Table 4 Assessment of decision spaces and the desired adjustments in capacities and accountability mechanisms for the health sector functions of (a) Management of Facilities, Equipment and Supplies, (b) Health Workforce Management, and (c) Data Monitoring and Utilisation

Management of Facilities, Equipment and Supplies

Director in the DOH Central Office, 28 years in government:

“If you would look at how the DOH works with local governments now, it seems that a bulk of our budget actually goes to them. It’s as if it is not devolved. During the last years, DOH upgraded their facilities. DOH is also providing the commodities for the programmes. DOH is giving them the drugs, TB drugs, and now even hypertensive drugs, diabetic drugs. So there is always that question, are we really in a devolved set-up? It has been observed that the local governments really do not have the capacity for health services. I am not saying that this is happening across the country, but in most municipalities and provinces, most especially in the low-income ones, well, even in some first-class provinces. Why? Because the population has increased but there was no increase in the infrastructure and the personnel. That’s why the DOH augments the local governments.”

Moderate

Institutional:

 • Creativity in partnering with the private sector to enhance the delivery of care in local health facilities

Individual:

 • Management skills for running health facilities and public health programmes effectively

Currently in place but may be enhanced:

 • Licensing and accreditation of local health facilities that meet the standards of quality, while supporting those facilities that do not qualify to eventually meet the standards

 • National/central support for upgrading local health facilities (especially in resource-poor settings to achieve equity) conditional on the local government’s provision of counterpart

Potential policy consideration:

 • Central-procurement of selected equipment and supplies on behalf of local governments to gain leverage in negotiating prices; provision of these resources as augmentation to local governments but conditional on satisfactory utilisation of past augmentations

Health Workforce Management

Provincial Health Officer of a low-income province, 29 years in government:

“A poor province could only afford this much, and cannot provide salaries like a wealthy province could. In my case, my salary is only for a second-class province, because my province has the capacity of only a second-class local government. If the province becomes first-class, then the salaries will go up too. That is why when you compare the salaries in different classes of provinces or municipalities across the country, the rates would be different. I think salaries should be standardised across the country, regardless of where one is serving, because we are all doctors anyway, same with nurses and midwives. We are all health professionals, right?”

Moderate-to-narrow

Institutional:

 • Sufficient financial capacity and regulatory authorisation to:

  ◦ Hire (and fire) the cadres and number of health workers needed to serve the local population

  ◦ Provide health workers’ full range of salaries and benefits, including security of tenure

Individual:

 • Deeper appreciation at various levels of governance on the important role played by the health workforce at local levels

Currently in place but may be enhanced:

 • Deployment of centrally hired health workers to local health facilities that lack them, but conditional on the local government’s:

  ◦ Provision of counterpart support for the deployed health workers

  ◦ Commitment to eventually allocate the budget required to hire health workers on their own

Potential policy considerations:

 • Central/regional levels to be officially responsible for providing capacity-building of local government health workers across the country

 • Implementation of a national policy that discourages local health workers form being partisan during local elections

Data Monitoring and Utilisation

Assistant City Health Officer of a highly urbanised city, 22 years in government:

“Perhaps if you ask the DOH, they would tell you that they are having a hard time with the data because of devolution. It takes a long time for us to submit reports to them. Why am I taking a long time? For my part, I am consolidating all of the reports, including those from our hospitals. So, it is difficult, right? Oh, we do our own surveillance and DOH also does its surveillance, that’s why it is difficult. Actually, there are instances when DOH detects cases first before we do. And there was a time also when we detected it first before they did. So before the DOH even learns about it, we already have a report. That is why maybe for them the DOH is saying that it’s more difficult. Because they feel there is an extra step before the data gets to them, and the city still needs to gather the data from all our health centres.”

Moderate

Institutional:

 • Systemic capacity for an integrated and harmonised manner of data monitoring and utilisation in spite of decentralisation and the use of interoperable electronic medical records

Individual:

 • Basic knowledge of epidemiology to understand the relevance of the indicators collected

 • Skills for evidence-informed public health, or for translating data into action at local levels

Currently in place but may be enhanced:

 • Deployment of centrally hired data collectors to local governments to validate the local data collected and accelerate data transmission to the central level

 • Maintenance of a central electronic database, into which local governments will be required to transmit data in a timely manner

Potential policy consideration:

 • Publication of rankings of local governments in achieving selected target outcomes