Health Devolution: Revisiting Bohol's Pandemic Stricken Healthcare System

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Health Devolution: Revisiting Bohol’s Pandemic-Stricken Healthcare System
An Undergraduate Thesis
Presented to the faculty of the
College of Arts and Sciences
Holy Name University
City of Tagbilaran, 6300
By
Bayona, Argie O.
Bicar, Rey Jay C.
Hibaya, Maria Victoria G.
June 2022
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APPROVAL SHEET
This thesis is entitled Health Devolution: Revisiting Bohol’s Pandemic-Stricken
Healthcare System, prepared and submitted by Argie O. Bayona , Rey Jay C. Bicar,
and Maria Victoria G. Hibaya, in partial fulfillment of the requirements for the degree of
Bachelor of Arts in Political Science, has been examined and recommended for
acceptance and approval for the oral examination.
THESIS COMMITTEE
DR. ANNE MARIQUIT D. OPPUS, J.D.

Content Adviser
Faculty, College of Arts and Sciences
DR. FE R. JANIOLA
Statistician
Faculty, College of Arts and Sciences
PANEL OF EXAMINERS
Approved by the Committee of Oral Examination with a grade of ______________.
DR. RAMON A. BOLORON

Chairperson
Dean, College of Arts and Sciences
DR. FREDERICO B. TICONG,LLB PROF. JAY JEORGIENITA T. OBENZA,JD

Member Member
Faculty, College of Arts and Sciences Faculty, College of Arts and Sciences
.
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ACCEPTANCE SHEET
Accepted and approved in partial fulfillment of the requirements for the degree
Bachelor of Arts in Political Science.
DR. ANNE MARIQUIT D. OPPUS, J.D.
Chair, Department of Political Science
_____________________
Date
DR. RAMON A. BOLORON
Chairman
Dean, College of Arts and Sciences

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ACKNOWLEDGMENT
The researchers would like to express the profound gratitude to the following people for
the invaluable contribution that helped in the completion of the study:
Dr. Anne Mariquit D. Oppus.JD, content study adviser, for the genuine support,
time, effort, and all the suggestions that completely guided the researchers throughout
the study;
Dr. Rosario M. Baseleres, technical study adviser, for sharing her mastery of
knowledge with regard to technicalities and grammar intricacies;
Dr. Fe R. Janiola, for helping the researchers in the statistical treatment of data
and her full support and encouragement to this study;
All the respondents, for the time and effort in answering the questions in the
questionnaires;
To the panelists for their invaluable suggestions and recommendations to
enhance the study;
The researchers’ family, for sustaining their love and faith, extending their moral
support, financially, emotionally, spiritually, and guidance;
And most especially to the Lord Almighty, for His divine mercy that kept the
researchers in good health, for giving them courage, determination, and providing all
the people who helped them to be strong and inspired to accomplish the study.

Argie, Vic, & Rey Jay

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TABLE OF CONTENTS
PAGES
TITLE PAGE . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . i
APPROVAL SHEET . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . .. . . . . . . .. . . . . .. . . . ii
ACCEPTANCE SHEET . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. iii
ACKNOWLEDGEMENT . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. iv
TABLE OF CONTENTS . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. v
LIST OF TABLES . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . .. viii
LIST OF FIGURES . . . . .. . . . . . …… . . . . . . . . . . . .. . . . . . .. . . . . . .. . . . . . . .. . . ix
CHAPTER I
I. THE PROBLEM AND ITS SCOPE
INTRODUCTION
Rationale . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . .1
Conceptual Background . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . 7
Conceptual Framework . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . 9
THE PROBLEM
Statement of the Problem . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . 16
Scope and Limitations . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . 17
Significance of the Study . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . 19
RESEARCH METHODOLOGY
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Research Design . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. 20
Research Participants . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . 21
Research Instrument . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . 22
Research Environment . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . 23
Research Procedure . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . 25
Data Gathering . . . . . . .. . . .. . . . . .. .. . . . . . . . . . . .. . . . . . . .25
Conflict of Interest . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . 26
Confidentiality and Privacy . . . . . . .. . . . . . . . . . . . .. . . . . . . . . 26
Informed Consent Process . . . . . . .. . . . . . . . . . . . .. . . . . . . . . 26
Recruitment . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . .. 27
Risks . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . .. .. 27
Benefits . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . .. . . . . . 27
Incentives . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . .. .27
Statistical Treatment .. ... . . . . . . . . . … . …… . . . . .. . . . . . . .28
DEFINITION OF TERMS. . . . … . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . .29
CHAPTER II
II. PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA
Analysis of data. .. . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . . . . .. 31
CHAPTER III
III. SUMMARY, FINDINGS, CONCLUSION, AND RECOMMENDATIONS
Summary of the Study. .. . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . .55
Summary of the Findings. .. . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . 56
Conclusion. .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
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Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Proposed Action Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61
REFERENCES.. . . . . . .. . .. .. . . . . . . . . .. . . . . . . . .. . .. . . . . . . .. . . . . . . . .. . .46
APPENDICES
Appendix A. Questionnaire or Data-Gathering Tool
I. Communications
II. Bohol Annual Report 2020
III. Ethical Review Board Clearance
IV. Informed Consent Form
V. Annual Investment Plan of the Provincial Health Office
VI. Revised Organization Structure and Staffing Standards for
Government Hospitals
VII. Self-made questionnaire
VIII. KII guide questions
IX. Researchers’ Waiver of Liability
X. Documentations
XI. Curriculum Vitae

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CHAPTER I
THE PROBLEM AND ITS SCOPE
INTRODUCTION
Rationale
In 1987, after the fall of the Marcoses, the Aquino administration ratified a
constitution that effectively replaced the infamous 1973 Constitution that had operated
for more than a decade under the former’s regime. The new constitution contains
several salient features that restore democracy in the country and lay the foundation
for redistributing and strengthening public services at the local level.
This change in the country's political atmosphere has paved the way for the
enactment of the country's Local Government Code in 1991, which was then
considered to be landmark legislation. It empowered Local Government Units (LGUs)
to have more autonomy in decision-making and resource allocation at the local level
(Atienza, 2004). The code has also devolved several services to the Local
Government units – including agriculture extension, local infrastructure push, and most
notably, the delivery of healthcare services, among others.
The LGC has brought about a massive reform in the delivery of health services.
By the time the LGC had taken effect, it had been noted to be the most radical
decentralization taken up by an Asian country regarding the degree of power,
responsibility, resources, and personnel decentralized to the LGUs (Atienza, 2004).
The once highly centralized health care system has been devolved from the
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Department of Health (DOH) to the different LGUs across the country (Cuenca, 2018).
In 1993, with P4.2 billion expenditure devolved, the DOH had the most considerable
absolute amount devoted to the LGUs.
This decentralization is aimed toward the efficiency and effectiveness of
delivering health services by transferring the burden of decision-making and allowing
greater independence in the allocation of resources as determined by the local
government concerned. However, years since the delivery of healthcare services have
been devolved to the LGUs; several challenges have risen, showing the defects of the
devolution.
According to Janet S. Cuenca (2018), the national government and local
governments must overcome several obstacles to make devolution work. These
challenges can be summarized into these highly interrelated categories: health
financing, health personnel, and organizational/structural changes.
Healthcare financing originates from a mismatch between the Internal Revenue
Allotment (IRA) and the cost of devolved functions (CODEF). This has been a problem,
particularly in the fourth quarter of 1992, when many LGUs realized that the CODEF
was more significant than their respective IRA share (Cuenca, 2018). With this, it is no
surprise why a huge gap can be observed among LGUs in the disposal of their
devolved functions, particularly in the delivery of public health care services across the
country.
Many provinces and smaller municipalities did not have enough funds to pay the
salaries of national workers devolved to them (Perez 1998a and Perez 199b), let alone
the cost of implementing the Magna Carta for public health workers mandated by
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Republic Act 7305 of 1992, which was not factored into CODEF's estimation has
placed many LGUs in a tighter spot in securing healthcare workers. In addition, LGUs
significantly decreased the hiring of health personnel due to tight budgets and high
salaries (i.e., due to Magna Carta benefits) of health workers, as evidenced by the
inadequate hospital and rural health unit staff (Wibulpolprasert, 1999). The vacant
plantilla positions were left unfilled to generate savings, which were then used to offset
the costs of Magna Carta benefits (DOH 1997). The inequitable IRA distribution
compared to CODEF also prompted LGUs to complain about insufficient funding for the
operation of health facilities, particularly hospitals (DOH 1997).
Years after the Code was implemented, the issue of CODEF burden inequity
among LGUs remained (Perez, 1998a). Inadequate IRA funds caused local
governments to fail in the implementation of national mandates, which are typically
unfunded, such as salary increases and Magna Carta benefits for health workers. As a
result, and as mentioned, the hiring of medical personnel decreased (Wibulpolprasert,
1999). This gap has resulted in a disparity of capacity in delivering healthcare services
among LGUs – creating limitations in accessing quality health services among the rich
and the poor LGUs (Bauer, nd).
In addition, Grundy et al. (2003) reiterated that underfunding of public health
services resulted in "understaffing, reduced utilization rates, un-maintained
infrastructure, and un-repaired or un-replaced equipment." The national government's
efforts to supplement local health budgets were ineffective in halting the steady
deterioration of the facilities (Grundy et al. 2003, p.7). However, because
pre-devolution investments intended for local health facilities were never utilized, the
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health facilities had already deteriorated when the LGUs took over (Gualvez, 1999).
"The years of neglect that provincial, district and municipal facilities had suffered long
before it was brought to the surface by health devolution (DOH 1999b, p.17)."
In addition to this, health devolution has resulted in significant
Organizational/structural changes to keep in phase with the changes being
implemented. An example of this is the creation of the Local Health Board (LHB), which
is expected to submit recommended policies for planning and implementing local
health programs (DILG-LGA 2003). However, due to financial constraints and some
other challenges, some LHB has already ceased functioning or have not fully carried
out their mandates (AYM, 2005).
As the world faces what is perhaps the worst health crisis in the 21st century – it
is indeed worth exploring the current posture of the country's healthcare sector. It must
be noted that governments around the world scramble in an attempt to contain the
virus immediately and save their respective economies, people, and different interests.
Nevertheless, the damage has already been done. Around two hundred million have
been infected throughout the world – and more than four million of which have
succumbed to the said disease. The virus is so contagious that some countries are
pushed to a desperate position of saving their collapsing healthcare system as it
struggles to attend to the needs of their people.
Sadly, the Philippines is not an exemption from this health crisis. It is regretful to
note that the Philippines has already recorded more than a million cases and more
than 20,000 deaths. Among these numbers are cases from the province of Bohol,
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which as of this writing, stands at 7,322 cumulative total confirmed cases, of which
5,920 have recovered, 1,320 are active, and 82 have ultimately died. These figures are
alarming to a province that has a limited facility to handle severe COVID-19 cases.
Although several hospitals are operating under the supervision of the Provincial
Government of Bohol, the province only has two DOH retained hospitals – one is the
Governor Celestino Gallares Memorial Hospital in Tagbilaran City (GCGMH), and the
other is the Don Emilio Del Valle Memorial Hospital (DEDVMH) in Ubay, Bohol.
However, Of the two DOH-operated hospitals, only the GCGMH has been categorized
by DOH as a level 3 facility, which means that it is the only hospital in Bohol that can be
fully designated to accept COVID-19 infected patients.
Moreover, it is noteworthy that all of the existing district hospitals across Bohol
are only categorized as either a level 1 or 2 health facilities. This means that, unlike the
GCGMH, these devolved facilities only have a lesser number of facilities and
personnel. Despite this, due to the growing number of individuals being admitted to
GCGMH, district hospitals are only given limited authority to handle COVID-infected
patients despite the concerns of not having enough facilities and equipment to handle
such highly contagious diseases.
In addition, with the resurgence in the number of people being infected by the
virus, the actual condition of the Philippines' corroding health care system has
Surfaced. Several health advocates and even lawmakers have called for a review of
the devolution of healthcare services in the Local Government Code of the Philippines.
Notably, the Third District Representative of Bohol, Rep. Alexis Tutor, also serves as
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the vice-chairman of the congress' committee on health. She has been a staunch
advocate of reviewing the devolution of healthcare services to the LGUs. The lady
solon from Candijay believes that the gaps in the country's devolved healthcare system
have hampered the delivery of basic healthcare services, particularly the response to
COVID-19.
Years after, the healthcare system has been devolved primarily to the LGUs.
There is only a limited number of studies regarding the effects of the matter. With the
introduction of new laws and mechanisms aimed to give LGUs greater financial
autonomy under the concept of decentralization and devolution, no study has been
produced focusing on the impact of devolution on the healthcare system of Bohol. This
knowledge gap has motivated the researchers to embark on the said study to
determine and analyze the impact of decentralization policies on the Healthcare
system of Bohol and provide recommendations to improve the province’s healthcare
system, especially in times of healthcare emergencies like the COVID-19 pandemic.
Theoretical Background
This study is anchored on the concepts of decentralization and devolution. In
addition, several legal bases, including the 1987 Constitution and the 1991 Local
Government Code of the Philippines, were also incorporated. This study treats health
devolution as a dependent variable.
In this study, health devolution is the dependent variable because an LGU’s
prioritization of a devolved healthcare system may affect the delivery of healthcare
services – such as the availability of healthcare personnel, health-related infrastructure

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and transportation, healthcare products, and financial aides to support patients’
expenses.
One factor that can significantly determine the trajectory of development is the
overall health condition of the populace that, in turn, can contribute to the country’s
human capital – necessary for keeping economic activities alive (Grosse & Harkavy,
1980). The importance of investing in a reliable and responsive healthcare system can
be said to have been acknowledged by the Philippine Government as enshrined in the
Philippine Constitution, wherein Article II section 15 provides for the protection and
promotion of the right of the public and instill consciousness on health among them.
The constitution in Art. 13, sec. 11, further provides that the state should adopt
an integrated and extensive approach for the development of health and making
essential goods and all services related therein to be affordable and available for the
Filipinos. The underprivileged, elderly, sick, disabled, women, and children should also
be given prioritization for the development of health.
These provisions have indicated the seriousness of the Philippine Government is
doing its part in delivering and establishing a healthcare system that will oversee the
welfare of the Filipinos as part of the duty of the government in serving and protecting
the lives of its people. Along the way, new laws were created to support the
development of this vital sector despite several challenges and financial constraints
that have marred the national government’s effort to revitalize the Philippine health
sector.
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In an attempt to support development in rural areas, decentralization policies are
usually utilized. This is to give more room for people to be included in the
decision-making and policy-making of the government (Fauget, 2016). By definition,
decentralization is transferring powers from the national government down to the local
governments to enable optimum participation of the people in the government and
community activities (de Leon, 1991).
Decentralization basically incorporates the meanings of the Latin origins, with
the broad meaning being "away from the center" (Meenakshisundaram, 1994, p. 11).
This interpretation means the transfer of authority from the central government to a
lower level of government. As defined by Wollmann, decentralization is the transfer of
powers and activities to subnational level actors.
According to Yash Gai (1998), decentralization acknowledges diversity; hence, it
calls for localization of decision-making to consider the different needs arising from
other communities, which a highly centralized government might neglect.
Decentralization aims to make a government that listens and gives people their right to
participate in matters concerning the public. In other words, decentralization's ultimate
goal is to strengthen those at the community's grassroots.
In addition, according to Bardhan (2002), decentralization is being viewed to
bring many benefits to the country adopting it. Bardhan added that decentralization is a
way to reduce the state's position in general by fragmenting central control and
bringing more intergovernmental competition and checks and balances, and making
government more flexible and effective.

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Figure 1.0 Conceptual Framework
According to the World Bank (n.d.), decentralization includes the transfer of
authority and responsibility and financial resources in providing public services, from
the national government down to the local governments. This type of decentralization
features three types: deconcentration, delegation, and devolution.

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Deconcentration is the diversifying of decision-making authority and financial and
management responsibilities at several national government levels. For instance, this
may include transferring responsibility from government officials at a health ministry's
headquarters to ministry workers in regions, provinces, or even districts.
Deconcentration rarely necessitates revisions to existing laws. However, in some
countries, Changes in who may wield legal power must follow a specific legal
procedure.
Meanwhile, delegation is the process of a national government delegating
decision-making and administration of public activities to semi-autonomous public
sector bodies such as hospital corporations. These organizations usually have their
legal status and a lot of latitude and autonomy regarding management decisions.
Delegation frequently necessitates significant legislative reforms, such as establishing
new public sector entities and defining their responsibilities, powers, accountability, and
relationship to the national government. It may also entail the implementation of
additional regulatory measures. This is because autonomous decision-making may
necessitate state control to ensure that autonomous entities' decisions are consistent
with the government's broader health policy goals.
Lastly, devolution refers to the transfer of functions from national governments to
subnational governments. Subnational governments often have distinct and legally
recognized geographical borders over which they exercise jurisdiction and perform
these functions in a decentralized system. Devolution may entail constitutional and
legal reforms to formalize the devolution of powers, responsibilities, and accountability.
In our very own laws, the Local Government Code of the Philippines identifies
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devolution as the removal of power and authority from the national government and its
transfer to a local government. (Art. 26[b], Rule V, Implementing Rules and Regulations
R.A. 7160).
Gerring, Thacker & Moreno (2006) added that the concept of decentralization
(which includes devolution) is widely popular among the academe, politicians, and the
people from the grassroots, making it the dominant political trend in our time. The
favorable view from different sectors has paved the way for the legislation of the Local
Government Code of the Philippines. The code has relieved the national government of
several responsibilities by transferring some of its functions to the hands of the Local
Governments to improve service delivery and efficiency. One of the devolved and
perhaps the most controversial is the devolution of the country's healthcare services.
Before devolution, the public health system had both national and local
components. The Department of Health oversaw a national service delivery system
that extended from barangay-level health and hospital facilities to local, provincial, and
national levels. However, it must be noted that from the 1970s to the mid-1980s, the
government's healthcare system performance still lags behind its neighboring countries
(Atienza, 2004).
The implementation of the LGC in 1992 specifically provided the health services
to be devolved to the Local Government Units. Section 17. b.1. ii. in the said code,
provided the responsibility of the barangay in the maintenance of barangay health
centers. Meanwhile, Sec. 17. b.2.iii. mandated municipalities in implementing projects
to address primary health care for children and pregnant women, control
communicable and non-communicable diseases, and purchase medicines, medical

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supplies, and equipment needed to carry out the said services. Section 17.b.3.iv. also
devolved tertiary health services and hospitals to the province. Lastly, Section 17.b.4.
has given the city all the services and facilities of the municipality and province.
Meanwhile, the Bureau of Local Health Development reported in 2013 that in
1992, budgets, personnel, and facilities from the DOH were transferred to the local
government units. In that year, of the 78,080 personnel from the national government,
46,080 were transferred to the LGUs, while 32,000 were retained. On the other hand,
in terms of facilities, 595 hospitals were devolved, and only 50 of them have been
retained. Meanwhile, all 12,580 RHU/MHC/BHS have been devolved to all LGUs in the
country.
However, despite devolving most healthcare personnel and facilities to the LGUs,
the devolved budget was less than the retained budget – Php 4.215 billion devolved to
the LGUs vs. Php 6.012 billion maintained by the national government. Nevertheless,
this vast and perhaps overwhelming transfer of health personnel and healthcare
services expenses (e.g., maintenance of hospital buildings, operations, and equipment)
have caused new challenges to the LGUs, such as finding enough budget to fund and
maintain the devolved personnel, infrastructure, and services.
The mismatch between the Internal Revenue Allotment (IRA) and the Cost of
Devolved Functions (CODEF) is at the root of the health financing problem. This has
been a problem since the transition, especially in the last quarter of 1992, when many
LGUs realized that the CODEF was more significant than their respective IRA share
(i.e., inequitable CODEF burden across LGUs). Many provinces and smaller
municipalities lacked the financial resources to pay the wages of national employees
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devolved to them (Perez 1998a and 199b), not to mention the expense of enforcing the
Magna Carta for public health workers, as required by Republic Act 7305 of 1992,
which was not factored into CODEF's calculations.
Due mainly to tight budgets and high wages (i.e., as a result of Magna Carta
benefits), LGUs have reduced their hiring of health professionals, as demonstrated by
insufficient hospital and rural health unit employees (Wibulpolprasert, 1999). To save
money and defray the costs of Magna Carta benefits, the unfilled positions or
vacancies were left unoccupied (DOH 1997). The IRA distribution is inequitable.
CODEF also compelled LGUs to convey their dissatisfaction with the lack of funding for
the operation of health facilities, especially hospitals (DOH 1997). The IRA mismatch
with the cost of devolved hospitals resulted in lower (i.e., pre-devolution) province-level
hospital spending (DOH 1999(b).
The number and scale of devolved hospitals have exceeded what the LGUs can
afford to maintain and operate. The Department of Health Task Force on
Decentralization drafted the "DOH Rules and Regulations Implementing the Local
Government Code of 1991 (hereafter DOH IRR)" in August 1992 to make health
devolution easier to enforce. In addition, the DOH established the Local Government
Assistance and Monitoring Service (LGAMS) in December 1992, initially as an ad hoc
unit but later gaining its line item in the DOH budget in 1994, to function as a liaison
between the DOH and local governments (Perez 1998b).
The LGAMS was created to address issues and problems that arose as a result
of the devolution process. The Master Plan for Local Government Code of 1991 was
developed by the Department of Interior and Local Government (DILG) through the
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Bureau of Local Government Development to maintain the momentum of the
decentralization process (DILG-BLGD n.d.). The introduction of devolution in the
country was divided into three phases.
Firstly is the Changeover phase (1992-1993). This phase sets the formal transfer
of roles and responsibilities from the DOH to the LGUs. This includes staff, properties,
and other liabilities. The next phase is the Transition phase (1994-1996). During this
period, the DOH and LGUs aim to institutionalize their reforms to the code's new
features. During this time frame, the health department and the respective LGUs were
also tasked with the implementation of the Stabilization phase by helping LGUs learn
the needed expertise to manage health services. The Stabilization phase (1997 and
onwards) is the last of the three phases. During this time, it is expected that LGUs have
already developed the essential skills in administering local affairs, such as gaining
complete authority in handling local health services. In this period, the DOH merely
performs by providing the necessary support and technical assistance to the LGUs.
Nearly two decades after the code's enactment, the Department of Health (DOH)
described significant issues relating to the delivery and funding of health services as
part of its attempt to draft the Health Sector Reform Agenda (HSRA) (Solon and Herrin
2017). Among these problems are (i) the existence of disparity in the access and the
level of quality of available health care services and facilities among LGUs; (ii) some
LGUs have failed to maintain or improve the devolved facilities to them. Also, due to
financial constraints, some LGUs could not give their healthcare workers their
mandated benefits; (iii) Meanwhile, other LGUs experienced a lack of professional
cooperation. And lastly, (iv) the huge out-of-pocket expenses only show the sluggish
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implementation of the Philippine Health Insurance Corporation as a social insurance
program which is the country's main health-financing concern (Romualdez et al., 2011).
Recognizing the challenges it faces, the Department of Health in 2013 released
its Revised Organizational Structure and Staffing Standards for Government Hospitals.
The said document determines the different classifications of hospitals and their level of
functional capacity. It also provides for the organizational structure model of each level
of hospital as well as the Department of Health’s official standard staffing pattern.
The Revised Organizational Structure and Staffing Standards for Government
Hospitals were released to monitor the current classification and capacity of existing
hospitals in the country. It also set forth the standardization of medical workers a
healthcare institution must have depending on the level of capacity they were accredited
and the number of beds a healthcare facility has.
More than ever, the country is in a dire situation to strengthen its healthcare
system to immediately respond to people's needs. The already struggling healthcare
system of the Philippines is now being tested on hot waters as thousands of Filipinos
continuously are getting infected by the COVID-19 virus. The rise in the number of
people getting infected is putting more pressure on the country's healthcare system –
stretching its financial and human resources to their limits.
In good light, LGUs will be receiving a fresh breath from all these pressures. In
2022, the national government is bound to implement the Mandanas ruling, which the
Supreme Court issued on June 10, 2019. In this landmark decision, the Supreme Court
has ruled that both national taxes, not just national internal revenue taxes, must be
included in the just share of LGUs. As a result, customs duty and other taxes should be
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factored into IRA calculations. By 2022, it is expected that LGUs will receive a Php
235.39 Billion-increase in their expected IRA.
Despite this development, there is no enabling mechanism to compel LGUs to
spend more funds on their respective healthcare system. Under the ruling, LGUs are
still given the maximum independence in the designation of their funds.
In addition, It is left to be seen if Bohol’s devolved healthcare system will take this
opportunity to improve its existing healthcare facilities and provide better healthcare
service to Boholanos by following the Revised Organizational Structure and Staffing
Standards for Government Hospitals set by the Department of Health.
THE PROBLEM
Statement of the Problem
This study aims to determine and analyze the impact of decentralization policies
on the Healthcare System in Bohol amidst the COVID 19 Pandemic.
Specifically, the study aims to answer the following questions:
1. What are the plans, policies, and projects of the Provincial Government of Bohol
in delivering healthcare for the devolved district hospitals in Bohol in response to the
COVID 19 pandemic?
2. What are the benefits encountered by the devolved district hospitals in the
delivery of healthcare services during the pandemic in the areas of:
2.1. Availability of Healthcare Personnel
2.2. Availability of Necessary Health-related infrastructure and transportation

17
2.3. Availability of Healthcare products (e.g., vaccines, medicines, equipment,
and technology)
2.4. Availability of Financial Aid to support patients’ expenses, healthcare
personnel compensation, and hospital administration.
3. What are the problems/challenges encountered by the devolved district
hospitals in the delivery of healthcare services during the pandemic in the areas of:
3.1 Availability of Healthcare Personnel
and technology)
4. What recommendations may be proposed to ensure effective and efficient
healthcare delivery in the Province of Bohol, especially in times of healthcare
emergencies like the COVID 19 pandemic?
Scope and Limitations
The study determined and analyzed the impact of decentralization on Bohol’s
healthcare system. The researchers looked at the different district hospitals situated in
Bohol. The scope of the study included nine of Bohol’s ten (10) district hospitals,
namely; Candijay Community Hospital in Candijay; Congressman Simeon Toribio
Hospital in Carmen; Catigbian District Hospital in Catigbian; Clarin Community Hospital
in Clarin; Francisco Dagohoy Memorial Hospital in Inabanga; Teodoro B. Galagar
District Hospital in Jagna; Congressman Natalio Castillo Hospital in Loon; Maribojoc

18
Community Hospital in Maribojoc; and President Carlos P. Garcia Memorial Hospital in
Talibon. Meanwhile, the researchers were not able to receive a response from Pres.
Carlos P. Garcia Municipal Hospital in Pres. Carlos P. Garcia, thus the said district
hospital, was excluded. The Chiefs of each District Hospital, the Chief Nurses, the
Administrative officers of the district hospitals, the Chief of the Provincial Health Office,
and Bohol’s Sangguniang Panlalawigan chair for Culture and Arts, Personnel and
Related Policies, Health and Public Sanitation were the respondents of this study.
The data gathering process was done in a face-to-face setup. A survey
questionnaire was provided to all target respondents in each respective district
hospital. To secure the safety of all parties involved in the said study, the researchers
have complied with all necessary documents and requirements imposed by Holy Name
University to conduct the study. On top of this, an email was sent to respondents
informing them of the said study. Efforts were also made to reach respondents through
landline calls.
The researchers also retrieved existing documents concerned with the policies,
plans, and projects of the Provincial Government of Bohol during the pandemic. This
will help the researchers determine the impact of decentralization policies on the
pandemic-stricken healthcare system of Bohol.
The study is strictly limited to the impacts of devolutions on the healthcare system of
Bohol as well as the policies, plans, and projects of the Provincial Government.
Significance of the study

19
The study hopes to assess and examine the effect of decentralization policies on
the healthcare system in Bohol amid the COVID 19 Pandemic. Furthermore, the study
could be of importance to the following:
Community. The study has high value to society. It can provide important information
and awareness about the devolved health care system and the implementations of
programs, projects, and services.
District Hospitals. The study can provide information about the availability of
healthcare personnel, transportation, and budget to fund and maintain the devolved
personnel, infrastructure, and services.
Future Researchers. The concepts discussed can be used as a starting point for new
research or to verify the validity of other similar findings. The research will also serve
as a cross-reference for them, providing them with a history or summary of the effect of
decentralization policies. Future researchers may explore other capabilities of Bohol's
healthcare system.
Provincial Government. The provincial government will use the study to assess the
conditions of district hospitals throughout the province. It can also be used to determine
policies, plans, and projects.
Students. The study may serve as a guide and reference for other students
undertaking similar study. The study will help them in understanding what needs to be
done in the future.
RESEARCH METHODOLOGY
Research Design
20
This study utilized the quantitative and qualitative research approaches. In
gathering data, the researchers used self-made questionnaires to help determine and
analyze the impact of decentralization policy on Bohol's pandemic-stricken health care
system.
The quantitative research approach is appropriate for the study since quantitative
research gathers and interprets numerical data. It is used to detect patterns and
averages, make predictions, evaluate causal linkages, and generalize results to
broader groups.
The paper has mobilized the qualitative research approach through the conduct
of Key Informant Interviews (KII) to Sangguniang Panlalawigan Chair for Culture and
Arts, Personnel and Related Policies, Health and Public Sanitation, and the Chief of
the Provincial Health Office of Bohol.
Standard qualitative methodologies include open questions interviews,
word-described insights, and literary reviews that discuss topics and theories. The
research respondents of this study are the District Hospital Chief, Chief Nurse, and the
Administrative officer from the 9 district hospitals in Bohol. Lastly, an annual investment
plan for the year 2020-2022 was secured. The plan was used for additional reference
to this study.
Research Participants
21
RESPONDENTS NO. OF
RESPONDENTS
Chief Officers Of District Hospitals 9
Chief Nurses Of District Hospitals 9
Administrative Officers From District Hospitals 9
Chief of the Provincial Health Office 1
Sangguniang Panlalawigan Chair for Culture and 1

Arts, Personnel and Related Policies, Health and Public
Sanitation
TOTAL NO. OF RESPONDENTS 29
Table 1. Total Number of Participants
This study utilized a purposive sampling design since the criteria for choosing
the participants are highly dependent on their knowledge and experiences as key
officials/personnel working in the healthcare system of Bohol or in the Provincial
Government of Bohol tasked with handling policies relating to the province’s healthcare
system.
Hence, respondents who fit the inclusion criteria are the randomly selected
health workers from district hospitals in Bohol and some key government officials,
namely, the Chief Officers of the district hospitals in Bohol; the Chief of the Provincial
Health Office of Bohol; the Sangguniang Panlalawigan Chair for Culture and Arts,
Personnel and Related Policies, Health and Public Sanitation; the Chief of every district
hospital; the Chief Nurse; and the Administrative officer.
There are 29 respondents; (9) the district hospital chiefs, (1) the Chief of the
provincial health office of Bohol, (1) the Sangguniang Panlalawigan Chair for Culture
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and Arts, Personnel and Related Policies, Health and Public Sanitation, (9) Chief
Nurses and (9) Administrative Officers from the district hospitals in Bohol.
The researchers have included the chief executive officers of each district
hospital as a respondent to the study to successfully determine the current situation of
their respective district hospitals to allow the researchers to have a glimpse of the
current posture of the devolved hospitals amidst the challenges brought about by the
pandemic.
As the chief of the devolved healthcare system in the province, the Chief of the
Provincial Health Office (PHO) will also be a respondent to this study. The PHO is
tasked with controlling and managing the district hospitals in the entire province of
Bohol. Another respondent of the study is the Chair for Culture and Arts, Personnel
and Related Policies, Health, and Public Sanitation of the Sangguniang Panlalawigan
of Bohol.
The said official will serve as a key informant to successfully determine the
impact of decentralization on the local policies of the province on its healthcare system.
In addition to this, they are responsible for approving healthcare budgets and creating
the matrix for the decentralization policy. The Chief nurses and Admin officers are also
included as respondents as they serve as the frontliners in delivering the healthcare
services. The above-mentioned respondents and their participation in the study have
significantly contributed to shedding light on the questions this paper seeks to answer.
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Research Instruments
The researchers have utilized self-made questionnaires in the Likert Scale as the
source of their quantitative data collection. A Key Informant Interviews (KII) was
conducted to gather qualitative data on the impact of decentralization policy on the
healthcare system of Bohol.
The researchers utilized the Key Informant Interview technique, which involves a
set of interview questions aimed to gather data from, The Chief of Provincial Health
Officer, Sangguniang Panlalawigan Chair for Culture and Arts, Personnel and Related
Policies, Health and Public Sanitation.This helped the researchers determine and
analyze the impact of decentralization policy on the pandemic-stricken healthcare
system of Bohol. Its purpose is to gather data from individuals who have essential
information and expertise on the research topic.
Another research instrument utilized is the self-made questionnaires in the Likert
Scale. This is done through a survey questionnaire where the answers usually include
"strongly agree," " Somewhat agree," "neutral," "Somewhat disagree," and "strongly
disagree" from the list of potential responses to a particular issue or declaration. The
answer groups are also coded numerically; for this specific analysis, the numerical
values, such as 1 = strongly agree, 2 = agree, and so on, must be specified. This will
allow the researchers to gather data from the selected healthcare workers of each
district hospitals in Bohol. The collected data will help the researchers fully understand
the impact of decentralization policies in Bohol from the perspective of the frontliners.
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Research Environment
Bohol is an island province in the central Philippine region. The province is
renowned for its tarsiers being among the smallest primates on earth, and the
limestone hills in the summer, so-called Chocolate Hills. Bohol also boasts an exciting
flora and fauna on an untouched white beach background, rich limestone karsts, and a
laid-back locale.
The Bohol Sea still sits between the north of Mindanao. It's 700km south of
Manila and about 70km southeast of the island of Mactan. Bohol is the tenth largest
island in the Philippines, with an area of 4,117.26 km2 or 1,608 sq. km and a coastline
of 390 km. There are 4117 km2 of land, and as of 2015, there are 1.31 million
inhabitants.
At present, Bohol has ten (10) district hospitals scattered around the province.
These hospitals are situated in: Candijay, Carlos P. Garcia, Carmen, Catigbian, Clarin,
Inabanga, Jagna, Loon, Maribojoc, and Talibon. These will allow the researchers to
successfully determine and analyze the impact of decentralization policies on the
Healthcare System in Bohol amidst the COVID 19 Pandemic.
Figure 2. Map of Bohol

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Research Procedure
Data Gathering
The researchers wrote a letter to the Provincial Health Office (PHO) through its
appointed chief officer Dr. Yul Lopez. The PHO has provided an endorsement letter
allowing the researchers to conduct the said research in the respective district
hospitals of Bohol. Thus, the researchers have highlighted the medium for data
gathering that is the only applicable technique called virtual gathering due to covid-19
pandemic restrictions. This technique has utilized printed survey questionnaires which
were accomplished by the selected respondents from 9 district hospitals. Thus, the
approval of Dr. Yul Lopez, being the chief officer of the entire district hospitals in the
province, was crucial for the data gathering procedure.
The researchers, through the PHO, gathered contact information such as the
email addresses and phone numbers of each chief executive officer, chief nurses, and
administrative officers of each district hospital in Bohol to establish a line of
communication.
Further, the researchers distributed a copy of the informed consent form to the
chief executive officers, the chief nurses, and the administrative officers, asking for
their consent to take part in the data gathering process. Thus, after their approval, the
researchers for the chief executive officers and the head of the provincial health office.
However, for the randomly selected health workers, the google form link for the Likert
scale designed survey will be given to access and answer the said form.
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The same letter will also be sent to the email address of the Sangguniang
Panlalawigan Chairperson – Culture and Arts, Personnel and Related Policies, Health
and Public Sanitation Hon. Elpidio L. Bonita. After his approval, an interview was also
scheduled based on his availability.
With this, the researchers will be able to retrieve existing documents about the
plans and programs of the Provincial Government of Bohol in the delivery of healthcare
for the devolved district hospitals in Bohol in response to the COVID 19 pandemic.
The data from the respondents will be tabulated, analyzed, and interpreted with
the assistance of a statistician. Rest assured that their identifications will be kept
confidential. All of the data gathered will only be used for research purposes.
Statistical Treatment
To determine the benefits and the problems/challenges encountered by the
devolved district hospitals in the delivery of healthcare services during the pandemic in
the areas of availability of healthcare personnel, necessary health-related
infrastructure, healthcare products (e.g. vaccines, medicines, and technology), and the
finances to support patients’ expenses, the weighted mean formula was used:
Weighted Mean = ΣfxN

where: fx- the sum of frequencies and its weight
N- the number of respondents
The computed weighted mean will be interpreted using the following scale:
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5- Strongly Agree
4- Agree
3- Undecided
2- Disagree
1-Strongly Disagree
Definition of Terms
Decentralization. Regulation of an operation or agency is delegated to several
municipal offices or authorities rather than a single one.
Devolution. The transfer or delegation of authority from the central government to
local or regional administration at a lower level.
District hospital. Refers to a front-line hospital with its own catchment area and the
capability and equipment to provide secondary medical services to cases that
necessitate hospitalization and the expertise of qualified physicians.
Financial aides. The capacity of district hospitals to provide free or discounted medical
services to patients who meet certain eligibility standards and are unable to pay for their
medical treatments.
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Health care system. A healthcare system is a way of financing, coordinating, and
providing healthcare to a community. Entry (for whom and to which services), costs,
and resources are all covered (healthcare workers and facilities).
Health care worker/ Health care professional/ Health care personnel. Physicians
and nurses, or indirectly as assistants, helpers, laboratory technicians, or even medical
waste handlers, one who provides treatment and services to the sick and ailing.
Health devolution. The mechanism by which healthcare is funded, coordinated, and
distributed to a community is referred to as a healthcare system. Entry (for whom and
to which services), expenses, and resources are all addressed (healthcare workers
and facilities).
Health related infrastructure and transportation. Infrastructure refers to the physical
building and equipment necessary in treating patients such as hospital beds,
specialized laboratory equipment, and life support machineries. Meanwhile,
transportation refers to the availability of emergency vehicles operated by district
hospitals in responding to emergencies and bringing patients to their health facility.
Healthcare Products. Any product used in the management of health care that
includes medicines, vaccines, and personnel protective equipment.
Impact of Decentralization. This is the positive and negative areas of decentralization
policies towards the health care system of Bohol.
Respondents. the specific health personnel who have agreed to participate in this
study.
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Chapter II
PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA
Chapter II presents, analyzes, and interprets the data gathered from the three
groups of respondents, namely the chiefs of hospitals, chief nurses, and administrative
officers of the nine district hospitals included in the study.
This chapter is divided into two parts. The first part presents the provincial
government's plans, policies, and projects in delivering healthcare for the devolved
district hospitals in Bohol in response to the COVID-19 pandemic.
The second part is the presentation of data, as well as the discussion on the
benefits and challenges of the devolved hospitals as determined under four categories:
the availability of health care personnel, availability of necessary health-related
infrastructure and transportation, availability of healthcare products, and lastly,
availability of financial aid to support patients’ expenses, health care personnel, and
hospital administration.
1. Plans, policies, and projects of the Provincial Government of Bohol in
delivering healthcare for the devolved district hospitals in Bohol in
response to the COVID-19 pandemic.
1.1 Plans
During the Key Informant Interview (KII), the researchers determined Bohol's
provincial government's plans, policies, and projects for its devolved healthcare system.
30
Accordingly, Bohol will be part of the Universal Health Care Law (UHC) pilot provinces;
wherein the province is expected to receive much-needed technical, logistical, and
financial support from the Department of Health (DOH) and Philhealth. This UHC is a
tri-partnership among LGUs, the DOH, and Philhealth, all aimed at improving the
healthcare system of devolved hospitals throughout the country.
The additional funds from the UHC will be utilized for hospital supplies, patient
care, and preventive medicines, which are cheaper than curative medicines. The UHC
provides mandates that focus on preventing diseases through active surveillance of
emerging diseases that could put the health of Boholanos at risk and enhance the
delivery of healthcare at the barangay level by collecting family profiles and determining
what risks they might encounter.
Moreover, the Sangguniang Panlalawigan of the province is also pushing for an
ordinance that seeks to increase the salaries and provide more incentives and hazard
pay for front liners and health workers assigned in the province’s devolved hospitals.
1.2 Policies
On top of this, the provincial government of Bohol has been keen on observing
and listening to the concerns of the PHO to ensure that the provincial government can
immediately address the existing deficiencies to provide the best quality of medical
attention to patients. According to the respondents, this “administrative observation”
approach has always been the policy of the provincial government to enhance the
delivery of healthcare to Boholanos and improve the overall posture of the province’s
healthcare system.
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1.3 Programs
In an attempt to increase the number of healthcare workers in the province, the
researchers’ interview also revealed that the provincial government, through the Bohol
Island State University, started to provide scholarship programs for Boholanos who will
be studying medical-related programs. It is expected that soon, Bohol will see more
Boholano doctors working for their province. Bearing in mind that a lot of Boholano
medical students before are enrolled in other provinces to pursue medicine. However,
due to these scholarship programs, Boholanos need not travel outside the province just
to attain their desired degree in medicine.
According to the data provided by the 2020 Bohol Annual Report, which was
retrieved by the researchers in coordination with the Provincial Health Office and the
Provincial Budget Office, for the year 2020 alone, the Provincial Government has
utilized 320 million pesos in response to the growing threat of the COVID-19 virus.
Table 2.0 Programs / Project / Activity for 2022
Program/Project/ Activity Implementing Cost

Office
For 2022
Provision of Latrine for sustainable PHO 3,000,000.00

sanitation to municipalities and
island
Procurement of Medical Equipment/ PHO 24,300,000.00

Machines for the Bohol Provincial
Diagnostic
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Procurement of Medical Equipment PHO 2,100,000.00

for the Provincial Isolation Center
Procurement of Equipment for the PHO 44,000,000.00

Hemodialysis Centers (Carmen,
Jagna and PHO Loon)
Procurement and Distribution of PHO 15,000,000.00

Covid-19 Kits for the Barangays to
build capacities to manage
COVID-19
Free Medical Assistance to PHO 100,000,000.00

Boholano Senior Citizens Program
for Health PHO Development
The programs presented above are in response to the programs which are set to
be done by the Provincial Health Office of the Provincial Government of Bohol. This
information was gathered from their Annual Investment Plan for 2022 in relation to the
enumeration of programs and services above. It is evident that even after two years
after the outbreak of the pandemic, the Province’s initiatives to combat Covid 19 have
persisted, keeping in mind that they have not compromised any areas in health for
development and upgrade.
Other initiatives were instituted to address the Covid 19 Pandemic in Bohol in 2020.
These programs were initiated during the outbreak of the pandemic no individual was
able to predict. Having been able to experience a medical emergency due to COVID,
the provincial government was able to adapt to this by focusing on programs that are
relevant to the present situation, as mentioned above. Considering the hindrances that
33
were evident in their annual report for 2020 in delivering healthcare services, they were
able to realize that certain areas of the devolution of health are in need of advancement.
Because of this, the Provincial Government of Bohol is now embarking on a 400-million
hospital modernization program. This will provide devolved hospitals with additional and
more modern equipment and facilities to combat the insufficient number of hospital
instruments, medicine, facilities, supplies, etc.
This shows that the introduction of new mechanisms for devolution, such as the
passage of the UHC Law and Bayanihan we Heal as One Law gave more financial
autonomy and much-needed assistance, especially during the times of the pandemic to
Local Government Units that are left with the daunting obligation to fund and operate
devolved district hospitals. Moreover, this “autonomy” will give local government units
the freedom to determine which organ or institution under them must be prioritized.
However, without a law requiring local governments to spend a specific percentage of
their budget on their healthcare systems, the prioritization of policies, plans, and
projects for the healthcare system remains largely at the discretion of the local
government. In other words, no matter how much funds will be devolved to a local
government, the decision-making on the utilization of said funds remains with the local
governments as they are given vague freedom to determine their prioritization based on
what their LGU’s needs.
2. Benefits and challenges experienced by the devolved district hospitals in the
delivery of healthcare services during the pandemic.

34
Shown below in Table 1, which speaks of the category availability of health care
personnel. The table presents the mean of each indicator as reflected in the answers
collected from the three groups of respondents. This table represents the following::
Table 3.0 Availability of Healthcare personnel
Indicators Mean Description

1. There are enough physicians to attend to the needs of 1.81 Agree
the people.
2. The number of nurses is enough to cater to the number 1.70 Strongly

of patients. Agree
3. Medical Technologists are available to support the 1.67 Strongly

laboratory needs of the patients. Agree
4. There are enough number of Caregivers, pharmacists, 1.85 Agree

and radiology technicians in the hospital.
5. There is no shortage in sanitary engineers, electricians, 2.44 Agree

cooks, accounting officers, and other non-medical staffs
in the hospital.
Composite mean 1.90 Agree

Legend:
1.00-1.79 – Strongly Agree (SA) - The statement is 100% true. And is visible in the Hospital (Ang pahayag 100%
tinuod. Ug makita sa Hospital)
1.80-2.59- Agree (A) - The statement is 50% true. And is sometimes visible in the Hospital (Ang pahayag 50%
tinuod. Ug usahay makita sa Hospital)
2.60-3.39- Undecided (U) - You don't have any idea about the statement (Wala ka'y bisan unsang ideya bahin sa
pahayag)
3.40-4.19- Disagree (D) - The statement is 50% false. And is sometimes not visible in the Hospital. (Ang pahayag
50% bakak. Ug usahay dili makita sa Hospital.)
4.20-5.00- Strongly Disagree (SD) - The statement is 100% false. And is not visible in the Hospital (ang pahayag
100% bakak. Ug dili makita sa Hospital)
In getting the actual number of healthcare providers, the researchers have
reached out to the Human Resource Development Unit of the Provincial Health Office.
Over which, we were told that the aforementioned office doesn’t have the statistics that
the researchers are requesting. The office advised the researchers to communicate with
the district hospital administrator to retrieve the data we are requesting for. With that
35
being put to mind, the researchers were able to contact the administrators, the results of
which will be discussed further in this section.
The first item on the indicators depicts the availability of physicians to attend to
the needs of the people. According to the survey conducted by the researchers, the
mean of the indicator 1.81 falls in agreement which means that this indicator is
sometimes observed. This data allowed the researchers to analyze why the indicators
fell into such numbers.
With this, the researchers retrieved existing data stored in the Human Resource
and Development Unit of the Provincial Health Office, which showed that there is a
standard staffing pattern in government hospitals set by the Department of Health. Over
which, the researchers have discovered that in every bed capacity of 25, there should
be 15 doctors, and for a 50-bed capacity, there should be 18 doctors in total; for a
75-bed capacity, there should be 20 doctors currently working in the hospital, and for a
100-bed capacity, the number of doctors should be 45 of them.
This is where the district hospitals of Bohol fall short; the data presented in Table
2 collected from the different administrators of the district hospital shows that out of 9
district hospitals, only one is in compliance with the standard staffing pattern set by the
Department of Health. It is evident in Table 2.0 that there is a shortage of physicians in
the district hospital of Bohol.

36
Figure 3.0 Actual Number of Doctors
In terms of the availability of nurses to cater to the number of patients, The
survey gave the researchers the mean of 1.70, which indicates strong agreement, which
means that the number of nurses is enough and is always visible in the hospital. To
counter-check whether this result is reliable or not. The researchers once again made
use of the staffing pattern of 2013, which connotes that for every 25-bed capacity, there
should be 30 nurses; for a 50-bed capacity, there should be 41 nurses; for a 75-bed
capacity, it is required to have 50 nurses, and for 100-bed capacity, there should be 93
nurses. This pattern was then used to determine if the number of nurses currently
working in the hospital is in accordance with the standard being set by the Department
of Health. As shown in Table 2.1, none of all district hospitals is in compliance with
government standards. And one of which is overstaffed. This means that the answers of
the respondents are not in accordance with the statistics.

37
Figure 4.0 Actual Number of Nurses
Furthermore, the third indicator demonstrates the availability of medical
technologists to support the laboratory needs of the patients. After treating the data, it
shows that the mean falls on 1.67, which is classified as strongly agree. This result was
also tested for reliability using a comparative method utilizing the prescribed staffing
pattern used by the department of health for government hospitals. Thus, in every
25-bed capacity, there should be five medical technologists; for a 50-bed capacity, there
should be six medical technologists; for a 75-bed capacity, there should be 7 of them;
and for a 100-bed capacity, there should be nine medical technologies. This comparison
is one of the most compliant among all designations. Some of the hospitals are
overstaffed, and the others only lack a few personnel.

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Figure 5.0 Actual Number of Medical Technologies
Meanwhile, the fourth indicator explains the data on the availability of
pharmacists and radiology technicians in hospitals. The indicator fell on the mean of
1.85, which is considered agreeable and indicates that the above-mentioned healthcare
workers are sometimes visible in the hospitals. The researchers did the same thing of
treating the data by comparing it to the staffing pattern. Thus, to successfully integrate
this, table 2.4 presents the total number of pharmacists and Table 2.4 for radiology
technicians working in the district hospital of Bohol. This data will be compared to the
staffing pattern reflected in the charts below.

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Figure 6.0 Actual Number of Pharmacist
Regarding the availability of non-medical healthcare workers such as sanitary
engineers, cooks, accounting officers, etc. This will answer whether there is a shortage
of the non-medical healthcare workers mentioned above. According to the self-made
questionnaire result being treated by the researchers, This indicator has a mean of
2.44, which is equivalent to agree, which means that the indicator stated above is not
visible all the time, but rather it is only visible sometimes. Table 2.6 compares the
standard staffing patterns versus the actual statistics of healthcare workers.

40
Figure 7.0 Actual Numbers of Non-Medical Personnel
It is evident that the devolution of Health has brought significant advancement to
Bohol’s healthcare system, especially with its human resources. According to Janet S
Cuenca, devolution aims to shift from a highly centralized government to a more
decentralized one to achieve efficiency and effectiveness in delivering healthcare
services. The researchers have realized that there is a huge gap regarding the actual
number of healthcare workers vs. the standard staffing pattern the Department of Health
set forth. This is an implication that there is a shortage of healthcare personnel.
Regarding the composite mean, it has landed on 1.90, indicating that the availability of
healthcare personnel is only visible sometimes. This connotes an inconsistency in terms
of the respondents' perceptions vs. the actual data the researchers were able to
retrieve.
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The overall analysis of the researchers for table number 3.0 revealed the
unequal distribution of healthcare workers in the district hospitals. This connotes the
inadequacy of delivering healthcare services is at stake concerning the distribution.
In addition, the researchers have analyzed the implications concerning the
inconsistencies of the data gathered to the standard set forth by the Department of
Health in terms of staffing patterns. Because of this, the researchers came up with an
interpretation that the reason behind the inconsistencies is the inadequate top-down
communication scheme between the Provincial Health Office and the District hospitals.
The respondents' perception of the availability of healthcare personnel is highly
influenced by the notion that the number of healthcare workers currently employed can
deliver necessary services amidst the gap between the actual number of health workers
and the standard staffing pattern. Thus this gap will never be addressed until the
Provincial Head Office Human Resource Department has existing statistics on file to
successfully monitor the number of health workers in a district hospital. This will help
address inequality of distributions of health workers and inadequacies in quantity.
Table 4.0 Availability of Necessary Health Related Infrastructures and
Transportation
Presented below is how all groups of respondents rated the indicators belonging
to the category availability of health-related infrastructure and transportation.
Indicators Mea Description

n
1. A specialized COVID-19 ward is created for 2.41 Agree
COVID-positive patients.
42
2. Swabbing sites are established within the hospitals. 1.81 Agree
3. There are enough beds available to provide inpatient 1.70 Strongly

care. Agree
4. Overall the physical hospital building is in good 2.11 Agree
condition.
5. Ambulances are available to respond to emergencies. 1.41 Strongly

Agree
Legend:
pahayag)
As shown by the first and second indicators, the availability of specialized COVID
19 wards created for COVID-positive patients falls on the weighted mean of 2.41. This
indicates that the latter is only visible sometimes. This notion is supported by the Annual
Investment Plan of 2021, where Garcia Memorial Provincial Hospital in Talibon
established a multi-purpose building for COVID-19 patients and was allocated 10 million
pesos for its fulfillment.
According to Dr. Yul Lopez of the Provincial Health Office, the district hospitals
can admit COVID-positive patients, but it only depends on the patient’s COVID status. If
the said patient is considered to have mild to moderate symptoms, the latter remains to
be admitted to district hospitals, but for unstable-critical conditions, patients are to be
directed to a national hospital. In the case of Bohol, only Governor Gallares Memorial
Hospital is considered to be a tertiary level having an ICU department with

43
high-technology specialists. The Provincial government made sure that only Gallares
Memorial hospital was made exclusive for COVID-related illnesses.
In terms of the availability of swabbing sites within the hospitals, the second
indicator’s result falls within the weighted mean of 1.81, where the respondents agreed
on the statement. This entails that swabbing sites are only visible sometimes. Swabbing
sites are made available for district hospitals; however, samples are sent to the
containerized RT PCR Laboratory of Bohol. This acquisition is part of the investment
plan of Bohol, where the provincial government of Bohol constructed a containerized
molecular laboratory within the Bohol Medical Care Institute (BMCI) campus, which is
projected to double its coronavirus illness testing capability in 2019. (Covid-19).
On the matter of availability of beds to provide for in patient care, all respondents
strongly agree. This implies that district hospitals' bed capacity is always visible.
According to the categorization of hospitals according to their bed capacity, 4 out of 10
district hospitals are currently in Level 1, and the rest with fewer bed capacity is
considered to be an infirmary. The researchers have observed that the total number of
implementing bed capacity is greater than the authorized bed capacity set forth by the
department of health. This entails that infrastructure is enough to cater to a larger
number of beds to cater to the needs of the people. In addition, this expansion is one of
the goals of the hospital modernization program, which is currently ongoing.
With regards to the overall physical condition of hospitals, the weighted mean
resulted in 2.11, which means that the latter is only visible sometimes. The Province
was able to provide solar panels for Cong. Simeon Toribio Memorial Hospital in
Carmen.
44
However, A factor affecting the results of this indicator is the onslaught of
Typhoon Odette, which brought physical damage to the hospitals. An example of this is
Clarin Community Hospital, where the researchers were able to observe that the
hospital was severely damaged. The reconstruction program is ongoing for the repairs
that need to be done.
In view of the fifth indicator that entails the availability of ambulances, the
respondents strongly agree, which means that it is always observed in the hospital. At
present, the province of Bohol acquired sea ambulances to serve the constituents in all
districts of Bohol. This acquisition was allotted 156 million pesos. Another project
implemented for ambulatory care service is the existence of Bohol Provincial Diagnostic
and Ambulatory Care Center, which was duly implemented by the Provincial health
office. This entails that in terms of transportation, modernization and improvements are
evident and are always observed by the hospitals.
The Department of Health gave nine ambulances to the Province of Bohol in
2021. The ambulances were divided as follows: (2) for the Provincial Health Office, (2)
for the Cong. Sr. Natalio Castillo (1) Carlos P. Garcia Municipal Hospital in Carlos P.
Garcia town, (1) Garcia Memorial Provincial Hospital in Talibon, (1) Teodoro B. Galagar
District Hospital in Jagna, (1) Candijay Community Hospital, and (1) Cong. Carmen
Simeon G. Toribio Memorial Hospital The ambulances will be utilized to improve health
care for the people of Bohol.
Table 5.0 Availability Of Health Care Products (E.G. Vaccines, Medicines,
Equipment, And Technology)

45
Indicators Mea Description

n
1. There are enough medicines available for in and 2.15 Agree
outpatients.
2. Oxygen tanks are available in case of emergencies. 1.33 Strongly

Agree
3. Personal Protective Equipment is regularly supplied to 1.78 Strongly
the hospital to protect healthcare professionals. Agree
4. Vaccines are readily available for health care workers. 1.30 Strongly
Agree
5. Laboratories are well equipped. 2.19 Agree
Composite mean 1.75 Strongly

Agree
Legend:
pahayag)
As indicated therein, all respondents Strongly Agreed on the availability of
oxygen tanks and personal protective equipment (PPE). Also, Vaccines are readily
available for health care workers to protect them from the risk(s) of the COVID-19
infection. This means that these aforementioned healthcare products are Always
Visible in all district hospitals.
Meanwhile, all respondents agree on the availability of medicines for in-patients
and out-patients. They also agree that the laboratories of the district hospitals in Bohol
are well equipped. Meaning, that these indicators are Sometimes Visible in devolved
hospitals.
46
Overall, the composite mean of this category has reached the “Strongly Agree”
range. This means that the availability of healthcare products in Bohol’s district hospitals
is Always Visible.
As a reflection of the perception of the three groups of respondents, researchers
believe that it shows consistency with the data gathered by the researchers as
presented in Bohol Annual Report for the year 2020. Purchase of drugs and medicines
alone has almost reached a total of 7 million pesos. Despite this, the researchers see
this amount as not enough to fully address the demand for in and outpatients in Bohol’s
devolved hospital.
In 2020, despite the 29 million expenditure of the province for medical equipment
– which includes laboratory equipment, with an “agree” rate attained, this only shows
that laboratory equipment is still not enough. Hence, this is why it is included in the
400-million modernization initiative for the hospitals.
Meanwhile, researchers have already high expectations for indicators of the
availability of oxygen tanks, PPE for healthcare professionals, and COVID-19 vaccines.
This is because of the creation of the Bayanihan We Heal As One Law. This Bayanihan
Law provided ample funds as Bayanihan grants were given to provinces across the
Philippines – including Bohol at the height of the pandemic. These grants were utilized
for equipment and vaccines aimed at addressing the threat of COVID-19, as reflected in
the 2020 Bohol Annual Report.
Although limited funds and resources have remained the top contributor to the
challenges encountered in this category, respondents remain hopeful that responsible

47
utilization of resources will somehow ease the problems encountered in this category.
Efforts are also being made to lobby for a huge chunk of the budget to be given to the
Provincial Health Office (PHO).
However, it must be noted that the Bayanihan Law is an outlier in this study.
Benefits received from the Bayanihan Law are not related to the concept of
decentralization nor to the Local Government Code. This law is carved out based on the
necessity encountered by the country during the onslaught of the COVID-19 pandemic.
Table 6.0 Availability Of Financial Aid To Support Patients’ Expenses, Health Care
Personnel Compensation, And Hospital Administration.
Indicators Mea Descriptio

n n
1. Poor inpatients have been provided sufficient financial 1.96 Agree
support to access necessary healthcare services
2. Outpatients from the economically disadvantaged families 3.19 Undecided

are supported in the purchase of medicines.
3. There are enough resources to duly compensate Health 2.26 Agree

care professionals.
4. Funds available are sufficient to hire non-medical staff 2.07 Agree

necessary for hospital operations.
5. Financial support from the provincial government is 2.07 Agree

enough to keep optimum hospital operations and for
hospital maintenance expenses.

Legend:
pahayag)
48
Respondents agree that indigent (poor) in-patients have been provided sufficient
financial support to access necessary healthcare services. They also agree on the
sufficiency of resources to duly compensate health care professionals and that there are
sufficient funds to hire the non-medical staff necessary for hospital operations. They
also confirm enough financial support from the provincial government to keep optimum
hospital operations and maintenance expenses.
However, respondents are undecided on the statement that outpatients
from economically disadvantaged families are given support in the purchase of
medicines. This means that the availability of the said indicator Cannot Be Determined.
The composite mean in this category fell within the “Agree” range. This means
that the availability of financial aid to support patients’ expenses, health care personnel
compensation, and hospital administration is only Sometimes Observed.
The researchers have observed that despite reaching the range of “agree,” this
specific category attained the lowest mean of the four categories. The researcher
acknowledged this result as it has been apparent to them that budget constraints have
remained the main issue of health devolution in the country.
The researchers believe that the respondents' perception of this category
is highly motivated by the establishment of malasakit centers and the support patients
get from other government institutions that provide financial assistance to patients in
need of financial assistance.
In addition, despite not having a concrete policy on financial support for poor
inpatients and economically disadvantaged families, the Bohol Provincial Government
augmented this through medical assistance for Boholano Senior Citizens, as can be
49
reflected in table 2. The researchers view this policy as the basis of respondents'
answers in responding “agree” to the first two indicators in this category.
In addition, during the KII, the researchers found out that the problem of funding
has remained to be a major problem for the Provincial Government to provide the best
healthcare system for Boholanos. Accordingly, respondents reveal that the problem of
funding has existed from the very beginning of the devolution of the healthcare systems
across the country.
Interestingly, when the devolution of the healthcare system was first
implemented, funds remained with the national government, while most of the facilities
and personnel were devolved to the provincial governments. The cost of maintaining
these facilities and personnel has become a significant challenge for provincial
governments.
However, respondents are hopeful that with the Universal Healthcare Law (UHC) and
the Mandanas ruling, things will be better for Bohol’s healthcare system. Respondents
also shut down the notion of re-nationalization of district hospitals. For them, the
re-nationalization of district hospitals would mean an additional burden to the national
government, and it will only further hamper the development of the country’s healthcare
system.
It must be noted that the Mandanas ruling was born out of the idea of greater financial
autonomy as enshrined in the RA 7160. The ruling will play great significance in giving
the province a chance to better its healthcare system and provide much-needed funds
that have hampered the better quality of the healthcare system for Boholanos.
50
The researchers have found out that the perception of the respondents towards
this indicator is highly motivated by the establishment of malasakit centers and the
allotment of the Bohol Provincial Government of medical assistance to Boholano Senior
Citizens.
CHAPTER III
SUMMARY OF FINDINGS, CONCLUSION, AND RECOMMENDATIONS
This chapter summarizes the data presented, interpreted, and analyzed in the
preceding chapter. Moreover, this chapter will outline the significant findings from the
retrieved data to draw conclusions and recommendations.
SUMMARY OF THE STUDY
This study aimed to determine and analyze the impact of decentralization policies
on the Healthcare System in Bohol amidst the COVID 19 Pandemic.
Specifically, the study aimed to answer the following questions:
1. What are the policies, plans, and projects of the Provincial Government of Bohol
in delivering healthcare for the devolved district hospitals in Bohol in response to
the COVID 19 pandemic?
2. What are the benefits experienced by the devolved district hospitals in the
delivery of healthcare services during the pandemic in the areas of:
2.1. Availability of Healthcare Personnel
and technology)
51
3. What are the problems/challenges experienced by the devolved district hospitals
in the delivery of healthcare services during the pandemic in the areas of:
and technology)
4. What recommendations may be proposed to ensure effective and efficient
healthcare delivery in the Province of Bohol, especially in times of healthcare
emergencies like the COVID 19 pandemic?
The researchers conducted a Key Informant Interview with some of Bohol’s
Provincial Government key officials, such as the Chief of the Provincial Health Office
and the Sangguniang Panlalawigan Chair for Culture and Arts, Personnel and Related
Policies, Health and Public Sanitation. Necessary data/reports were also retrieved from
these offices, which were utilized to analyze data.
Also, a self-made survey questionnaire on the availability of healthcare personnel,
necessary health-related infrastructure and transportation, healthcare products, and
financial aid to support patients’ expenses, healthcare personnel compensation, and
hospital administration was also distributed to the chiefs of the hospital, chief nurses,
and administrative officers of the nine district hospitals included in this study.
52
SUMMARY OF THE FINDINGS
Based on the preceding data presented, interpreted, and analyzed, the researchers
were able to formulate the following findings:
1. The plans, policies, and projects of the Provincial Government of Bohol in
delivering healthcare for the devolved district hospitals in Bohol in response to
the COVID 19 pandemic are:
● the participation of the Province of Bohol to take part in the pilot test for
the implementation of universal healthcare law;
● Sangguniang Panlalawigan’s initiative to increase salaries , provide
incentives, and hazard pay to front liners.
● Implementation of Administrative Observation policy
● Scholarship programs for Boholano Medical Students.
● Provision of Latrine for sustainable sanitation to municipalities and island
● Procurement of Medical Equipment/ Machines for the Bohol Provincial
Diagnostic
● Procurement of Medical Equipment for the Provincial Isolation Center
● Procurement of Equipment for the Hemodialysis Centers (Carmen, Jagna
and PHO Loon)
● Procurement and Distribution of Covid-19 Kits for the Barangays to build
capacities to manage COVID-19
● Free Medical Assistance to Boholano Senior Citizens Program for Health
PHO Development
● Hospital Modernization Program

53
2. The benefits experienced by the devolved district hospitals in the delivery of
healthcare services during the pandemic in the areas of:
2.1 Availability of Healthcare Workers
Based on the result of the survey conducted duly compared to the Key
informant interviews and the data retrieved from the administrators of the district
hospital. The researchers were able to observe no known benefits in the matter
of availability of healthcare personnel.
2.2 Availability of necessary health-related infrastructure and transportation
According to the data being collected, the researchers have found that the
Province of Bohol was able to receive a lot of benefits from the devolution in
terms of infrastructures and transportation. The benefits are (9) ambulances duly
awarded to the province that was distributed among certain district hospitals, the
budget for building specialized COVID wards, Molecular RT PCR laboratory, the
acquisition of brand new sea ambulances to be utilized by the people of Bohol in
an emergency, and the installation of Solar Panels for Cong. Simeon Toribio
Memorial Hospital in Carmen.
2.3 Availability of Healthcare Products
In line with the findings made by the researchers, they were able to
determine the benefits encountered by the devolved hospitals. One of which is
the purchase of drugs and medicines that reached a total amount of 7 million
pesos in total, and the support of the Bayanihan we heal as one law. The grants
given by the aforementioned law were utilized for equipment, vaccines, and
54
addressing the threat of COVID-19 as illustrated in the 2020 Annual Budget of
Bohol.
2.4 Availability of Financial Aid to support patients’ expenses, healthcare
Based on the findings of the researchers, The results of the survey were
compared to the key informant interviews and the data obtained from the district
hospital administrator. The researchers discovered that there are no known
benefits in terms of financial aid to support patients’ expenses, healthcare
3. What are the problems/challenges experienced by the devolved district hospitals in
the delivery of healthcare services during the pandemic in the areas of:
After a thorough review and comparison of the data survey, the actual
number of healthcare workers and the standard staffing pattern. The researchers
were able to determine the challenges that arose from the result. The study has
revealed that all designations lack healthcare personnel.
3.2 Availability of Necessary Health-Related Infrastructure and Transportation
In relation to the challenges encountered by districts hospital in terms of
availability of necessary health-related infrastructure and transportation. The
researchers have identified the underlying factor that affected the challenges
faced by the hospitals. One major factor is the physical damages caused by the
onslaught of Typhoon Odette. One of the affected hospitals is Clarin Community
Hospital which resulted in a cease in their health services operations.

55
3.3 Availability of Healthcare Products
Availability of medicines and sufficiency of equipment in laboratories are
the challenges faced in this category based on the responses of the
respondents.
3.4 Availability of Financial Aid to support patients’ expenses, healthcare
The researcher acknowledged the result, stating that money restrictions
have remained the most pressing issue in the country's health devolution. The
same information was also disclosed by KII researchers. The Provincial
Government's ability to provide the greatest healthcare system for Boholanos has
been hampered by a lack of resources. As a result, responses demonstrate that
the issue of funding has existed since the devolution of healthcare systems
across the country began.
CONCLUSION
Based on the study's findings, the researchers found that despite funding
availability through mechanisms of health devolution, demand has exceeded availability.
Though enough to keep its healthcare system functioning, resources devolved to
Bohol's healthcare system are still inadequate to address all the needs and concerns of
Bohol’s healthcare system, specifically in the areas of availability of health care
personnel, availability of necessary health-related infrastructure, and transportation,
availability of healthcare products, and lastly, availability of financial aid to support
patients’ expenses, health care personnel, and hospital administration.

56
RECOMMENDATION
Based on the preceding conclusion, the researchers recommend the following:
1. The Provincial Health Office must conduct a recalibration of its administrative
procedure and observation policies.
2. To address the need for financial assistance for patients, the Provincial
Government of Bohol must register more Boholanos with the Philippine Health
Insurance Company (PhilHealth). This can be done through coordination with the
Department of Health to ensure more Boholanos would be covered by the benefit
of the Universal Health Care Law.
3. The Provincial Government of Bohol should build partnerships or tap
non-governmental organizations acting as a third party that can provide technical
help in addressing the problems of Bohol’s healthcare system.
4. With Mandanas Ruling being implemented in the year 2022, the Provincial
Government of Bohol should conduct a re-assessment of the budget planning
and expenditure for the Provincial Health Office.
5. To address the Unequal distribution of health workers, the research recommends
to designate the human resource and development office to be in charge of the
employment process and supervise the distribution of healthcare personnel
through the guidance of the Standard Staffing Pattern set by the Department of
Health.
57
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1

Health Devolution: Revisiting Bohol’s Pandemic-Stricken Healthcare System

Presented to the faculty of the

College of Arts and Sciences

Holy Name University

City of Tagbilaran, 6300

Bicar, Rey Jay C.

Hibaya, Maria Victoria G.

This thesis is entitled Health Devolution: Revisiting Bohol’s Pandemic-Stricken

acceptance and approval for the oral examination.

DR. ANNE MARIQUIT D. OPPUS, J.D.

Approved by the Committee of Oral Examination with a grade of ______________.

DR. RAMON A. BOLORON

DR. FREDERICO B. TICONG,LLB PROF. JAY JEORGIENITA T. OBENZA,JD

Bachelor of Arts in Political Science.

DR. ANNE MARIQUIT D. OPPUS, J.D.

Chair, Department of Political Science

DR. RAMON A. BOLORON

Dean, College of Arts and Sciences

the invaluable contribution that helped in the completion of the study:

knowledge with regard to technicalities and grammar intricacies;

and her full support and encouragement to this study;

To the panelists for their invaluable suggestions and recommendations to

enhance the study;

support, financially, emotionally, spiritually, and guidance;

Argie, Vic, & Rey Jay

ACCEPTANCE SHEET . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. iii

TABLE OF CONTENTS . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. v

LIST OF TABLES . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . .. viii

I. THE PROBLEM AND ITS SCOPE

Statement of the Problem . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . 16

Scope and Limitations . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . . . 17

Significance of the Study . . . . . . … … . . . . . . . . . . . . . . . . .. . . . . . . 19

Data Gathering . . . . . . .. . . .. . . . . .. .. . . . . . . . . . . .. . . . . . . .25

Confidentiality and Privacy . . . . . . .. . . . . . . . . . . . .. . . . . . . . . 26

Informed Consent Process . . . . . . .. . . . . . . . . . . . .. . . . . . . . . 26

Statistical Treatment .. ... . . . . . . . . . … . …… . . . . .. . . . . . . .28

DEFINITION OF TERMS. . . . … . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . .29

II. PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA

III. SUMMARY, FINDINGS, CONCLUSION, AND RECOMMENDATIONS

Summary of the Study. .. . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . .55

Summary of the Findings. .. . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . 56

Proposed Action Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

Appendix A. Questionnaire or Data-Gathering Tool

II. Bohol Annual Report 2020

III. Ethical Review Board Clearance

IV. Informed Consent Form

V. Annual Investment Plan of the Provincial Health Office

VI. Revised Organization Structure and Staffing Standards for

VII. Self-made questionnaire

VIII. KII guide questions

IX. Researchers’ Waiver of Liability

XI. Curriculum Vitae

THE PROBLEM AND ITS SCOPE

for redistributing and strengthening public services at the local level.

considered to be landmark legislation. It empowered Local Government Units (LGUs)

notably, the delivery of healthcare services, among others.

decentralization taken up by an Asian country regarding the degree of power,

responsibility, resources, and personnel decentralized to the LGUs (Atienza, 2004).

absolute amount devoted to the LGUs.

This decentralization is aimed toward the efficiency and effectiveness of

delivering health services by transferring the burden of decision-making and allowing

greater independence in the allocation of resources as determined by the local

According to Janet S. Cuenca (2018), the national government and local

Health Devolution: Revisiting Bohol's Pandemic Stricken Healthcare System

Health Devolution: Revisiting Bohol's Pandemic Stricken Healthcare System