of capacity and initiative to persuade and/or call the attention
of the mayor contributed to the non-functionality of the LHB and the lack of empowerment
of its members.
Regular MeetingS
The FGDs also revealed that frequency of regular meetings ensured the functionality of
the LHB. Regular meetings kept all members up-to-date and informed of the health situation,
issues, and current status of programs and projects. The meetings served as venues for the
MHO to persuade and/or call the attention of the Mayor and the SB on Health to support and
speed up the process of coming up with ordinances or approving resolutions by influencing
other members of the Sanggunian. Citing the case of Dao, the MHO takes advantage of LHB
meetings to persuade the Mayor and SB on Health to speed up the process of legislating
resolutions by getting other members of the Sanggunian to agree. It also established better
interpersonal relationships among LHB members.
Interpersonal Relationship among Members
There were also social factors that contribute to the functionality of the LHB, including
good interpersonal relationships that go beyond their role as members of the LHB. Open and
frequent formal and informal communication on topics that may go beyond health issues
facilitated better relationships among members. This eventually helps quiet members to open
up to the dominant member (usually the mayor), who then learns to listen.

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Zuellig Family Foundation

Former Sta. Fe Mayor Florante Gerdan (left) discussing health plans with his MHO Dr. Ernesto Robancho, Jr.

Synthesis and Recommendations


Given the enormous challenges of decentralization, local chief executives need to
maximize enabling mechanisms set by the LGC of 1991 and the MMAA No. 25 (in the case of
ARMM) such as the local health board. The study provides cases that support the proposition
of various literature on the importance and impact of LHB functionality on local health system
development, keeping other things constant. The study shows positive correlation between
the functionality of the LHB and key indicators of desirable outcomes, such as a bigger budget
allocation for health, adequacy in the number of rural health workers, and provision of
BHW honorarium.
Most of the LGUs have taken for granted the institutionalization of the LHB, regarding it
as merely another layer of the bureaucracy. However, as literature has shown and as this study
suggests, LHBs can have direct and indirect roles in addressing some of the pressing concerns
at the local levels. The level of LHB functionality affects the local health system development.
In response to the results of the research, and recognizing the role of the LHB,
the Foundation identified the need for an intervention to strengthen LHBs. During validation
with LHB members, the need to review the basic mandate and the added value of having a
functional and active LHB was suggested. The members of the LHB admitted their lack of
awareness and knowledge about their mandate and functions. To address this, the Foundation
developed a training intervention designed to help build the capacity of LHB members.
The training design is based on the provisions of the Local Government Code on the LHB and
on insights and lessons from the case studies of partner municipalities.

Local Health Board

11

SOURces:
Bautista, A. B. (1993). Rules and regulations implementing the Local Government
Code of 1991 with related laws and concept of decentralization. Mandaluyong City:
National Bookstore.
Campos, J. E. and J. S. Hellman (2005). Governance gone local: Does decentralization
improve accountability?, in R.White and P. Smoke (eds.) East Asia Decentralizes: Making
Local Government Work. Washington, DC: The World Bank. pp. 237-252.
Department of Health; Autonomous Region of Muslim Mindanao and Department of HealthARMM (2008). ARMM-Wide Investment Plan for Health (AIPH).
Ramiro, Laurie S., Fatima A. Castillo, Tessa Tan-Torres, Cristina E. Torres, Josefina G. Tayag,
Rolando G. Talampas, and Laura Hawken (2001). Community participation in local health
boards in a decentralized setting: cases from the Philippines. Oxford University Press.
Ronquillo, Kenneth, Fely Marilyn Elegado-Lorenzo, Rodel Nodora. (2005) Human Resources
for Health Migration in the Philippines: A Case Study and Policy Directions. Paper for ASEAN
Learning Networks for Human Resources for Health (August 2-5, 2005) Bangkok, Thailand.
Department of Interior and Local Government. Local Government Code 1991. 1992.
Local Government Code of the Autonomous Region in Muslim Mindanao: Muslim Mindanao
Autonomy Act No. 25. An Act Providing for a Local Government Code of the Autonomous
Region in Muslim Mindanao. Autonomous Region in Muslim Mindanao, Regional Legislative
Assembly 1995].
Local Governance Performance Management System(2005). Department of Interior and
Local Government. Bureau of Local Government Supervision, Department of the Interior and
Local Government. Quezon City.

Ana Katrina A. Go
Author

Juan A. Villamor
Director
Zuellig Family Foundation Institute
Editor

Ernesto D. Garilao
President
Zuellig Family Foundation
Executive Editor-in-chief

12

Zuellig Family Foundation

Dr. Alberto G. Romualdez


Usec. Gerardo Bayugo
Dr. Ernesto Domingo
Dr. Benny Reverente
Advisory Board Members