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 thePhilippines during the last four decades. It shows how
prescriptions during the1950s and 1960s led to the creation of a centrally planned Philippine health care system.
The dysfunctions of this centralised system motivated development administrationspecialists to call for
decentralisation in the 1970s. Initial attempts atdecentralisation 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 decentralisation 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
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 development 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, political science, health, biology, and engineering). An analysis of development
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 constraints 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 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 employment, which would also
raise the income-generating capacity of the population in general. 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.
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. According 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 writers 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."
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 indigenous 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.

2. Dependency perspective

Andre Gunder Frank, Johan Galtung, Enzo Faletto, Paul Baran, and Fernando Cardoso argued
for a Neomarxist perspective for stimulating development. Frank's research findings on Latin
America emboldened him to argue against Sen and the other mainstream development
economists along the following lines: underdevelopment and undevelopment are two different
concepts because the presently developed countries were never underdeveloped, 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 countries;
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, economic, 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.

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
administrative system which would increase its capacity to implement such programmes.
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. 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. According to G.
Starling, development planners used this capital accumulation-based economic growth plan to
survey current economic 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.
Predominant Management System
As implied by the discussion above, the most common development management system
prescribed by development experts to complement 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 goveminent 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 executive leadership
frequently complements these centralisation traits.
Development administrators believed that using this centralised management 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
institutions thought comprehensive national planning orchestrated by the state would direct the
resource-allocation of the country into appropriate investment areas. Some of the investment
areas they had in mind were: export-oriented industrialisation, import-substitution
industrialisation, 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 consumption 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 American- finished products. In addition, the Philippines was
established as a base for penetrating the growing Asian markets in China, Japan, 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
independence 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
situation.

Following the logic of the current thought on administrative reform, they recommended the
revival and enhancement of the centralised 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-organised 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
recommendations, 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
locations around the country.

Politically, the Philippines responded to the Bell mission recommendations by establishing the
Government Survey and Reorganisation Committee (GSRC) under the Philippine Republic Act
No. 997.
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, economic planning, education and
culture, health, labour, public works and communications, revenue system and statistics, and
allied research. This marriage between centralisation and planned development was clearly
manifested in the high priority given to the reorganisation of the National Economic Council, the
central planning body of the Philippine government. 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 (Manila); 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 Development Authority
(1964); the Mindoro Development Board, the Bicol Development Company, and the
Catanduanes Development Authority (1965); and the Laguna Lake Development Authority
(1966). 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 development model prescribed by the Bell mission and adapted
into law by the Philippine legislature, the Department of Health established a system 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 administrative 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 ineffective — 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 traditional health system by dispatching
medical professionals who prescribed 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 because 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. 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 para professionals (for example,
midwives and sanitary health inspectors). 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 practices.
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, the reorganisation of 1958
increased the centralised power of the health bureaucracy by adding more national-level staff and
administrative, 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.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 politicians 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.
As in the case of previous reforms, organisational changes during this centralised development
period streamlined the planning operations 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 administration
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
implementation 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.
Unfortunately, centrally planned development did not lead to the expected capital accumulation
and rapid economic growth in a significant number of less developed countries. One reason was
the prevalence of the self-interest of those administering the economic development 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 development 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 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
concentration of manpower in the central office in Manila and other urban centres. This
arrangement existed notwithstanding the fact that 80 percent 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 responsibilities (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 approach to planning and implementation, including:
1. Decentralisation affords greater authority for development planning 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 decisionmaking.
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.
In order to increase the likelihood of implementation, development experts of the 1970s
concentrated their decentralisation approach 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 prescriptions was supposed to
make the administrative system more effective in implementing development plans especially at
the community 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 nongovernmental entities helps
alleviate some of the lesource inadequacies of the governmental bureaucracy. These non-
traditional, nonhierarchial, non-governmental entities were expected by development experts to
increase the prospects of project and programme implementation 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 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 departments 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.
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 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, dysentery, malignant neoplasm, tetanus, mental disorder, accidents, bronchitis,
heart disease, vitaminosis and other nutritional deficiencies, and diseases of the vascular system.
According to health experts, these diseases and illnesses are easily preventable with proper
immunisation programmes and improved sanitation. 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 legislative 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 representation from the academic, private, and government
sectors. Bureaucrats 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 Decree No. 1,
the first major administrative reform measure under martial law. Presidential Decree No. 1
mandated a review of theIntegrated 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 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
sustaining efforts, not only on the basis of administrative consideration, but also with respect to
geographic, economic, and cultural factors."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 programmes: 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.
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." 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 Programme created access to hospital-based health care facilities
for the rural areas.

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 mandatory requirement for all medical and nursing
graduates before receiving 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."
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
implementation 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 nongovernmental 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 approach, health was seen only as a part of an
overall village development package. Hence, village health workers also facilitated community
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 Programme 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 administration discovered that even the best designed development
blueprints were susceptible to failure especially if carried out in a centralised 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 labelled a
success if the effective start-up of the programme or project could be effectively completed.
Management experts in the developed countries learned later that the structural and functional
changes proposed in structural decentralisation were effective only in advancing peripheral
changes (for example, eliminating overlapping activities and duplication of functions). 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
somewhat 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 concluded 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 dimension 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 modification,

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 decentralisation
is the institutionalisation of participatory modifications on
the traditionally non-participatory processes perpetuated by governmental
bureaucracies. The theoretical descent of process decentralisation
in development management could be traced to the debate
between the Weberian-inspired school of management and the response
by organisational humanists.
186
Philippine Health Care System
The Weberian-inspired centralised approach was seriously challenged
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 beneficiaries
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 administration
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 organisations
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 processes
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
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participation. This, combined with a strengthened local resource
mobilisation, would lead to sustainability at the village communitylevel.
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 bureaucracy
but also in the service-delivery field units. The role of the
structurally decentralised grassroots units in policy-making was increased
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, community
participation and active beneficiary and proponent collaboration).
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
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Philippine Health Care System
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 Declaration
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 selfreliant
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 statement
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.
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Asian Journal of Public Administration
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 hospitalbased
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 renamed
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 reorganisation
was at the provincial level with the merging of the Provincial
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. Promotive
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 diseases,
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
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Philippine Health Care System
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. Nonetheless,
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 infectious
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 common
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 Philippine
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 supervision,
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 technically
to respond to its expressed health needs.50
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Asian Journal of Public Administration
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 reconstituted
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 consultants
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.
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Philippine Health Care System
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 corporations,
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 department
model of government was again revived.
This reorganisation furthered the cause of process-oriented decentralisation
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 Epidemiology
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 system;
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 "sustainable
health development through participation mandate," more
definite and specific operating principles and approaches towards
process decentralisation were produced by the Aquino administration.
52
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Asian Journal of Public Administration
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 humanistoriented
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 alternative
school to centralisation thought — the human relations school of
management.
Practical Constraints
Despite some positive changes, the problem of resources for health
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Philippine Health Care System
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 implementation
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 implementation
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
Asian Journal of Public Administration
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 Under development (New York: Random House, 1988).
3. A. Lewis, "Economic Development with Unlimited Supplies of Labour," in A.
Agarwala, Economic of Under development (New York: Oxford University Press,
1958).
4. A. Gerschenkron, Economic Backwardness in Historical Perspective (Cambridge:
Harvard University Press, 1962).
5. A.G. Frank, "The Development of Underdevelopment," in R. Rhodes, Imperialism
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,
Planning for Progress: The Administration of Economic 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 California
Press), p. 254.
9. Inayatullah, ed., Rural Organisations and Rural Development: Some Asian
Experiences (Kuala Lumpur, Malaysia: Asian & Pacific Development Administration
Centre, 1978), p. 278.
10. See F. Riggs, Frontiers of Development Administration (Durham, North
Carolina: Duke University Press, 1971) and F. Riggs, "Bureaucracy and Development
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
Philippine Health Care System
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 responsibility
of the Department of Health.
23. See B .M. Gross, Action Under Planning: The Guidance of Economic Development
(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, Administrative
Reforms in Asia (Manila: Eastern Regional Organization for Public Administration,
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, "Administrative
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, organising,
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
Asian Journal of Public Administration
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, "Decentralisation
and Development: A Framework for Analysis," Community Development
Journalll (1986): 88-100; S. Gregory and J. Smith, "Decentralisation Now,"
Community Development 21 (1986): 101-6; M. Khan, "The Process of Decentralisation
in Bangladesh, Community Development Journal 21 (1986): 116-25; R.
Shields and J. Webber, "Hackney Lurches Local," Community Development Journal21
(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 Administration
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 Administration
(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 Philippines
(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 Requirements for Health Professionals (Manila:
University of the Philippines-College of Public Administration, 1978).
198
Philippine Health Care System
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: Massachusetts,
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," Philippine
Journal of Public Administration 24 (1990): 295-99.
41. For instance, E. Mayo, The Human Problems of an 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," Psychological
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 Managerial
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 Administration
(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.
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Asian Journal of Public Administration
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 of Health (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 Bar an 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 of Public 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