Phil Lip Pine Health System

ASIAN JOURNAL OF PUBLIC ADMINISTRATION VOL.
18, NO 2 (DECEMBER 1996): 168-200
EVOLUTION OF THE PHILIPPINE HEALTH

CARE SYSTEM DURING
THE LAST FORTY YEARS OF
DEVELOPMENT ADMINISTRATION
JOAQUIN L. GONZALEZ III
This article discusses the influence of the evolving development administration

emphases - centralisation and decentralisation — to health care delivery in the
Philippines during the last four decades. It shows how prescriptions during the
1950s and 1960s led to the creation of a centrally planned Philippine health care
system. The dysfunctions of this centralised system motivated development admin-
istration specialists to call for decentralisation in the 1970s. Initial attempts at
decentralisation were mainly functionally and structurally-oriented, that is, the
health care bureaucracy was reorganised and streamlined to ensure improved
programme implementation especially at the local community level. However, the
limitations of structural decentralisation created the demand for process decen-
tralisation efforts—an approach which concentrates on more social-behavioural
changes and active stakeholder participation. Process decentralisation was used
not only to improve implementation but also to ensure sustainability. Governmental
andnon-governmental organisations of the 1980s andearly 1990s have emphasised
this dimension of decentralisation as manifested in their projects and programmes.
introduction
Development administration is an emerging interdisciplinary field of

scholarly research. Although some academics argue that the practice
of development administration could be traced as far back as the
history of man on this planet, the available literature indicates that the
168
Philippine Health Care System
integrated and systematic study of this field began to flourish only

after World War II. This was a period in history when most nations,
rich and poor, initiated systematic programmes of economic develop-
ment and social and political change. Being a multidisciplinary field,
the study of development administration has evolved with conceptual
influences from a variety of established disciplines (for example,
economics, geography, management, sociology, psychology, politi-
cal science, health, biology, and engineering). An analysis of develop-
ment administration theory has revolved over three rather distinct
approaches — each with its own theoretical underpinnings and each
with its own concepts of success and failure. Since development
administration is closely tied to concepts of political economy, both
economists and political scientists have played a role in defining the
scope and focus of this process.
This article discusses the general theoretical interrelationships of
key development administration approaches and their impact on
Philippine health care effectiveness during the past forty years. These
three concepts are:
1. the centralised planning approach;
2. the decentralised structural approach; and
3. the decentralised process approach.
This article concludes with some conceptual and practical con-

straints on which present and future public health care managers and
providers should reflect.
Centralised Planning Approach
Justifications for Centralisation
1. Economic imperative
Based on the linear growth theories (for example, the Harrod-Domar

Model and the Rostow Model), development economists argued that
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Asian Journal of Public Administration
planned change was more or less considered to be synonymous with

capital formation. Development experts believed that once capital is
accumulated and reinvested, it would increase production and em-
ployment, which would also raise the income-generating capacity of
the population in general.1
The planned economic growth system prescription is supported by
development economist Amartya Sen who identified similar policy
themes as the proper approach to the problem of development,
including: industrialisation; rapid capital accumulation; mobilisation
of underemployed manpower; and planning and an economically
active state.2
Sen, among others, argued that centralised development through
industrialisation is definitely important if any Third World economy
is to accumulate capital and to emerge from its backwardness. Accord-
ing to mainstream development economists, capitalist profits are the
main source of rapid capital accumulation. If an unlimited supply of
labour is available at a constant wage, then the rate of profits on capital
would not fall. If any part of the profits is reinvested in productive
capacity, profits would grow continuously. Capital formation would
also grow continuously and development would then take place rather
naturally. Moreover, besides rapid capital accumulation, there must
also be the existence of an entrepreneurial class willing to invest and
control accumulated capital in industrial activities.3 Mainstream writ-
ers believe these preconditions must be satisfied to propel a Third
World nation's economic development efforts.
According to these same development writers, the establishment
of an active state and a system of centralised planning is needed to
overcome the dysfunctions associated with "late industrialisation."4
Because most Third World countries lack an industrialised sector
relative to the advanced developed countries, it is believed that a
strong state apparatus is needed to protect the interests of the indig-
enous capitalist class. Indeed, a large part of the industrialisation
process would be carried out and financed by the state itself. Yet in the
case of most Third World societies, the state was perceived to be more
an instrument of foreign capital and its local surrogates.
170
2. Dependency perspective
Andre Gunder Frank, Johan Galtung, Enzo Faletto, Paul Baran, and
Fernando Cardoso argued for a Neomarxist perspective for stimulat-
ing development. Frank's research findings on Latin America em-
boldened him to argue against Sen and the other mainstream develop-
ment economists along the following lines:
underdevelopment and undevelopment are two different concepts

because the presently developed countries were never underdevel-
oped, though they may have been undeveloped;
underdevelopment is not an internal condition;
the mainstream thesis of a dualist society put forward by Arthur

Lewis and stages of linear economic growth proposed by Walt
Whitman Rostow and Harrod-Domar are false;
- contemporary underdevelopment is in large part a product of past

and continuing economic, political, and social relations between
the underdeveloped satellite and the developed metropolitan coun-
tries; and
satellites have been observed to develop faster when their ties with
the metropole (highly developed countries) are weakest.5
Frank concluded that development would be most effective if the

satellite "delinks" itself from the metropole. For Frank, the mechanics
of how to effectively delink is the main issue in each Third World
nation because each of them has different degrees of political, eco-
nomic, and social links with the metropole. Compared to Frank's
Neomarxist prescription, a classical Marxist would probably see
domestic social revolution as the initial step to delinking.
Despite their differences, it seems that development economists
from the mainstream, Neomarxist, and classical Marxist perspectives
all agree that a centrally planned economic system is necessary to
propel development.
171
3. Administrative Synthesis
In the 1960s, the goal of development administration all over the world
was based upon planned economic growth.6 In separate studies,
Montgomery and Milne noted that if development was to occur it was
supposed to be manifested as planned changes in the economy (in
agriculture or industry, or the capital infrastructure supporting either
one) and, to a lesser extent, in the social services of the nation-state
(especially education and public health).7 Several authors followed
with their own parallel arguments on the need for a centrally planned
development administration. Friedman argued that planned change
should include two components: the implementation of programmes
designed to bring about modernity; and changes within an administra-
tive system which would increase its capacity to implement such
programmes.8
Inayatullah argued that development administiation is supposed
to be carried out with a heavy emphasis on planning by public
authorities in order to succeed in attaining socio-economic goals and
nation-building.9
One of the leading authorities during the 1960s, Fred Riggs argued
that long-term development changes are the result of collective
decisions organised in a cohesive plan and implemented through a
western-oriented system of administration.10
According to G. Starling, development planners used this capital
accumulation-based economic growth plan to survey current eco-
nomic conditions and the social situation; to evaluate preceding plans;
to state new objectives, estimates of growth, suggested measures to
raise growth rate; and produce a revised programme of government
expenditures.11
Predominant Management System
As implied by the discussion above, the most common development

management system prescribed by development experts to comple-
ment this economic objective was the utilisation of strong centralised
control and supervision over all development endeavours through the
nation-state's administrative bureaucracy. The centralisation of gov-
172
eminent refers to the dominant role taken by the central, as opposed to

the local, administrative units (for example, municipalities and village
communities). Centralisation manifests itself in the governmental
bureaucracy adopting the roles of revenue collector, distributor of
financial aid to local units, creator of standards to be followed by local
governments, and implementor of services throughout its territorial
jurisdiction by means of central government officials. Strong execu-
tive leadership frequently complements these centralisation traits.12
Development administrators believed that using this centralised man-
agement system would enable countries, which had just gained
independence from their colonial masters, to harness their scarce
resources towards the goal of acquiring much needed capital. In
addition, centralisation of control was prescribed by international
financial institutions as part of their assistance package towards
modernisation. Policy-makers in these international financial institu-
tions thought comprehensive national planning orchestrated by the
state would direct the resource-allocation of the country into appropri-
ate investment areas. Some of the investment areas they had in mind
were: export-oriented industrialisation, import-substitution industri-
alisation, agricultural exports, and raw materials export.13
Centralisation in the Philippines
A centrally planned economic system was already in place in the

Philippines as early as the 1600s. The Spaniards were the first to
establish an administrative system that unified the Philippine Islands.
Through the traditional hacienda system, the Spaniards established
massive plantations that produced coffee, sugar, and spices for con-
sumption in Europe. Spain utilised this economic system to exploit the
resources of the Philippines until the late 1800s.
After losing the Spanish-American War, Spain was forced to cede
the Philippines to the United States under the Treaty of Paris in 1898.
The Americans continued the concept of a centrally planned economic
system, focusing however on their own interests. The Americans saw
the Philippines as a source of raw materials and a market for Ameri-
can- finished products. In addition, the Philippines was established as
a base for penetrating the growing Asian markets in China, Japan,
173
India, and the Middle East. The United States lost the Philippines to
Japan during the Second World War. Under the Japanese, the centrally
oriented economic system in the Philippines was again used to channel
much needed resources to another nation.
On July 4,1946, in accordance with the provisions of the Tydings-
McDuffie Independence Act, the Philippines was granted independ-
ence by the United States of America. Filipino administrators found
themselves faced with responsibilities far greater than they had
envisioned. The Second World War had left the Philippines with
severe economic and physical destruction. Within months after the
declaration of independence, Filipinos found themselves requesting
development assistance from the United States.
In 1950, the Philippines asked the United States to send a survey
mission "to recommend measures that will enable the Philippines to
become and to remain self-supporting."14 In response to this request,
the American government sent a team of elite consultants headed by
Daniel Bell. The Bell mission provided a very dismal picture of the
economic and political realities of the Philippines. The Bell mission
made numerous recommendations in response to this post-War situ-
ation. Following the logic of the current thought on administrative
reform, they recommended the revival and enhancement of the cen-
tralised administrative system, which was established before the
granting of independence. The Bell mission noted that the Philippines
inherited from their American colonisers a "reasonably well-organ-
ised administration and a well-trained civil service," but the war and
the disarray that followed made it difficult to restore the administrative
efficiency it used to enjoy.15 A centralised administrative bureaucracy
recommended by the Bell mission would facilitate the political and
economic rebuilding of the country. Based on these recommenda-
tions, the Philippines adapted a planned economy heavily geared
towards the exportation of agricultural products and raw materials.
The trade-off for development financing to the Philippines was the
establishment of American military bases in selected strategic loca-
tions around the country.
Politically, the Philippines responded to the Bell mission recom-
mendations by establishing the Government Survey and Reorganisa-
tion Committee (GSRC) under the Philippine Republic Act No. 997.
174
The GSRC was tasked with the recentralisation of the administrative

bureaucracy based on the specifications it had before the Japanese
occupation of the Philippines. The GSRC conducted evaluations and
made organisational adjustments to government agencies pertaining
to agriculture and natural resources, commerce and industry, eco-
nomic planning, education and culture, health, labour, public works
and communications, revenue system and statistics, and allied re-
search.
This marriage between centralisation and planned development
was clearly manifested in the high priority given to the reorganisation
of the National Economic Council,16 the central planning body of the
Philippine government.17 The prescriptions of development experts
for reforming the Philippine administrative system clearly reflected
the dominant trend in American public administration, which was the
creation of a Weberian notion of bureaucracy. In addition, the GSRC
subdivided the country into eight geographic regions: Region I
(Dagupan City); Region II (Tuguegarao, Cagayan); Region III (Ma-
nila); Region IV (Naga City); Region V (Iloilo City); Region VI (Cebu
City); Region VII (Zamboanga City); and Region VIII (Davao City).
The guiding principles of the National Economic Council were used
as the main blueprint for development planning in the various regional
development bodies that were created. These regional development
entities were the Mindanao Development Authority and the Central
Luzon Cagayan Valley Authority (both organised in 1961); the
Hundred Islands Conservation and Development Authority (1963);
the Panay Development Authority (1964); the San Juanico Straits
Tourist Development Authority (1964); the Mountain Provinces De-
velopment Authority (1964); the Mindoro Development Board, the
Bicol Development Company, and the Catanduanes Development
Authority (1965); and the Laguna Lake Development Authority
(1966).18 Each was highly centralised and structured to reflect the
logic of modern public administration theory.
The recommendations for the establishment of a reorganised
central administrative structure affected all government departments
including the Department of Health. Based on this planned develop-
ment model prescribed by the Bell mission and adapted into law by the
Philippine legislature, the Department of Health established a system
175
of hospital-based health care administered by and accountable to the

head office in Manila.
A major part of this centralisation plan was the creation of
Presidential Sanitary Divisions which sought to extend the adminis-
trative grasp of policy-makers to a number of presidentially selected
rural areas. Manila-trained public health professionals were quick to
reject local health systems in the rural areas as primitive and ineffec-
tive — labelling traditional village-level healers as "quacks" who
often did more harm than good through their "herbal concoctions and
cures." The Department of Health presented alternatives to the tradi-
tional health system by dispatching medical professionals who pre-
scribed drugs manufactured in the West. Unfortunately, as the
population grew, the demand for health services also expanded. The
Department of Health then found itself unable to keep up with the
demand for more medical professionals and western medicine be-
cause people with even minor ailments travelled great distances
demanding to see a doctor in the government hospital. On top of
bedside duties, public health professionals in this centralised health
care system were also laden with administrative responsibilities like
planning, budgeting, and personnel management.19
In the late 1950s, Presidential Sanitary Divisions were slowly
replaced and renamed Rural Health Units (RHU). Rural Health Units
were established in every municipality. The Department of Health
introduced the health team approach in each Rural Health Unit.
Distinct but complimentary roles were assigned to a Rural Health Unit
team composed of a public health doctor, a public health nurse, and
paraprofessionals (for example, midwives and sanitary health inspec-
tors). This new system authorised public health nurses and
paraprofessionals to deal with simple cases requiring immediate
attention and to educate the community on healthy habits and prac-
tices.20
The public health physician was required to deal only with the
most demanding and difficult cases aside from his administrative
duties.
Further consolidation of the Department of Health's control over
the administration of rural health care services was implemented in the
reorganisation of 1958. Instead of creating more autonomous units,
176
the reorganisation of 1958 increased the centralised power of the

health bureaucracy by adding more national-level staff and adminis-
trative, regulatory, and advisory bodies. The full implementation of
the reorganisation plan was completed in the 1960s. Instead of
decentralising its administrative responsibilities, the reorganisation of
1958 further consolidated the supervisory and administrative powers
of the Department of Health through bureaucracy-related structural
changes, that is, creation of new units and removal of offices with
duplicating functions.21
With the exception of the creation of regional offices, these
organisational reforms only reinforced the central planning function
of the Manila-based health bureaucracy. These offices also created
additional bureaucratic conditions for field operations to pass through.
Some of the reforms were changes only in agency name but did not
affect the service-delivery and operation-effectiveness of the office,
e.g., the Bureau of Research and Laboratories was renamed the Public
Health Research Laboratories — same dog, new collar. Even the
creation of regional offices was not enough to bring health care service
planning and implementation closer to the people in the village
communities. The main beneficiaries of these reforms were politi-
cians and bureaucrats who were able to use the newly created positions
in the Manila office as political rewards. Additional organisational
changes between 1958 and 1969 again reinforced the centralisation of
planning and administration in the Department of Health.22
As in the case of previous reforms, organisational changes during
this centralised development period streamlined the planning opera-
tions of the bureaucracy but showed only symbolic concern for field
operations. They remained oriented towards the prescriptions of
public administration for the use of an effective centralised Weberian
bureaucracy.
Outcome of the Central Planning Approach
This period of planning-oriented development characterised by a

centralised and top-to-bottom planning and management process had
little effect on people at the village community-level. Based on central
planning principles, practitioners and scholars of development admin-
177
istration during the 1960s assumed that the careful anticipation of the
village community's problems and the meticulous application of the
central government's prescriptions would lead to success. If imple-
mentation failed it was blamed on the beneficiaries' negligence in
following procedures that were carefully described in the initial
project blueprint.23 The people at the national level assumed that they
knew what was best for the people at all levels of the political system,
from the nation-state to the village community-level.24 Practitioners
of planned development adopted the following simple procedures to
project design:
1. identified the mistakes in former blueprints;
2. prepared contingencies ahead of time;
3. laid out a plan that incorporates the contingencies; and
4. accomplished the goal.25
Unfortunately, centrally planned development did not lead to the

expected capital accumulation and rapid economic growth in a signifi-
cant number of less developed countries. One reason was the preva-
lence of the self-interest of those administering the economic devel-
opment plans under the centralised system. Another reason was that
different interpretations of these national plans led to conflicts over
how to implement development efforts. The most glaring fact was that
instead of alleviating the problem of resource inequity, the gap
between a small rich minority and a larger poor majority widened.
Quality health care remained within the reach of only the privileged
segment of the population who lived in metropolitan Manila. In
addition, the implementation of the central government's develop-
ment plans at the local level met heavy resistance especially from the
very people they were supposed to assist. The carefully laid out
programme and project plans met failure especially when it came to
village-level implementation.
As demonstrated by development strategies in general and the
Philippine health care experience in particular, the predominantly
178
centralised management approach used during this period did not

allow for participation by the lower units in development planning.
This in effect limited the implementability of development activities.
Within the Department of Health, implementation of health care
services at the village community-level was hampered by the concen-
tration of manpower in the central office in Manila and other urban
centres. This arrangement existed notwithstanding the fact that 80 per
cent of the population lived in the rural areas. The creation of regional
offices in 1958 did not provide for delegation of functions and
authority. A heavy concentration of administrative duties and respon-
sibilities (for example, appointments, leave matters, promotions,
teaching permits, and overtime services) was still found in the Manila
Central Office. The health problems of the 1970s were not much
different from the 1950s.
Decentralisation — Structural Emphasis
Shift in Focus of Development Administration
Development experts believed that a solution to the dysfunctions

associated with planned development through a highly centralised
administrative system is to decentralise the bureaucracy. The problem
of implementing plans through a centralised development approach
has led to a call for a more decentralised administrative approach to
development administration. In one of his studies, Dennis Rondinelli
summarised a plethora of arguments for a more decentralised ap-
proach to planning and implementation, including:
1. Decentralisation affords greater authority for development plan-

ning and management to officials who are working in the field and
hence closer to the problems.
2. Decentralisation cuts through the enormous amounts of red tape

and the highly structured procedures.
3. Decentralisation allows greater representation of various political,

religious, ethnic, and tribal groups in development decision-
making.
179
4. Decentralisation increases administrative capability among local

governments and private institutions in the regions and provinces;
and
5. Decentralisation institutionalises the participation of citizens in

development planning and management.26
In order to increase the likelihood of implementation, develop-

ment experts of the 1970s concentrated their decentralisation ap-
proach on prescribing ways and means aimed at reorienting the
structure and function of the governmental bureaucracy as evidenced
by Rondinelli's enumeration above. This type of decentralisation was
the same response provided by American public administrators during
the debureaucratisation efforts of the United States in the 1930s and
1940s.27 A major reorientation of the structural and functional pre-
scriptions was supposed to make the administrative system more
effective in implementing development plans especially at the com-
munity level. The reoriented organisational structure should allow
participation in the decision-making process by field personnel and
target beneficiaries. This was assumed to be the key to successful
implementation.
There are basically four major types of structural reorientations
advanced in the decentralisation literature: deconcentration, delelation,
devolution, and privatisation.28 The first three pertain to different
types of structural bureaucratic reforms used to decentralise whereas
the fourth refers to non-governmental alternative delivery systems
(for example, PVOs, NGOs, IGOs). It was argued that the use of non-
governmental entities helps alleviate some of the lesource inadequa-
cies of the governmental bureaucracy. These non-traditional, non-
hierarchial, non-governmental entities were expected by development
experts to increase the prospects of project and programme implemen-
tation because of their simple and flat organisational structure, which
was conducive to beneficiary involvement in the decision-making
procedure.
Predominant Management System
During the 1970s, experts and scholars who advocated implementable

180
development assumed that because planning was always carried out at

the top, development administration problems were the result of
inefficient and ineffective management by higher echelon depart-
ments supervising offices at the local levels (for example, departments
of agriculture or ministries of planning). The participation of the
members of the bureaucracy, especially those in the field offices, was
missing. The most common solution was heavily influenced by the
experiences of the western democracies — decentralise the highly
centralised planning system of the state.29 Decentralisation as a means
for organisational reorientation (or reorganisation) was a solution that
development administrators learnt from the developed nations, and
they readily adapted this solution for the eradication of organisational
barriers to development in the less developed countries.
It gradually became evident that development administration
managers became much more effective to the extent that they adopted
a more decentralised approach to decision-making and were open to
the various contextual variables often outside their control. Some of
the contextual variables that projects face are political changes,
natural disasters, and economic factors. Project managers with even
the best laid-out plans could not foresee all the problems related to
these areas: financing, personnel, management, infrastructure, and
community participation.30
Structural Decentralisation in the Philippines
Despite the centralisation of planning for effective development

administration, the Philippines continued to deteriorate politically and
economically. Graft and corruption permeated Philippine politics.
Moreover, the creation of additional personnel positions in the central
administrative system was used by politicians as a place for political
rewards. The centralised economic development plan, which geared
the economy towards the exportation of raw materials, was not enough
to deal with the balance of trade deficits created by the heavy
importation of consumer goods and finished products.
The leading causes of mortality during the 1950s and 1960s were
pneumonia, tuberculosis, heart disease, gastroenteritis and colitis,
disease of the vascular system, avitaminosis and other nutritional
181
deficiencies, accidents, malignant neoplasm, bronchitis and asthma,

tetanus, and diseases of early infancy. The leading causes of morbidity
during the 1950s and 1960s were influenza, gastroenteritis and colitis,
tuberculosis, pneumonia, malaria, measles, whooping cough, dysen-
tery, malignant neoplasm, tetanus, mental disorder, accidents,
bronchitis, heart disease, vitaminosis and other nutritional deficien-
cies, and diseases of the vascular system. According to health experts,
these diseases and illnesses are easily preventable with proper immu-
nisation programmes and improved sanitation.31
On September 9,1968, President Marcos signedinto law Republic
Act No. 5435. This Act provided for the creation of a Presidential
Commission on Reorganisation (PCR), a joint executive and legisla-
tive body. The PCR was given the task of developing an Integrated
Reorganisation Plan. The final Integrated Reorganisation Plan for the
executive bureaucracy was to be approved by the President. Unlike
previous attempts at administrative reorganisation, which only further
centralised decision-making and resource control, the Integrated
Reorganisation Plan sought to decentralise the Philippine political
system.
The Integrated Reorganisation Plan received critical reviews from
members of Congress and government administrators despite repre-
sentation from the academic, private, and government sectors. Bu-
reaucrats objected because the merging and abolition of overlapping
and redundant positions would displace many of them. Legislators
were afraid that the number of political appointments which they
could use as political rewards would be reduced.
Upon the declaration of Martial Law on September 21, 1972,
President Marcos abolished the Philippine national legislature. With
the abolition of Congress, President Marcos issued Presidential De-
cree No. 1, the first major administrative reform measure under
martial law. Presidential Decree No. 1 mandated a review of the
Integrated Reorganisation Plan for implementation during the martial
law period.
The 1972 Reorganisation Plans impact was felt mostly at the
regional level. Under this reorganisation plan, regional health offices
were established in the newly created regional subdivisions of the
country. Each region had a designated regional center in the twelve
182
major cities of the Philippines. According to Alex Brillantes, "the

Inter-Agency Committee that made the subdivision proposals tried to
define relative homogeneous areas, capable of stimulating and sus-
taining efforts, not only on the basis of administrative consideration,
but also with respect to geographic, economic, and cultural factors."32
The reorganisation plan also authorised the regional directors, in
line with the policy of decentralisation and within the jurisdiction of
the regional office, to take final action on matters pertaining to
substantive and administrative functions of the agency.
In an effort to decentralise their administrative and resource
control over village community-level units, the Department of Health
in the late 1970s and early 1980s introduced the following pro-
grammes: the Restructured Rural Health Care Delivery System
(RRHCDS); the Medical Care Program; the Rural Health Practice
Programme; the Community Medicine Focus of Medical and Nursing
Schools; and the Community-Based Health Programme.33
1. Restructured Rural Health Care Delivery System (RRHCDS)
The RRHCDS was implemented in 1975 as part of a World Bank

Population Programme. The most significant contribution of the
RRHCDS Programme was the creation of Barangay Health Stations
(BHS). Barangay Health Stations are the first line of health care
available at the village community-level. They are staffed by a
government-trained midwife and other barangay health workers.
Through the financial support of the RRHCDS, the health structures
housing the BHS were also constructed.
2. The Medical Care Programme (MEDICARE)
According to the primer of the Philippine Medical Care Commission,

the MEDICARE programme was envisioned "to provide the people
with a practical means of helping themselves pay for adequate medical
care."34 This programme assisted in the construction of hospitals in
the far flung areas of the country. Although its main beneficiaries are
limited to the employed and their families, the MEDICARE Pro-
gramme created access to hospital-based health care facilities for the
rural areas.35
183
3. The Rural Health Practice Programme
In order to respond to the growing need for health care in the rural
areas, the Philippine government made rural health service a manda-
tory requirement for all medical and nursing graduates before receiv-
ing their professional licences. The volume of manpower injected into
the rural areas helped ease the burden on the Department of Health.
However, Carino noted that "questions have been raised in other
studies as to its effectiveness, efficiency, and effects on the morale of
regular personnel and efficacy as a training tool for underboard nurses
and medical doctors."36
4. The Community medicine focus of medical and nursing schools
Pioneered by the Rural Health Programme of the University of the

East-Ramon Magsaysay Memorial School of Medicine in 1964,
Philippine medical and nursing schools created programmes that
stressed preventive and social medicine and rural medical practice.
These medical and nursing schools emphasised heavy implementa-
tion of the pregraduation requirement of rural health practice. They
also made curriculum changes that aimed at placing more attention on
Philippine medical problems. In addition, a Bachelor of Science
Degree in Rural Medicine was introduced at the University of the
Philippines-Tacloban City. A rural practice internship at the nearby
Carigara area was the highlight of this programme. The programme
combined features of community-based health care programmes and
the community medicine approach utilised by the regular medical
schools.
5. The Community-Based Health Programme (CBHP)
In the early 1970s, the CBHP approach was endorsed by both non-
governmental and governmental organisations as their contribution to
bringing health care closer to the rural areas. This approach promoted
the use of multi-function village health workers who administer first
aid, teach health education, provide sanitation attention, and serve as
the frontline staff dealing with people with minor ill nesses. Under this
184
approach, health was seen only as a part of an overall village develop-

ment package. Hence, village health workers also facilitated commu-
nity organising and impart income-generation skills to members of the
village community. Victoria Bautista enumerated several individuals
who promoted pilot projects targeting specific rural areas using the
CBHP approach (for example, De La Paz with the Katiwala Pro-
gramme in Davao City, Viterbo of Roxas City, Macagba of La Union,
Flavier of the Philippine Rural Reconstruction Movement, Campos of
the University of the Philippines Comprehensive Community Health
Programme, Solon of the Paknaan Cebu Institute of Medicine Project,
and Wale of Silliman University).37 In addition, Galvez-Tan noted
that attempts at replicating this programme nationally was promoted
by the Rural Missionaries of the Philippines.38 Other religious groups
like the National Council of Churches in 1977 and the AKAP in 1978
followed suite with their own nationwide applications of the CBHP
approach. These groups applied almost similar types of participation
approach towards the institutionalisation of an appropriate health
service delivery system.
Decentralisation — Process Emphasis
Including Concern for Process in Decentralisation
The 1970s saw a shift in concentration from planning to the effective

and improved implementation of the development plan at the lower
units of the administrative system. Proponents of development admin-
istration discovered that even the best designed development blue-
prints were susceptible to failure especially if carried out in a central-
ised and autocratic fashion. The completion of development activities
at the lowest level of jurisdiction became the main focus of this
implementation-oriented period. The development activity was la-
belled a success if the effective start-up of the programme or project
could be effectively completed.39
Management experts in the developed countries learned later that
the structural and functional changes proposed in structural decen-
tralisation were effective only in advancing peripheral changes (for
example, eliminating overlapping activities and duplication of func-
185
tions). They did not deal with the issues of effective impact and
efficient use of resources.40 It quickly became apparent that a new
organisational structure free from these duplications and overlapping
problems did not guarantee changes to the dysfunctional behaviour of
people inside the central ministries and governmental agencies.
Development experts saw that structural decentralisation some-
what increased the prospects of project implementation but did not
necessarily ensure the effectiveness or the sustainability of projects
and programmes. Based on the Philippine findings, researchers con-
cluded that it was not enough to create channels for participation
because the process of interaction was still cooptive, manipulative,
and at most only consultative. How superiors and subordinates should
interact in a genuinely participatory manner within the decentralised
structure, as well as how much a government system should interact
with local communities, was still a major issue. Clearly a concern for
the institutionalisation of behavioural changes and the human dimen-
sion of decentralisation required reform both within the administrative
system and also in the linkage mechanism between bureaucracies and
communities.
Development experts agreed that a social and behavioural modi-
fication, or process reorientation, was necessary to complement the
structural aspect of decentralisation. Once the human dimension of
decentralisation was in place, it was assumed that projects and
programmes would become more implementable and sustainable.
During this development period, Philippine development experts
assumed that an emphasis in creating a decentralised and participatory
structure would improve planning and increase implementability.
Management System Under a Decentralised Process Approach
As advocated by development experts of the 1980s, process decen-

tralisation is the institutionalisation of participatory modifications on
the traditionally non-participatory processes perpetuated by govern-
mental bureaucracies. The theoretical descent of process decentralisa-
tion in development management could be traced to the debate
between the Weberian-inspired school of management and the re-
sponse by organisational humanists.
186
The Weberian-inspired centralised approach was seriously chal-

lenged in theory and practice by authors who subscribed to the
organisational humanist school of management.41 Herbert Simon and
Robert Dahl criticised the advocates of the classical approach to
management for promoting a "scientific" and value-free paradigm of
domestic and international administration. Moreover, arguments based
upon Weber's bureaucratic model were also criticised by Robert
Merton as having psychosocial dysfunctions.42
The advocates of the human relations school of management
argued that there is no such thing as a rational and value-free approach
to management since the interpretations of rationality and values
varied from person to person and culture to culture. Structural and
functional reforms remain successful only in the short run because
structural and functional reforms pay only lip service to the human
beings inside the organisational charts and boxes. Project beneficiar-
ies are always perceived as a hindrance to development instead of a
facilitating force of change. These criticisms and shortcomings of
logical positivism and Weberian-inspired development administra-
tion practices were carried over into the implementation decade of
rural development. It was time to propose a more radical change.
Advocates for a more humanist approach to managing organisa-
tions lambasted the "principles" advocated by the Weberian-inspired
school of management as mere "proverbs" and an exercise in Simon's
"architectonics."43 The humanist school of management presented
such alternatives to the positivist-oriented approaches as management
by objectives (MBO), linking pin, quality circles, job redesign, clarity
of goals, T-groups, contingency management, motivation techniques,
organisation development (OD), job enrichment, and participative
management.44 These techniques are based on the interaction proc-
esses and interpersonnal relations of individuals and groups inside
organisations.
Using these human relations school prescriptions involves going
beyond the structural adjustments advocated by Rondinelli and other
development experts as enumerated in the previous section. Ideally,
process decentralisation should be used together with the structural
rearrangements and functional redescriptions described earlier. Using
this combined approach ensures that local units will institutionalise
187
participation. This, combined with a strengthened local resource

mobilisation, would lead to sustainability at the village community-
level. Hence, the ultimate goal is to create the appropriate interaction,
collaboration, participation, and involvement to complement the
reorganised organisational structure.
Development proponents from donor and recipient countries
employed approaches patterned after these more humanist techniques
to help in the effective planning, implementing, and sustaining of their
development efforts. Based on the activities of this period, sustainable
development essentially became human development.
These behavioural changes were applied not only in the bureauc-
racy but also in the service-delivery field units. The role of the
structurally decentralised grassroots units in policy-making was in-
creased through community participation and organisation schemes.
Participation as an institutionalised behaviour was assumed to raise
the level of commitment by the beneficiaries, thus encouraging them
to seek ways and means to sustain the project. Both governmental and
non-governmental groups immersed themselves in making their
projects participatory not only in structure but also in process.
Decentralised Process Approach in the Philippines
Structural changes in Philippine health care continued until the 1980s

but they were no longer central to decentralisation reforms. The
highlight of the 1980s was the adoption of primary health care all over
the world. Primary Health Care was essentially a call for sustainable
health development through behavioural changes (for example, com-
munity participation and active beneficiary and proponent collabora-
tion). This shifted the emphasis of decentralisation from a structural
focus to a more process orientation.
In 1977, the Alma Ata conference sponsored by the World Health
Organisation (WHO) formally mandated the international goal of
"Health for All by the Year 2000" (HFA). The goal of "Health for All
by the Year 2000" could be traced back to the Constitution of the
World Health Organisation, which was adopted in 1946. It took the
WHO more than thirty years to actually formalise a programme that
dealt with the issue of sustainability. This delayed reaction was similar
188
to the OECD's late response to sustainability which had been in the

OECD Constitution since 1961.45 The international delegates present
at the conference agreed that Primary Health Care was the key to
achieving this long-term objective. The framers of the HFA Declara-
tion envisioned Primary Health Care to be:
an approach that recognises the inter-relationship between

health and overall socio-economic development. It aims to
provide essential health services that are community-based,
accessible and sustainable at a cost which the community and
the government can afford through community participation
and active involvement. Ultimately, it aims to develop a self-
reliant people, capable of achieving an acceptable level of
health and well-being.46 (Italics provided).
As opposed to previous strategies that concentrated on prescribing

structural decentralisation of the bureaucracy and its parts, this state-
ment clearly implied that health care projects under the Primary
Health Care programme were to be grounded on sustainability through
collaboration, interaction, and involvement at the community-level.
In response to this, the Philippines together with the international
community of nations redefined their health care approaches towards
the achievement of "Health for All by the Year 2000."
Primary Health Care and Participation in the Philippines
The health problems of the 1960s and the 1970s did not change
significantly. The leading causes of morbidity in the 1970s continued
to be acute respiratory infections, diarrheal diseases, tuberculosis,
malaria, skin infections, and enteritis. The leading causes of mortality
in the 1970s also remained: pneumonia, tuberculosis, bronchitis,
diarrhea, health disease, malignant neoplasms, and accidents.47
Solutions to these health care problems were hampered by various
administrative and resource constraints including the problem of
insufficient funds; the lack of medical and paramedical manpower; the
inefficient use of scarce health services available; and the lack of
community support for health programmes.
189
With this backdrop in mind, President Marcos issued Letter of

Instruction 949, mandating the implementation of the Primary Health
Care approach throughout the country starting in 1981. Primary
Health Care offered a new perspective different from the hospital-
based western health care models which proved to be ineffective in
less-developed countries like the Philippines. A national coordinating
council for primary health care headed by the Depiirtment of Health
and other concerned departments (for example, Food and Agriculture,
Social Service, Natural Resources) was immediately established. This
coordinating council was duplicated in the different administrative
regions, provinces, municipalities, and villages of the country. In
1981, President Marcos declared a new Philippine Republic and
ordered the implementation of the revised Integrated Reorganisation
Plans of all departments subject to his approval. In addition, he
changed the Philippine administrative system from a presidential to a
parliamentary model. Hence, all government departments were re-
named ministries.
According to the Minister of Health at that tune, J. Azurin, the
adoption of Primary Health Care all over the Philippines moved him
to seek immediate presidential approval of the revised organisational
chart of the Ministry of Health (MOH) contained in Executive Order
No. 851. Minister Azurin added that this action would accommodate
all of the behavioural changes needed to make the MOH more
participation-oriented. The most significant change of the 1982 reor-
ganisation was at the provincial level with the merging of the Provin-
cial Health Office and the Provincial Hospitals.48
In the Philippines, the Primary Health Care approach concentrated
on the main health problems in the village community, providing
promotive, preventive, curative, and rehabilitative activities. Promo-
tive health activities are personal and environmental hygiene, sound
food and dietary practices, regular physical exercise, and a less
stressed lifestyle. Preventive health activities are occupational health,
immunisation, quarantine, vector control, and disease surveillance.
Curative health activities are early diagnosis and treatment of dis-
eases, emergency care of the injured, and other applications of medical
technology to repair tissue damage brought about by acute or chronic
illness or injury. Rehabilitative health activities are the restoration of
190
normal physical, mental and social functions to individuals afflicted

with disabling injuries and illnesses as well as the extension of services
to minimise the extent of disability caused by impaired or damaged
body tissues and organs.49 Since these services reflect and evolve
from the economic conditions and social values of the country and its
village communities, they vary by country and community. Nonethe-
less, they include at least the promotion of proper nutrition and an
adequate supply of safe water; basic sanitation; maternal and child
care, including family planning; immunisation against major infec-
tious diseases; prevention and control of locally endemic diseases;
education concerning prevailing health problems and the methods of
preventing and controlling them; and appropriate treatment for com-
mon diseases and injuries.
In order to make Primary Health Care universally accessible in
Philippine village communities as quickly as possible, maximising
community and individual self-reliance for health development was
mandated. Specifically, the attainment of such self-reliance in Philip-
pine village communities required full community participation in the
planning, organisation, and management of Primary Health Care.
Such participation was best mobilised through appropriate education,
which would enable village communities to deal with their real health
problems in ways most suitable to them. Village communities were
thus in a position to make sure that the right kind of support was
provided by the other levels of the national health system. These other
levels were organised and strengthened so as to support Primary
Health Care with technical knowledge, training, guidance and super-
vision, logistic support, supplies, information, financing, and referral
facilities, including institutions to which unsolved problems and
individual patients could be referred.
Philippine programme administrators believed that for Primary
Health Care to be most effective they had to employ means that were
understood and accepted by the community, and applied by the
community health workers at a cost the community and the country
could afford. These community health workers, including traditional
practitioners where applicable, function best if they reside in the
community they serve and are properly trained socially and techni-
cally to respond to its expressed health needs.50
191
Since Primary Health Care was an integral part of the country's

health system and of overall economic and social development, it had
to be coordinated on a national basis with the other levels of the health
system as well as with the other sectors that contribute to the country' s
total development strategy.51 Mutually beneficial linkages as opposed
to administrative direction were encouraged by the Primary Health
Care approach.
Upon the assumption of power in 1986, President Corazon Aquino
immediately called for another comprehensive reorganisation of the
Philippine administrative system. One of the first pieces of legislation
President Aquino issued was Executive Order No. 5. This law recon-
stituted and renamed the Presidential Commission on Reorganisation
as the Presidential Commission on Government Reorganisation
(PCGR). The five guiding principles of the PCGR were as follows:
1. private initiative;
2. decentralisation;
3. cost-effectiveness;
4. efficiency of frontline-services; and
5. accountability.
The PCGR organisation was composed of high calibre Filipino

consultants from both the private and public sectors. These consult-
ants were divided into survey teams headed by a coordinator. The
PCGR had a policy group and a special studies group. These groups
were in charge of standardising, collating, and compiling all the
survey team's findings. The final approval of the each departmental
reorganisation plan was left solely in the hand of President Aquino.
This was due to the absence of a legislature, which was abolished after
the coup d'etat facilitated by Fidel Ramos and Juan Ponce Enrile. The
absence of a legislature also gave the Chief Executive the power to
carry out the reforms without opposition from the other political
branches of government.
192
The scope of the PCGR's mandate as defined under Executive

Order No. 5 was encompassing. It involved the overall reorganisation
of the administrative branch, government-owned and controlled cor-
porations, and local government. Never in the history of Philippine
government restructuring has a single entity been accorded this
massive task of reorganisation. Under President Aquino, the depart-
ment model of government was again revived.
This reorganisation furthered the cause of process-oriented decen-
tralisation by constitutionally encouraging Primary Health Care through
collaboration, interaction, and involvement from the national-level to
the village community-level. The changes instituted under the 1987
Reorganisation of the Department of Health were:
1. the creation of the Community Health Service and Field Epidemi-

ology Training Programme;
2. the development of a simplified and realistic health information

system;
3. the computerisation of the main Department of Health for greater

efficiency of services;
4. the creation of an NGO coordinating desk within the Department;
5. the rationalisation of the Health Department's procurement sys-

tem;
6. the development of legislative liaison; and
7. the strengthening of the District Health Office, Rural Health Units,

and Barangay Health Stations.
Following the general guidelines of Primary Health Care's "sus-

tainable health development through participation mandate," more
definite and specific operating principles and approaches towards
process decentralisation were produced by the Aquino administra-
tion.52
193
Conclusion: Some Theoretical and Practical Constraints
Theoretical Constraints
After examining the experiences of the bureaucracy4evel application

of structural and process decentralisation in a number of countries,
including the United States, the Philippines, Peru, South Korea, and
Venezuela, policy-makers admit that there is an inherent difficulty in
introducing behavioural reorientation to government reforms. Hence
the more manoeuvrable structural decentralisation techniques are still
likely to predominate.
One argument against the interface of OD and other humanist-
oriented management approaches with decentralisation efforts are
their "application constraints in the public sector." Some public
administrationist claim that these techniques are better suited to the
business or profit-oriented sector where their success is more easily
identified and can be more readily proven. Robert Golembiewski
enumerates some structural, habitual, and management constraints to
the application of process decentralisation techniques to the public
sector.53 Other development management writers simply contend that
public bureaucracies have an "organisational imperative," which
dictates that government bureaucrats advocate the status quo and are
disposed towards systems maintenance.
Some public administration experts argue that the organisational
humanists may have simply provided a more sophisticated array of
techniques for administrators in securing more compliance from the
bureaucracy and the local units.54 Hence, decentralisation is actually
a recentralisation technique because the more predominant theme is
still taken from classical management theory and centralisation.
Indeed, it is an irony that some of the techniques like manipulation,
cooptation, and intervention have actually emerged from the alterna-
tive school to centralisation thought — the human relations school of
management.
Practical Constraints
Despite some positive changes, the problem of resources for health
194
care delivery at the rural areas continues to be demonstrated by the

actual number of barangays in the Philippines as opposed to the
number of Barangay Health Stations. Seven years after the implemen-
tation of Primary Health Care in the Philippines, the total number of
barangays in the country is 45,000, while the combined total of Rural
Health Units (1,991) and Barangay Health Stations (7,991) remains at
only 9,982. This means that over 35,000 barangays (78 per cent) still
do not have immediate access to health care services. A large number
of these barangays, which do not have readily available health care, are
located in the most remote and depressed areas of the country. The
Philippine Department of Health admits that it does not have the
necessary resources to fill this gap. The national government spending
on health during the presidencies of Aquino and Ramos has increased
over the years but still remains below the World Health Organisation
expectation for countries like the Philippines.
Hence, whenever the Department of Health and nongovernmental
organisations receive additional funding from local or international
sources, they seek to establish much needed health care projects which
target those village communities still in need of health care services.
This accounts for the evolution of two distinct sets of start-up imple-
mentation flow of resources to the village communities in the 1980s
which provided greater concern for community participation — a
much needed and distinct process decentralisation objective.
These alternative local and international donor-supported projects
are not enough when the overall rural health picture is examined.
Nevertheless they offer hope for village communities which do not
have any health care services at all. Keeping in mind the conceptual
and practical pitfalls discussed in this article, the issue of the
nonsustainability or sustainability of projects that will enhance the
health care delivery and development should now be the focus of
concern for current and future Philippine policy-makers.
NOTES
1. E.D. Domar, Essays in the Theory of Economic Growth (Oxford: Oxford
195
University Press, 1957); R.F. Harrod, Towards a Dynamic Economics (London:

Macmillan Press, 1948); and W.W. Rostow, The Process of Economic Growth
(Oxford: Clarendon Press, 1960).
2. A. Sen, "Development: Which Way Now," in C. Wilber, The Political Economy
of Development and Underdevelopment (New York: Random House, 1988).
3. A. Lewis, "Economic Development with Unlimited Supplies of Labour," in A.
Agarwala, Economic of Underdevelopment (New York: Oxford University Press,
1958).
4. A. Gerschenkron, Economic Backwardness in Historical Perspective (Cam-
bridge: Harvard University Press, 1962).
5. A.G. Frank, "The Development of Underdevelopment," in R. Rhodes, Imperi-
alism and Underdevelopment (New York: Monthly Review Press, 1970).
6. A. Waterston, Development Planning: Lessons of Experience (Baltimore,
Maryland: Johns Hopkins Press, 1969).
7. See J.Montgomery, "A Royal Invitation: Variations on Three Classic Themes,"
in J. Montgomery and W. Siffin, eds., Approaches to Development- Politics,
Administration, and Change (New York: McGraw-Hill, 1966) and R.S. Milne,
Planningfor Progress: The Administration ofEconomic Planning in the Philippines
(Manila: Institute of Public Administration, University of the Philippines, 1960).
8. J. Friedman, A Spatial Framework for Rural Development: Problems of
Organisation and Implementation (Los Angeles, California: University of Califor-
nia Press), p. 254.
9. Inayatullah, ed., Rural Organisations and Rural Development: Some Asian
Experiences (Kuala Lumpur, Malaysia: Asian & Pacific Development Administra-
tion Centre, 1978), p. 278.
10. See F. Riggs, Frontiers of Development Administration (Durham, North
Carolina: Duke University Press, 1971) and F. Riggs, "Bureaucracy and Develop-
ment Administration," Philippine Journal of Public Administration 21 (1977): 35-
50.
11. G. Starling, Managing the Public Sector (Homewood, Illinois: Dorsey Press,
1982), p. 188.
12. I. Sharkansky, Public Administration: Policy-making in Government Agencies
(Chicago, Illinois: Rand McNally, 1978), pp. 46-7.
13. See M. Blomstrom and B. Hettne,Development Theory in Transition (London:
Zed Books Ltd, 1984).
14. J. Endriga, "Stability and Change: The Civil Service in the Philippines,"
Philippine Journal of Public Administration 29 (1985): 145.
15. D. Bell, U.S. Economic Survey Mission's Report (Manila Philippine Book Co.,
1950).
16. The NEC was later renamed the National Economic Development Authority
(NEDA), the government's overall economic planning arm.
17. J.L. Gonzalez and L. Deapera, "A Review of Philippine Reorganisation,"
Philippine Journal of Public Administration 31 (1987): 257-70.
18. A.B. Brillantes, "Decentralization in the Philippines: An Overview," Philip-
196
pine Journal of Public Administration 31 (1987): 131-48. See also P.D. Tapales,
Devolution and Empowerment (Quezon City: University of the Philippines Press,
1993).
19. L. Carino, "Policy Directions for Health in the 1980s," Philippine Journal of
Public Administration 25 (1981): 192-206.
20. Carino, "Policy Directions for Health in the 1980s," p. 193.
21. Aside from J.C. Azurin, Primary Health Care: Innovations in the Philippine
Health System 1981 —1985 (Manila: J.C. Azurin Foundation, 1988), the author
examined various inter-office communications pertaining to the Department of
Health's 1958 reorganisation.
22. The National Nutrition Programme was later integrated into the budget respon-
sibility of the Department of Health.
23. See B .M. Gross, Action Under Planning: The Guidance of Economic Develop-
ment (New York: McGraw-Hill, 1967) and S. Padilla, ed., Tugwell's Thoughts on
Planning (Puerto Rico: University of Puerto Rico Press, 1975).
24. See H.W. Wickwar, The Modernization of Administration in the Near East
(Beirut: Kyatas, 1962); R. Gomez, The Peruvian Administrative System (Boulder,
Colorado: University of Colorado Press, 1969); H. Lee and A. Samonte, Adminis-
trative Reforms in Asia (Manila: Eastern Regional Organization for Public Admin-
istration, 1970); R. Groves, Action Under Planning: The Guidance of Economic
Development (New York: McGraw-Hill, 1967); and D. Myers, ed., Venezuela: The
Democratic Experience (New York: Praeger, 1977).
25. R.P. Misra, Local-level Planning and Development (New Delhi: Sterling
Publishers, 1983), p. 75.
26. G.S. Chcema and D. Rondinelli, eds., Decentralization and Development.
Policy Implementation in Developing Countries (Beverly Hills, California: Sage
Publications): 14-15. Similar arguments are presented in D. Rondinelli, "Adminis-
trative Decentralisation and Economic Development: The Sudan's Experiment with
Devolution," Journal of Modern African Studies 19 (1981): 596-624 and D.
Rondinelli, et al., Decentralization in Developing Countries: A Review of Recent
Experience (Washington, DC: World Bank, 1984).
27. See L. Gulick and L. Urwick, Paper on the Science of Administration (New
York: McGraw-Hill, 1937) where the authors outlined the following functional jobs
of the executive in iheir famous POSDCORB, which stands for planning, organis-
ing, staffing, directing, coordinating, reporting, and budgeting. Gulick and Urwick
argued that these seven principles of good management should be the basis for
reorganising the executive bureaucracy. Another author, L. Brownlow, et al.,
"Report of the President's Committee on Administrative Management," in U.S.
Government, Administrative Management in the Government of the United States
(Washington, DC: USGPO, 1937) argued that reorganisations have to address the
issue of a strong executive and a large bureaucracy. Reorganisation principles have
to be developed andapplied successfully to decentralise the organisation. Moreover,
L. Mcrriam, in Reorganization of the National Government: What Does it Involve?
(Washington, DC: The Brookings Institution, 1939) argued that reorganisations
197
should eliminate functions and activities of the bureaucracy which are no longer
essential or justifiable. Eliminating or curtailing these would lead to substantial
reductions in expenditure. Other alternative structural arrangements to
debureaucraticise were contained in the proposals of W. Bennis, "Organisation of
the Future," Personnel Administration 24 (1967). These involve the use of more
"organic-adaptive structures." A. Toffler, in Future Shock (New York: Bantam,
1971) also prescribed the use of "adhocracies." Other writers called for almost
similar structural adjustments like a flexible structure, a flat structure, a project team
approach, a matrix organisation, or a committee system [see P. Drucker, The
Practice of Management (New York: Harper and Row, 1958)].
28. Rondinelli, et al., Decentralization in Developing Countries: A Review of
Recent Experience, p. 67. Similar arguments are presented by D. Conyers, "Decen-
tralisation and Development: A Framework for Analysis," Community Develop-
ment Journalll (1986): 88-100; S. Gregory and J. Smith, "Decentralisation Now,"
Community Development 21 (1986): 101-6; M. Khan, "The Process of Decentrali-
sation in Bangladesh, Community Development Journal 21 (1986): 116-25; R.
Shields and J. Webber, "Hackney Lurches Local," Community Development Jour-
nal21 (1986): 133-40; P. Sills, etal., "Decentralisation: CurrentTrends and Issues,"
Community Development Journal 21 (1986): 84-87; M. Taylor, et al., "For Whose
Benefit? Decentralising Housing Services in Two Cities," Community Development
Journal 21 (1986): 126-32; W. Boyer and M. Byong Ahn, "Local Government and
Development Administration: A Case of Rural South Korea," Planning and Admin-
istration 2 (1989): 21-29; and D. Rondinelli, "Decentralising Public Services in
Developing Countries: Issues and Opportunities," Journal of Social, Political and
Economic Studies 14 (1989): 77-98.
29. See R. Polenberg, Reorganizing Roosevelt's Government: The Controversy
Over Executive Reorganization 1936-1939 (Cambridge: Massachusetts: Harvard
University Press, 1966).
30. J. Pressman and A. Wildavsky, Implementation: How Great Expectations are
Dashedin Oakland (Berkeley, California: University of California Press, 1973)and
G. Honadle, "Implementation Analysis," International Development Administra-
tion (New York: Praeger, 1977).
31. United Nations, Demographic Yearbook (New York: United Nations, 1964,
1965, and 1977) and World Health Organization, World Health Statistics (Genera:
World Health Organization, 1977).
32. Brillantes, "Decentralization in the Philippines," p. 141.
33. See Carino, "Policy Direction for Health in the 1980s;" and Azurin, Primary
Health Care.
34. Philippine Medical Care Commission, The Medicare Program of the Philip-
pines (Quezon City: PMCC, 1974), p. 1.
35. Carino, "Policy Direction for Health in the^l980s."
36. Carino, Ibid, p. 194; see also M. Reforma, The Rural health Practice Program:
An Evaluation of the R ural Service Requirementsfor Health Professionals (Manila:
University of the Philippines-College of Public Administration, 1978).
198
37. V. Bautista, "Structures and Interventions in the Philippine Health Service

Delivery Syslcm: State of the Art," in Philippine Institute of Development Studies,
Survey of Philippine Development Research III (Manila: Philippine Institute of
Development Studies, 1989).
38. J. Galvez-Tan, "Primary Health Care: Health in the Hands of the People,"
Health Policy Development Consultation Series (Quezon City: Health Action
Information Network, 1986).
39. Sec P. Agarwal, "Some Aspects of Plan Implementation," Indian Journal of
Public Administration 24 (1973): 218-40. J. Montgomery, Technology and Civic
Life: Making and Implementing Development Decisions (Cambridge: Massachu-
setts, 1974); G. Iglcsias, Implementation: The Problem of Achieving Results
(Manila: Eastern Regional Organization for Public Administration, 1976); and J.
Cohen and N. Uphoff, Rural Development Participation: Concepts and Measures
for Project Design Implementation (Ithaca, New York: Cornell University, 1977).
40. L. Hammcrgrcn, Development and the Politics of Administrative Reform
(Boulder, Colorado: Westview Press, 1983); J.L. Gonzalez, "A Historical Survey of
Reorganization in the Philippines," Praxis 2 (1988): 45-63 and J.L. Gonzalez,
"Philippine and U.S. Administrative Restructuring: Same Basic Problem," Philip-
pine Journal of Public Administration 24 (1990): 295-99.
41. For instance, E. Mayo, The Human Problems ofan Industrial Civilization (New
York: Macmillan Company, 1933); H. Simon, "Proverbs of Administration," Public
Administration Review 6 (1946): 53-67 and R. Dahl, "The Science of Public
Administration: Three Problems," Public Administration Review 7 (1947): 1-11.
42. R. Mcrton, Reader in Bureaucracy (Chicago, Illinois: Free Press, 1952), p. 36.
43. See C. Barnard, The Function of the Executive (Cambridge, Massachusetts:
Harvard University Press, 1938); A. Maslow, "A Theory of Motivation," Psycho-
logical Review 50 (1943): 370-96. P. Appleby, Policy and Administration (Corgy,
Alabama: The University if Alabama Press, 1949); C. Argyris, Personality and
Organization (New York: Harper and Row, 1957); H. Simon, Administrative
Behavior (New York: Macmillan, 1957); D. McGregor, The Human Side of
Enterprise (New York: McGraw-Hill, 1960); R. Blake and J. Mouton, The Mana-
gerial Grid (New York: Gulf Publishing, 1964); F. Herzberg, Work and the Nature
of Man (New York: Thomas Crowell, 1966).
44. See P. Drucker, The Practice of Management (New York: Harper and Row,
1954); D. Deming, Company Organization for Packaging Efficiency (New York:
American Foundation for Management Research, 1962); R. Likert, The Human
Organization (New York: McGraw-Hill, 1967); M. Sashkin, A Manager's Guide to
Participative Management (New York: American Management Association, 1984);
R. Golembiewski and E. Eddy, eds., Organization Development in Public Admin-
istration (New York: Marcel Dekker, 1978); W. Ouchi, Theory Z (Reading,
Massachusetts: Addison-Wesley, 1981); P. Block, The Empowered Manager (San
Francisco, California, 1987); F. Herzberg, "Motivation to Work," in Russian
Academy of Sciences, Journal of Sociological Studies (Moscow: Academy of
Sciences, 1990): 32-46.
199
45. It was only after the 1985 Brundtland Conference that the OECD addressed this
important development issue. For more information about the 1 mplementation of the
PHC in the Philippines see Executive Order No. 851; Letters of Instruction No. 949;
and Presidential Decree No. 1397.
46. Azurin, Primary Health Care, p. 58.
47. Ministry of Health, An Overview of the Ministry ofHealth (Manila: Ministry of
Health, 1978) and Ministry of Health, Annual Report (Manila: Ministry of Health,
1979).
48. Azurin, Primary Health Care, p. 35.
49. /Wd., pp. 40-1.
50. Ministry of Health, Revised Training Module on the Five-Impact Programsfor
the Training of Baran gay Health Workers (Manila: Ministry of Health, 1985).
51. Ibid.
52. See Department of Health, Annual Report (Manila: Department of Health,
1988), p. 5.
53. R. Golembiewski, Humanizing Public Organizations (Maryland: Lomond
Publications, 1985), p. 5.
54. R. Denhardt, Theories ofPublic Organization (Pine Grove, California: Brooks/
Cole, 1984).
Joaquin L. Gonzalez III is Fellow at the Department of Political Science, the National
University of Singapore. He is grateful to Edith R. Borbon, Elise B. Gonzalez, colleagues at
the National University of Singapore, the University of the Philippines, De La Salle
University, the University of Utah, the World Bank, and an anonymous referee for their
valuable comments, suggestions, and encouragement.
200

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ASIAN JOURNAL OF PUBLIC ADMINISTRATION VOL.

18, NO 2 (DECEMBER 1996): 168-200

EVOLUTION OF THE PHILIPPINE HEALTH

JOAQUIN L. GONZALEZ III

This article discusses the influence of the evolving development administration

Development administration is an emerging interdisciplinary field of

integrated and systematic study of this field began to flourish only

1. the centralised planning approach;

2. the decentralised structural approach; and

3. the decentralised process approach.

This article concludes with some conceptual and practical con-

Centralised Planning Approach

Justifications for Centralisation

Based on the linear growth theories (for example, the Harrod-Domar

planned change was more or less considered to be synonymous with

underdevelopment and undevelopment are two different concepts

underdevelopment is not an internal condition;

the mainstream thesis of a dualist society put forward by Arthur

- contemporary underdevelopment is in large part a product of past

Frank concluded that development would be most effective if the

Predominant Management System

As implied by the discussion above, the most common development

eminent refers to the dominant role taken by the central, as opposed to

Centralisation in the Philippines

A centrally planned economic system was already in place in the

The GSRC was tasked with the recentralisation of the administrative

of hospital-based health care administered by and accountable to the

the reorganisation of 1958 increased the centralised power of the

Outcome of the Central Planning Approach

This period of planning-oriented development characterised by a

1. identified the mistakes in former blueprints;

2. prepared contingencies ahead of time;

3. laid out a plan that incorporates the contingencies; and

4. accomplished the goal.25

Unfortunately, centrally planned development did not lead to the

centralised management approach used during this period did not

Decentralisation — Structural Emphasis

Shift in Focus of Development Administration

Development experts believed that a solution to the dysfunctions

1. Decentralisation affords greater authority for development plan-

2. Decentralisation cuts through the enormous amounts of red tape

3. Decentralisation allows greater representation of various political,

4. Decentralisation increases administrative capability among local

5. Decentralisation institutionalises the participation of citizens in

In order to increase the likelihood of implementation, develop-

Predominant Management System

During the 1970s, experts and scholars who advocated implementable

development assumed that because planning was always carried out at

Structural Decentralisation in the Philippines

Despite the centralisation of planning for effective development

deficiencies, accidents, malignant neoplasm, bronchitis and asthma,

major cities of the Philippines. According to Alex Brillantes, "the

1. Restructured Rural Health Care Delivery System (RRHCDS)

The RRHCDS was implemented in 1975 as part of a World Bank

2. The Medical Care Programme (MEDICARE)

According to the primer of the Philippine Medical Care Commission,

3. The Rural Health Practice Programme

4. The Community medicine focus of medical and nursing schools

Pioneered by the Rural Health Programme of the University of the

5. The Community-Based Health Programme (CBHP)

approach, health was seen only as a part of an overall village develop-

Decentralisation — Process Emphasis

Including Concern for Process in Decentralisation