Table 3 Assessment of decision spaces and the desired adjustments in capacities and accountability mechanisms for the health sector functions of (a) Planning, (b) Financing and Budget Allocation, and (c) Programme Implementation and Service Delivery

Planning

Mayor of a low-income municipality who is also a medical doctor, 26 years in government:

“National government wants LHBs to be functional, but it’s up to us to make it functional. We meet for the municipal health action planning, which flows from the Barangay [village] health action planning. So the municipal plan is a consolidation of the various Barangay plans. The DOH has a representative in the LHB, and that is very good because the mayor does not know everything. It’s a coincidence that the mayor here is a doctor, but how about those areas whose mayor is not a doctor? We need help from the DOH for the technical aspects, for example, in the family planning programme, immunisation, etc. We also review our shortcomings. But, you know, it varies from one municipality to another [laughs]. That is the disadvantage of devolution, right? The way things are is not uniform and depends on municipal leadership.”

Moderate

Institutional:

 • Institutional commitment to perform the planning process regularly

 • Openness to the participation of multiple stakeholders in the planning process

Individual:

 • Strategic planning skills

Currently in place but may be enhanced:

 • Technical assistance to local governments for performing planning effectively

 • Local plans reviewed and approved at central/regional levels to ensure alignment with national objectives

 • Monitoring by the central/regional levels of local plan implementation

Potential policy consideration:

 • Continuing augmentation for local health services conditional on local government’s regular conduct of planning and satisfactory implementation of previous plans

Financing and Budget Allocation

Provincial Health Officer of a high-income province, 21 years in government:

“About 25–27% of our Internal Revenue Allotment is allocated for our hospitals, and about 5–7% for preventive services. I have an income recovery scheme here. The province provides the budget for maintenance and other operating expenses of hospitals, but I tell the hospitals to recover at least 90% of that and return the funds to the province. The hospitals are able to recover it through their PhilHealth income, and also through income from services not covered by PhilHealth but outpatients pay for, such as ultrasound or CT scan. So majority of our local budget is used for hospital operations, and that’s curative, right? That means we spend so little for preventive services, which should have a bigger investment. This is what I want to ask from DOH, to provide additional funding to enhance our delivery of public health programmes.”

Moderate-to-narrow

Institutional:

 • Ability to create alternative income sources (except user fees which may reduce access) that are earmarked for local health services

Individual:

 • Skills for priority-setting, with an emphasis for primary/preventive care

 • Capacity for evidence-informed, rather than politically motivated, funding decisions

Currently in place but may be enhanced:

 • Strict implementation of PhilHealth guidelines that limit local governments to use their PhilHealth income exclusively for health-related needs

Potential policy consideration:

 • Accreditation of local health facilities to be eligible for reimbursements from PhilHealth may include a requirement for local governments to provide a minimum allocation (depending on income class) from its own local budget as counterpart to finance local health services

Programme Implementation and Service Delivery

High-level official of the DOH Central Office, 28 years in government:

“As the devolution process evolved, and as local governments become more capable to handle their health services, there were circulars issued by the DOH programmes in the central office to ensure quality, for example, on how to package the tuberculosis control programme for their locality. Some of these guidelines sought to remedy the negative aspects of devolution, and so the concept of interlocal health zones or service delivery networks to group local governments together emerged to encourage different local governments serving the same catchment area to deliver health services in a harmonised manner.”

Moderate

Institutional:

 • Willingness to cooperate with neighbouring local governments for a functional service delivery network for sharing of resources and inter-facility patient referrals

Individual:

 • Innovation in the delivery of local health programmes (while maintaining fidelity to national objectives) that address unique health needs and are suitable to the local context

Currently in place but may be enhanced:

 • Development of technical guidelines that maintain fidelity in the delivery of nationally mandated programmes at local levels

 • Training of local government staff in implementing these programmes

 • Strengthening of service delivery networks by strategically grouping local governments together and facilitating their interlinking with one another

Potential policy consideration:

 • Wider recognition and promotion of models of innovative service delivery programmes by local governments