comparative analysis-5 ilhz
TRANSCRIPT
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COMPARATIVE ANALYSIS OF FIVE INTER-LOCAL HEALTH
ZONES: Current Practices, Policy, and Program Directions
Table of Contents
Foreword i
Acknowledgements ii
Acronyms iiiMap of the Philippines and Inter-Local Health Zones Sites vi
COMPARATIVE CASE ANALYSIS EXECUTIVE SUMMARY vii
1. Introduction 1
1.1 Project Objectives 31.2 Significance of the Project 4
2. Methodology 5
2.1 Actual Methods 5
2.2 Data Analysis 8
2.2 Validity and Reliability Checks 82.3 Data-Yield Description and Constraints 8
2.4 Limitations of the Study 8
3. Consolidated Findings 10
3.1 Key Health Operations Profile of Case Study Areas 103.2 Critical Steps in the Formation of ILHZ 15
3.3 Health Operations: Organization, Comparison of Services and Patterns 24
of Utilization
3.4 Organogram 313.5 ILHZ Mandates 32
3.6 Key Players and Collaborative Mechanisms 33
4. Best Practices 41
4.1 Strengths 42
4.2 Weaknesses 43
5. Policy and Programmatic Implications 44
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5.1 Policy of Health System Decentralization and Primary Health Care 44
5.2 Devolution and National Policies and Effects on Health Service Delivery 44
5.3 Policy and Programmatic Issues 455.3.1 Financial Administrative Issues 45
5.3.2 Management Systems and Processes 46
5.3.3 Human Resource Management 465.3.4 Management of Devolution by National, Regional and Local Bodies 46
5.3.5 Quality of Care in ILHZ Health Care Facilities 47
6. Policy and Programmatic Directions 50
6.1 Finance and Administrative 516.2 Management Systems and Processes 51
6.3 Human Resource Management 51
6.4 Management of Devolution by National and Regional NGOs 52
and Local Bodies6.5 Upgrading and Modernization of Health Services Hospital Services 53
and Public Health Services
7. Next Steps 55
Bibliography 56
Glossary 58
List of Appendices 60
1 Consolidated Sources of Data 61
2 Consolidated Sampling Frame 70
3 Number of FGDs / KIIs Conducted in ILHZ Case Study Sites, 2001 71
4 Consolidated List of FGD / KII Participants for the 72
ILHZ Case Study, 2001
5 Milestones in the ILHZ Development, All ILHZ Sites, 2001 89
6 Matrix of Functions and Responsibilities of District Health Boards, 2001 103
7 Examples of Mandates as Templates 112
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7.1 Executive Order 205 113
7.2 Health Covenant 1999, Sta. Bayabas Inter-LGU Health System, 117
Negros Oriental
7.3 Provincial Health Board Resolution No. 5, Series of 1999 119
(Recommendation to the Sangguniang Panlalawigan to
develop six district health systems province-wide)
7.4 Sangguniang Panlalawigan Resolution No. 678, Series of 2000 121
(Authorizing the Governor to enter into a MOA for theSta. Bayabas Inter-LGU Health System)
7.5 Sanggunaing Bayan Resolution No. 274, Series of 2000 123
Municipality of Bayawan
(Authorizing the Mayor to enter into a MOA for the Sta. BayabasInter-LGU Health System
7.6 Memorandum of Agreement for Sta.Bayabas 125
Inter-LGU Health System
8 Proposed National Health Service Delivery Reform Bill 136
9 SEC Registration of CVGLJ Inter-LGU Health Zone 151
List of Tables
1 ILHZ Case Study Areas by Population Coverage and 168
Component Health Facilities, Philippines, 2001
2 ILHZ Health Facilities Analysis Matrix 172
3 ILHZ Cross Case Analysis Matrix 173
4 Nearest Health Care Facility by Province, 214
ILHZ Case Studies, 2001
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5 Health Seeking Behavior by Province, 215
ILHZ Case Studies, 2001
6 Reference Health Facility by Province, 216
ILHZ Case Studies, 2001
7 Common Health Problems in the Family by Province, 217ILHZ Case Studies, 2001
8 Common Family Problems in the Community by Province, 220
ILHZ Case Studies, 2001
9 Satisfaction with Health Services at Reference Health 221
Facility, ILHZ Case Studies, 2001
List of Figures 222
1 Map of the Philippines and Inter-Local Health Zone Sites v
2 Baliuag Unified Local Health System in Bulacan 223
3 Arayat Unified Local Health System in Pampanga 224
4 Local Area Health Development Zone 2 in South Cotabato 225
5 Sta. Bayabas and CVGLJ Inter-LGU Health Systems in 226Negros Oriental
6 Linawa Zone in Kalinga 227
7 ILHZ Organograms 228
7.1 BULHS
7.1.1 District Health Board 229
7.1.2 Baliuag District Hospital 230
7.2 LADHZ
7.2.1 Integrated Health System Provincial Operational 231
Framework
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7.2.2 Norala District Hospital 232
7.2.2 Sto. Nio RHU 233
7.3 AULHS
7.3.1 District Health Board 234
7.3.2 Dr. Emigdio C. Cruz, Sr. Memorial Hospital 235
7.3.3 Arayat Rural Health Unit 236
7.3.4 Mexico Rural Health Unit 237
7.4 Sta. Bayabas and CVGLJ Inter-LGU Health Systems
7.4.1 Bayawan District Health System 238
7.4.2 Bayawan District Hospital 239
7.4.3 Bayawan Rural Health Unit 240
7.4.4 CVGLJ District Health System 241
7.4.5 CVGLJ District Health Board 242
7.4.6 CVGLJ Management Committee 243
7.5 Linawa Zone
7.5.1 District Health System 244
7.5.2 Linawa District Health Board 245
7.5.3 Kalinga Provincial Hospital 246
7.5.4 Tabuk Rural Health Unit 2477.5.5 Rizal Rural Health Unit 248
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1. Introduction
In undertaking the present health care sector reform, the Philippine Health Sectorembarks on a quest that will ensure the vitality of the system in assuring adequacy,
accessibility, efficiency and high quality health services that are equitable and thatmaximizes private participation: the organization of Inter-Local Health Zones or
ILHZs. These efforts address the complexities brought about by the advent of theLocal Government Code other wise known as R.A. 7160 of 1991. This law provided
for the devolution of health care services from centralized DOH to local government
health services and brought about quite a few challenges and issues.
First, it was observed that serious fragmentation of public health and hospital services
occurred since devolution. As a result, disintegration of the components of the centralhealth care system (DOH) and local health care became widespread. While provincial
governors took charge of the hospitals, public health remained the sole responsibility
of municipal mayors.
Second, there were reports that the regional health systems or centers for health
development (CHDs) were ill prepared to provide technical support to fledgling local
health care systems. Monitoring and supervision of health operations remained themajor responsibility of the CHDs but these were noted to have decreased
substantially.
Health Human Resource Development was a third area of weakness. Staff training
opportunities and career development activities markedly decreased. These led to low
morale of health care workers especially in economically disadvantaged areas where
training opportunities, staff benefits and support were inadequate. All these led to thefragmentation of local health services and exacerbated the problems related to quality
of care, as well as its attendant efficiency and equity issues.
The concept of the District Health System was initially proposed by the World Health
Organization sometime in 1983 in response to the declaration of Health for All, the
shift toward Primary Health Care, and consequently, the need to decentralize healthcare services, particularly in many developing countries. The Department of Health
of the Philippine government eventually introduced the District Health System in its
national health service in different parts of the country. The system intended tointegrate the public health system and the hospital system for a more coordinated and
effective delivery of health services within the catchment area of the District hospital.A District Health Office was set up to exercise supervision and control over thedistrict hospitals, municipal hospitals, rural health units, and barangay health stations.
At that time, the Philippine government carried out decentralization by
deconcentration, which meant that administrative but not political decongestion of thenational offices was implemented through the set-up of regional offices.
Deconcentration was also intended to bring government services closer to its clients
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and stakeholders. In this centralized but deconcentrated set-up, the District Health
System was operationalized, with budget allocation mainly coming from the national
government.
However, the 1991 Local Government Code was passed effecting decentralization by
devolution that transferred political and administrative powers to the localgovernment at municipal and provincial levels. Under devolution, the municipal local
government managed the public health units-the barangay health stations and the
rural health centers, and in some areas, the municipal hospitals. On the other hand,the provincial local government took over provincial and district hospitals.
The Department of Health found itself grappling with new roles vis--vis local
governments. Previous functions of planning, policy-making, programimplementation, monitoring and evaluation could no longer directly connect to the
public health and hospital system which were operated by local governments. In
many field studies commissioned by the Department of Health and in its own
observations, devolution shifted the burden of responsibility for health to localgovernment units that did not have the technical capabilities and financial capabilities
to manage public health services and hospital operations. There was confusion anddemoralization as DOH personnel were devolved and retained with initial
discrepancies in remuneration. There was a breakdown in the referral system, health
management information system, training and human resources development, and
drug procurement system. This was traced to the problem labeled as fragmentationof the health service system related to disparate levels of political and administrative
authority over health.
The solution seemed to emanate from the Local Government Code itself in section 33
allowing for inter-LGU cooperation through Memoranda of Agreement for mutually
beneficial purposes and sharing of resources. Anchored on this provision, ExecutiveOrder 205 called for the creation of the National Health Planning Committee and the
establishment of inter-local health zones throughout the country. The Department of
Health, Department of Interior and Local Government, and League of Governors also
signed the Health Covenant of 1999.
The Department of Health patterned the Inter-Local Health Zone or Inter-Local
Health System after the WHO District Health System such that these terms will befound conceptually interchangeable. However, it is called by a particular name in the
sites of operationalization-- referring particularly to the study sites in the provinces of
Bulacan, Pampanga, South Cotabato, Negros Oriental, and Kalinga.
Briefly, the concept calls for an integrated system of public health and hospital
services through a referral system within a convergence zone and of the localgovernment units that have the respective jurisdiction. Essentially, this appears to
provide wide latitude of possible levels of cooperation and integration.
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The District Health Board for the inter-local zone provides the mechanism for
integration and cooperation through planning, policy-making, and management.
However, it is not per se the political decision making body. The respective municipallocal health boards or the provincial health boards are the political body for decision-
making mandated by the Local Government Code where health policies can be
formulated.
However, there are existing models of inter-local health zone development initiatives
in different parts of the country that need to be documented and analyzed as casestudies in order to derive valuable lessons that may drive policy development and
health service program reforms. These health service reform lessons may then shape
the future of inter-local health initiatives to ensure integrated, effective and
sustainable local health systems.
The DOH through the Bureau Local Health Development thus requested technical
assistance from the Management Sciences for Health to conduct case studies on fiveexisting Inter-local Health Zones in the country to determine how these concepts were
put into effect. The areas that were examined were Bulacan, South Cotabato,
Pampanga, Kalinga, and Negros Oriental. The MSH in turn, subcontracted the
Institute of Health Policy and Development Studies of the National Institutes ofHealth in UP Manila to conduct these case studies. This document reports the
comparative analysis of the five ILHZ sites and highlights current practices, policy
and programmatic directions of Inter-local Health Zones in these sites.
1.1 Project Objectives
The ILHZ Case Study Project conducted multiple embedded case studies to
determine the processes and initial outcomes of existing models of inter-local health
zones with reference to certain configurations of health zone characteristics that
include organizational, managerial, financing and information variables. It sought todetermine motivating factors in establishing ILHZs and describes organization and
management schemes of current local health systems. Moreover, it described existing
management structures including financing schemes, information systems and toolsused in planning and referrals.
Specifically the project aimed to:1. Identify and describe the contexts of the multiple cases that will be the units of
analysis in this study;
2. Conduct review of documents and literature that will provide valuablebackground information and inputs to the case studies;
3. Conduct interviews of key stakeholders at central, regional and provincial levels
involved in the development of the inter-local health systems;
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4. Conduct focus group discussions of selected key players/implementers of local
health systems and their counterparts at the provincial and regional levels;
5. Conduct a rapid survey of community perceptions of local health care systemperformance and outcomes in selected case study barangays;
6. Conduct review of documents to ascertain the functionality of local health
systems;7. Identify variables that influence viability and sustainability of local health
systems;
8. Accomplish with-in case and cross-case analyses to determine similarities anddistinctions across cases that impact local health system performance and
outcomes;
9. Identify issues and problems encountered by existing local health systems and
their corresponding alternative solutions; and10. Identify policy and programmatic reform directions that may be recommended as
a result of the case studies.
1.2 Significance of the Project
This project is important in describing what occurred in the early stages of ILHZformation in different areas, how they developed and when possible, why. The study
brought out unique features of each site for cross-comparisons of lessons learned and
various nuances that made this possible including cultural, geographic, political,socio-economic, and administrative factors. Primary data that was gathered are vital
to all key stakeholders in the health sector that aim to make health care accessible to
all segments of the population. For the Department of Health at the national and
regional levels as well as for local governments, the information derived from theproject can be used to re-examine the concept and strategies of local health
development. The decisions they make on future directions, particularly on the
clustering of areas, the roles of participating stakeholders and various aspects ofmanaging local health systems can then be better guided.
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2. Methods
2.1 Actual Methods
For this case study, the local health development area zones (LAHDZ) in SouthCotabato were selected to represent AUSAID funded areas through their efforts to
assist in the development of local health systems through their Integrated CommunityHealth Services Project (ICHSP).
To document and analyze the LAHDZ efforts in South Cotabato, this study employedan embedded multiple case study design (Yin,1992). The units of analysis are the
district health systems, also designated as cases, and DOH-BLHD (Bureau of Local
Health Development) pre-determined areas that were documented and analyzed torepresent various models of existing local health zones.
The embedded case study design allowed the investigators to study the contexts of thecases at the municipal, provincial and regional levels. Moreover, the framework and
mechanisms set by central DOH within which the cases were initiated and nurtured
was likewise scrutinized. The district health system was chosen as the appropriate
level of the units of analysis because it is at this level that the integration of publichealth and hospital systems occurs.
Selected study variables that were investigated include ILHZ utilization rates;
budgets, funding and resource generation capabilities- private - public mix;
organization variables such as decision-making structures and processes, sharing or
resources, communication patterns, and information mechanisms; human resourcedevelopment schemes; community and private sector participation patterns; and
selected health service quality measures.
Study methods utilized include review of records of selected district hospitals andtheir selected corresponding catchment municipalities; Key informant interviews of
key stakeholders including, chiefs of hospital, municipal health officers, provincial
health officers, and selected local health board members i.e. mayors and DOHrepresentatives. In order to ensure triangulation of case study results, focus group
discussions were accomplished to determine the perceptions of selected community
members and ILHZ implementers and supervisors. A rapid survey of communityperception of ILHZ performance and outcomes was also conducted in selected
barangays to determine stakeholder satisfaction, which is one of the important quality
measures. A strength of the study is the linking of qualitative data with quantitativedata in order to come up with robust cases. Data collection instruments that were
developed for the study are exhibited in book 2 of the comparative case analysis.
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Review of Records
The five Inter-local Health Zones had exhibited a wide range of quality of
documentation. There were areas such as South Cotabato and Negros Oriental that
were well documented with voluminous data. Other areas had patchy informationwhile a couple had scant information perhaps owing to their young developmental
life. Among those that were reviewed were documents from the Provincial
Governments, the DOH Centers for Health Development, Municipal Developmentoffices, District hospitals and Rural Health Units. Please see appendix 1 for listing of
sources of data.
Key Informant Interviews and Focus Group Discussions
The key informant interviews and the focus group discussions were designed to elicit
important details on the processes of establishing and managing ILHZs. These weremeant to also yield important information to triangulate data that was derived from
the review of records and survey on perceptions of health services utilization andparticipation patterns. These interviews and discussions were likewise vital in
identifying key factors that influenced the success or failure of local health system
operations. The study team initially drew a list of key informants and participants in
the FGDs on the basis of known key stakeholders in the ILHZ. However, these wererefined in the field as soon as changes in assignments or identification of other key
informants and participants was recognized.
Rapid Survey
The rapid survey method utilized in this study was in accordance with the WHOprescribed method of RSM (Frerichs and Tar, 1998b and 1989). It aimed to gather
data on community perceptions and existing help seeking behavior with regards to
health that will describe utilization patterns at different levels i.e. at the Barangay
Health Station, Rural Health Unit, District Hospital and at the Provincial Hospitallevels. It also sought to determine satisfaction rates with these different health
services that they utilized. Finally, the investigators attempted to identify key factors
that influenced their utilization and satisfaction patterns. All these are meant to morecompletely describe the current health environment in the study sites.
SamplingA two-stage cluster sampling was utilized to determine the population sample to be
interviewed. Clusters of barangays within the catchment municipalities were selected
at the first stage and households within the clusters at the second stage. From a list ofall barangays and municipalities within the catchment area of the reference hospital, a
municipality cluster was randomly identified from which a cluster of barangays was
derived, with the probability of selection proportionate to the size of the resident
population (PPS or probability proportionate to size). The defining criterion is their
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location from the core referral or district hospital utilized in the study. The population
was differentiated according to whether they lived close to the reference hospital, i.e.
within five kilometers or whether they lived beyond five kilometers from the hospital.At the second stage, the first household to be visited is randomly selected. Thereafter
households to be interviewed are sampled from the nearest households until the
determined proportion for the barangay has been fulfilled.
Respondents
As a result of systematic sampling, a total of 2,239 respondents in all case study siteswere interviewed in the rapid survey comprising about 5% of the population they
represent. Of these, 1256 people or 56% were from areas within five kilometers from
the district hospital (more accessible areas) while 983 or 43.9 % made up the
respondents that came from the less accessible areas as shown in appendix 2. A totalof 41 key informants shared their detailed insights into the development of the ILHZ
in their area. Forty- three focus group discussions were likewise conducted involving
353 people to triangulate the validity and reliability of responses derived from the
rapid surveys and the key informant interviews.
Data collection was accomplished from in four waves. The first team comprising of
the whole study team but with the following designated roles: one case study writer,
three co-investigators, four research associates, and ten research assistants collected
data in Bulacan from January 22-26 2001. Two teams went out to South Cotabato andPampanga in the second wave of data collection from February 5-9,2001. One team
went to Negros Oriental From February 19-23 2001 and the last team left for Kalinga
and collected data from February 27 and 28 up to March 2, 2001. Each team wascomposed of one case study writer, one co-investigator, two research associates and
ten local research assistants who assisted in the survey except for the first team that
went to Bulacan.
Information gathered from the areas was validated at least two times: the first time
was during the debriefing sessions at the end of the data collection phase. The secondopportunity for validation happened during the second trip to the areas when the draft
of the case study was presented for comments, revisions and approval of the key
stakeholders in the area. After the information was validated and approved, cross-caseanalysis was then accomplished.
2.1 Data Analysis
Data derived from the Focus Group Discussions and the Key Informant Interviews
were transcribed, coded and displayed in qualitative data matrices using Microsoft
Word. Survey data was encoded using Epi-Info 6 and summarized, and organized
using Microsoft Excel. Statistical analysis including trend analysis was accomplishedusing STATA 7. Data display tables were crafted using Microsoft Word to aid the
report.
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2.2 Validity and Reliability Checks
Pre-testing the instruments in Maragondon, Cavite, safeguarded validity andreliability of the research instruments used, the FGD and KII topic guides and the
survey questionnaire. Furthermore, researchers ensured triangulation by source andmethod was achieved during the data collection process. Some information sought in
the review of records was validated in the rapid survey as well as in the FGDs andKIIs. Also, similar questions were posed to different respondents to determine the
degree of concurrence and variance of perspectives.
2.3 Data Yield Description of data gathered and
constraints
The data set is a mix of qualitative and quantitative data. The former consistingmainly of transcriptions of interviews and discussions and the latter comprised of
tables of summarized survey results. The corresponding data matrices that were
crafted to organize and display data are useful in determining patterns and trends.
However, the body of information is constrained by some factors.
An initial list of respondents for the FGDs and KIIs were initially drawn as pre-determined from the proposed methodology of the study. However, it was found that
many of the respondents had multiple responsibilities and titles. Hence, in the end
there were fewer interviews conducted than planned, as the same people comprised
the different groups that needed to be interviewed. The quality of available recordsand reports that were reviewed varied widely. There were areas like South Cotabato
that was meticulously documented so that trend analysis of their data was possible
while there were areas where the records were patchy or worse, where documentationwas not maintained. The records and documents that were reviewed were voluminous
and necessitated meticulous organization and analysis so that they could be useful to
achieve triangulation.
2.4 Limitations of the Study
While the study initially aimed to analyze selected trends in health status and healthservices indicators that would cover 10 years to account for the pre-devolution,
devolution, and post-devolution periods, due to unavailability of data for some years,
trend analysis was limited to 5 years at best for some indicators.
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Also the findings in this study are limited to observable phenomena regarding the
development of the Inter-local Health Zones in the study areas that were only
formally launched in 1999 except for Negros Oriental areas. While achievementsfrom inception up to the study period were described along with their plans for the
future, it may be possible that it was too early to discern the effects of some of their
efforts and strategies. Hence, this cross case analysis is only able to compare andcontrast what was evident and documented at the time of data collection and
validation.
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3.Consolidated Findings and Analysis
3.1 Key Health Operations Profile of Case Study Areas
These ILHZ case studies document efforts in the provinces of Bulacan, Kalinga,
Pampanga, Negros Oriental and South Cotabato. Each ILHZ area varies in terms of
population coverage and land area as shown in table 1. The largest populationcoverage in the study sites was reported in the Baliuag Unified Local Health System
covering 277,384 people and the smallest population coverage was found in Kalinga.
All of the case study sites were predominantly rural areas except for Bulacan and
Pampanga that were shown to be rurban, or a rural area developing into an urbancommunity. The Negros sites also incorporated cities within their catchment areas.
The relatively inaccessible rural areas of Kalinga were found to be the most sparsely
populated (pop. density 50/sq.km.) and the rurban areas namely Pampanga and
Bulacan were very densely populated with population densities of 1000, and 724.6respectively.
The case study sites are relatively poor with most municipalities classified as third to
fifth class municipalities or areas with annual average incomes of 5 million pesos and
less (DILG, 1997). However, the provincial sites have been shown to be well off with
their income classifications ranging from first class (Bulacan, Pampanga and NegrosOriental) to second class (South Cotabato) and third class (Kalinga). This may have
important policy implications as it seems essential that local resource generation and
sharing is vital to the viability of the organized inter local health zones. If networkedareas were all low-income areas from the regional level all the way to the municipal
level, local resource generation and sharing can prove to be difficult if not impossible.
All the study areas have been shown to have functional and extensive networks of
health facilities but some areas have been shown to be more endowed than others:
The BULHS in Bulacan reports 143 health facilities, 100 of which are public health
facilities and the rest private. In Kalinga on the other hand, there are only 21 healthfacilities, 15 of which are public and 6 private. South Cotabato LAHDZ 2 has been
shown to have an almost equal number of public and private health care facilities in
the area with 23 public facilities and 24 private facilities as shown in Table 1.
The case study areas also vary in terms of catchment area size and core referral
hospital size. The ILHZ areas with five municipalities in their catchment areas areBulacan ULHS and the CVGLJ District Health System in Negros Oriental. The others
have smaller catchment areas of two or three municipalities each.
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Table 1. ILHZ CASE STUDY AREAS BY POPULATION COVERAGE AND
COMPONENT HEALTH FACILITIES, PHILIPPINES, 2001
ILHZ Study Areas
their Catchment
Municipalities and
income classification
Coverage
(Population and Land
Size)
Network of Health Facilities
Bulacan, Region 3
-Baliuag Unified
Local Health System
Angat,-3rd class
Baliuag, -1st class
Bustos, -4th class
Dona Remedios
Trinidad- 3rd class
and
San Rafael-3rd class
Population Coverage
(277,384 people) accounts
for almost 14% of total
Bulacan pop. And 46,767
households ( 11.5%) of
Bulacan households in
land area of 45.05 sq.km
Population density
724.6people per sq.km.
Unified Local Health Zones clustered geographically
around core referral hospitals. BULHS is one among
15 ULHS in the region and has a total of 143 health
facilities
100 Public Health Facilities
Baliuag District Hospital- a 75-bed public
secondary core referral hospital refers to Bulacan
Provincial Hospital, a 200- bed public tertiary
hospital
Rural Health Units - 9; Baliuag- 4 , San Rafael 2
one each in Angat, Bustos and DRTBarangay Health Stations-85 ; Baliuag-26, San
Rafael-24, Angat 13, Bustos 14 , DRT 8
Lying In Clinics- 5 ; San Rafael 2, one each in
Angat, Bustos and DRT.
43 Private Health Facilities
Private Hospitals 11; Baliuag 6, Bustos 4, San
Rafael 1
Private Clinics 32 ; Baliuag 17, Angat 6, San
Rafael- 5 and Bustos 4.
Kalinga , CAR
-Lin-awa HealthZone
Tabuk,- 1st class
Tanudan
and
Rizal-5th class
Services 86,923 people or
36.5% of total Kalingapopulation; 16,056
households or 37.2% of
all households in the
province, in land area of
1,108.3 sq. km. or 35.5%
of population with a
population density of 50
people per sq.km.
Health Zones clustered geographically around core
referral hospitals. Lin awa health zone is one among3 health zones in the province of Kalinga
15 Public Health Facilities
Kalinga Provincial Hospital in Tabuk is a 100- bed
public secondary core-referral hospital that refers to
the regional hospital, Cagayan Valley Regional
Hospital, a tertiary hospital
Public hospitals - primary municipal hospital in
Tanudan
Rural Health Units 5; Tabuk- 3, one each in
Tanudan and Rizal
Barangay Health Stations- 9; Tabuk-4, Rizal 3 and
Tanudan 2
6 Private Health Facilities
Private hospitals - 5 in Tabuk with total of 77 beds.
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ILHZ Study Areas
their Catchment
Municipalities and
income classification
Coverage
(Population and Land
Size)
Network of Health Facilities
Negros Oriental,
Region 7
- Sta. BayabasDistrict Health
SystemCity of Bayawan-1st
class,
Sta. Catalina, 2nd
class
and Basay 4th class
CVGLJ District
Health SystemCanlaon City, 3rd
class
Vallehermoso, 4th
class
Guihulngan,La Libertad 4th class
and Jimalalud 5th
class
Sta. Bayabas covers171,979 people in
1483.4 sq. kms with
average population
density of 107.7 per sq.
km
CVGLJ covers 209,074
people in 930.4 sq.km.
with average population
density of 366.9 per
square km
District Health Systems clustered geographically
around district hospitals composed of one city and
component municipalities
Public Facilities
Bayawan Distict Hospital is the District Core
Referral Hospital that networks with 4 RHUs
(Bayawan I and II, Sta. Catalina and Basay two
Primary Hospitals (Kulombayan and Amio Primary
Hospitals)
Barangay Health Stations-
Provincial Hospital-
Governor William Villegas Memorial Hospital is
the District Core referral hospital
19 Private Health Facilities
Medical Clinics- 13, STA. BAYABAS-6, CVGLJ-7Dental Clinics- 4 STA. BAYABAS
Optical Clinics-2 STA. BAYABAS
Pampanga, Region 3
Arayat ULHSArayat-3rd class
Sta. Ana- 4th class
Mexico- 3rd class
Services 215,611 or
13.1% of total Pampanga
population or 36,997
households or 12.2% of
total households in the
province in land area of
283.1 sq. km or a
population density of1000 people in one sq. km
Unified Local Health Systems clustered
geographically around core referral hospitals.
AULHS is one among 15 ULHS in the region and
has a total of 11 health facilities
AULHS has a total of 11 health facilities.
Public Health FacilitiesArayat District Hospital (DECCS Memorial
Hospital) secondary public hospital with authorized
bed capacity of 25 beds and implementing bed
capacity of 50 beds that refers cases to the Regional
Hospital in San Fernando, Pampanga, a 200 bed
tertiary public hospital 18 kms away
Rural health Units - 8 Arayat-3, Mexico 4,
Sta.Ana-1
Private Health Facilities
Private Clinics 3
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ILHZ Study Areas
their Catchment
Municipalities and
income classification
Coverage
(Population and Land
Size)
Network of Health Facilities
South CotabatoLAHDZ 2 Norala, -
4th class
Sto. Nino- 4th class
Selected barangays
from Surrallah, 1st
class
Banga, 3rd class
Sultan Kudarat-2nd
class
Covers about 94,000people
Services mostly Ilonggos,
but also some Ilocanos,
Blaans and few Muslims
Local Area Health Development Zones (LAHDZs)organized around core referral hospitals
LAHDZ 2 has a total of 46 health care facilities:
Public Health Facilities
South Cotabato Provincial Hospital
Norala District Hospital - primary hospital core
referral hospital that refers to a tertiary provincial
hospital
Rural Health Units 2 main health centers with
Barangay health stations-19 (13 in Norala and 8 in
Sto, Nino)
Private Health Facilities
Private Hospitals 3; 2 primary and 1 secondary
Medical clinics 9
Dental Clinics -12
The hospital bed to population ratio in the case study areas have been shown to vary
widely from 1 hospital bed to 537 people in South Cotabato to 1 hospital bed to 958
people in Pampanga as shown in table 2. This finding is remarkable as the expectedlydeficient areas in terms of hospital beds to population ratio are the Mindanao areas
such as South Cotabato which is not observed in this study. The areas showing a
dearth of hospital beds are now the rapidly urbanizing areas of Bulacan andPampanga where the local number of beds has not increased proportionately with
population increase. Perhaps, this is also due to the fact that these areas are near to
Manila and with good roads have access to Metro Manilas hospitals.
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Table 2. ILHZ Health Facilities Analysis Matrix
No. of Health Facilities Health Facilities Adequacy
RatiosILHZ Area/
Province(ILHZ Popn.)
Hospital OPD
Facilities
Total Hospital
Bed/Popn
OPD Facilities/
Popn
BULHSBulacan
(253,044)
Public
Private
Total
2
11
13
99
32
131
101
43
144
1: 920 1: 1,931
LAHDZ 2
S. Cotobato
(94,000)
Public
Private
Total
2
3
5
23
21
44
25
24
49
1: 537 1: 2,136
AULHSPampanga
(215,611)
Public
Private
Total
2
0
2
92
1
93
94
1
95
1: 958 1: 2,269
STA.BAYABAS
CVGLJ
Negros Oriental
(381,053)
PublicPrivate
Total
Public
Private
Total
30
3
3
0
3
6212
74
55
7
62
6512
77
58
7
65
1:573
1: 696
1: 2,324
1: 3,372
LINAWAKalinga
(86,923)
Public
Private
Total
3
6
9
14
0
14
16
6
22
1: 620 1: 6,208
The ratio of OPD facilities to population has not varied as widely as this rangesbetween one OPD facility to 1,931 people in Bulacan to one OPD facility to 3,372 in
Negros Oriental. The exception to this observation was found in Kalinga howeverwhere we observed a ratio of one OPD facility to 6,208 people. Peripheral publichealth units seem to be sorely deficient in Kalinga.
Furthermore, it was observed that private health care providers have not been
sufficiently networked with public health facilities in terms of being formallyintegrated into the referral system of public health facilities. This is unfortunate as in
some areas, as in Cotabato LAHDZ 3; no other secondary health care provider was
available other than the private hospitals. Also many public hospitals have been foundto be downgraded by hospital accreditation and licensing bodies such as Philhealth
and DOH due to deficiencies in vital health human resources such as surgeons,
anesthesiologists, pathologists and other physicians with specialty training. Moreover,inadequate facilities, equipment and consumable materials such as diagnostic
reagents, sponges, cotton, etc. were rampant. Some private health care providers and
their facilities may be the answer to improve the functional capabilities of public
hospitals, if they were sufficiently linked to each other. On the other hand, the privatehealth providers will have access to more patients if they provided their services hand
in hand with public health care facilities.
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These findings are significant in pointing out that there seem to be enough health
facilities in the ILHZ study areas. However, only the public health facilities are
networked together through an organized referral scheme. In areas like SouthCotabato where there is a dearth of public hospitals in some areas, the need to relate
with private health care providers at different levels, especially at the secondary and
tertiary care levels become more acute.
Moreover, the clustering of the inter-local health zones are mostly based on
geographic considerations. These geographic clustering does not always provide thebest arrangements to ensure access especially to secondary and tertiary care facilities.
As a result, some residents of the ILHZ areas do not access the designated core
referral hospitals but access others such as provincial hospitals or regional hospitals
even, when the utilization of these facilities are more efficient as found in theAULHS in Pampanga and Linawa Health Zone in Kalinga.
3.2 Critical Steps in the Formation of ILHZ
In each of the cases study sites, there were key steps that were undertaken towards theformation of ILHZs as shown in the Milestones in ILHZ development as shown in
Appendix 5.
In the Baliuag Unified local Health Zone, the following were undertaken:1. Development of the Unified Local Health System Concept at the CHD level.
2. Orientation of Municipal Local Chief Executives, Local Health Board, Health
Staff at the Regional and Provincial level on the Unified Local Health System.3. DOH supported orientation live-in training for local health board members
(1993)
4. Securing the commitment and leadership of the provincial governor as chair of theULHS boards.
5. Mayors of the five participating municipalities together with the Governor of
Bulacan and the Director of the Center for Health Development of Region 3
signed a memorandum of agreement unifying the five municipalities throughcommunity participation, sharing of resources and expertise and effective
collaboration among local government units. (1999)
6. Provincial Health Office organized monthly meetings of the association of LocalHealth Board Chairman on health in 24 municipalities for 5 months until they
were capable of holding their own meetings.
7. Powerpoint presentation of Health Programs to local health board members byCHD 3 in every municipality.
8. Dissemination of IEC materials from CHD including health programs with policy
basis (RAs and EOs)9. Regular updates regarding health programs given to LCEs during health
municipal board meetings. The local health board meets monthly with the SB or
Mayor as chair.
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10. DOH representative designated as the coordinator of BULHS activities and acts
as liaison officer between provincial health office and the District
11. DOH- CHD 3 provides continuing technical supervision, training, planning,monitoring and evaluation of health programs, formulation or renewal of policies,
protocols and standards, promotion of health information system and research and
development.
In South Cotabato, the LAHDZ system was formulated in three phases, the
preparatory phase, the pre-implementation phase, and the implementation phase. Onlythe first two phases have been completed.
Preparatory Phase:
1. The South Cotabato Integrated Provincial Health Office (SCIPHO)
conceptualized the Integrated Health System (IHS) and specifically the LAHDZ
system after they identified factors in the derailment of health services in South
Cotabato.
2. The SCIPHO developed the concept paper and project proposals were submitted tofunding agencies. Multi-sectoral consultations were conducted for this.
3. Proposals for funding the LAHDZ systems were prepared and submitted to the
provincial government, DOH, USAID, and AUSAID.
Pre-implementation Phase:
4. Provincial Health Office finalized agreements with key stakeholders:
ICHSP planned to reintegrate the district hospital with the RHUs through theLAHDZs (1993)
Local Government Performance Project (LPP-USAID) was launched in 1994with a project life until 2000
ICHSP was terminated in 1994 and revived in 1996 and formally launched in1997
South Cotabato Integrated Health System (IHS) was officially proposed tothe provincial government at the Provincial Health Summit (1999)
South Cotabato Governor de Pedro signed a pledge of support for South
Cotabato IHS (1999)
IHS was formally launched (August, 1999)
5. Securing Mandates and legal bases
Provincial LHB Resolution no.1 s of 1999, endorsing the adoption of the IHSand the issuance of the Executive Order, signing of MOAs (March 1999)
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Provincial Governors Executive Order 99-08, series of 1999, establishing theIHS and creation of Local Area Development Zones (LAHDZs) (April 1999)
LAHDZ MOAs signed by the Governor and Mayors of componentmunicipalities (April-May, 1999)
Provincial Development Council (PDC) resolution for adoption and full
implementation of IHS (May, 1999) Sangguniang Panlalawigan (SP) resolution for adoption and full
implementation of IHS (May, 1999)
Presidential Executive Order No. 205 establishing Inter-local Health Zones(January, 2000)
6. Widespread Social Marketing of the Integrated Health System
First Provincial Health Congress was held to solicit consultation andfeedback on the IHS (July 2000)
Once a week radio program on health to address continuing issues in IHSimplementation.
7. Planning for Implementation
The CHD for Southern Mindanao set the planning and managerial supportsystems in motion by specifying the time frames for each phase of
development; no replication phases were specified (2000)
Implementation Phase
8. Phased and Province-wide dissemination of the IHS
On going planning
9. Development of Financing Options Counterpart funds for LAHDZ implementation provided by
Provincial and Municipal Local Governments in terms of salaries of
contractual workers
Municipal Local Governments provided funds for participationin PHIC Indigent program
Local Health Insurance Schemes and other financing options inthe planning process
10. Monitoring and Evaluation of the pilot and expansion areas
On going planning
The Kalinga Health Zones experienced similar critical steps in the formation of
ILHZs. However, it should be noted that even during devolution, the province of
Kalinga already started experimentation with the Balbalan Zone, now known as theBumilgan Health Zone. The province of Kalinga undertook the following in the
formation of the Kalinga Health Zones:
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Preparation Phase
1. Conceptualization of the Kalinga Health Zones
Conceptualization of the Balbalan Zone (1994)
ICHSP Conceptualization (November 1995)
Kalinga Apayao separated by RA 7878 (1995)
Province of Kalinga identified factors affecting the delivery of health
services: poor communication, transportation, difficult terrain, constraintsof mobility and inaccessibility and high cost in relation to low income
profile of municipalities especially those belonging to the 4th
and 5th
class.
DOH rationalized the national health system through the drafting of theHealth Sector Reform Agenda (January 2000)
DOH took the initiative to conceptualize the District Health System withInter-LGU cooperation (2000)
2. Developing Concept Paper and Project proposals
Preparation for the Balbalan MOA: one hospital and one municipalitymodel with the province of Kalinga Apayao (1993)
3. Finalizing proposals to funding agencies
Inception of the AUSAID/ADB supported Community Health Services(ICHSP, 1997)
4. Finalizing Agreements
ICHSP included the District Health System in its subsystems (1994)
ICHSP workshops for Kalinga-Apayao, South Cotabato, Guimaras and
Palawan (1994)
Signing of MOA between Kalinga Province and ICHSP
5. Securing Mandates
Signing of the Balbalan MOA (1994)
Health Covenant where the DOH, DILG, LGU and the League of Governorshave adopted an Executive Order directing all LGUs to establish Inter-localGovernment Cooperation and defining their mechanisms, structure, functions
and power of the zones (1999)
Signing of the Linawa MOA (1999)
Presidential Executive Order no.205 establishing Inter-local Health Zones(January 2000)
6. Conduct of Social Marketing
Consultative meetings with the Regional Health Office, Local ChiefExecutives, Provincial Health Office, Provincial Planning and DevelopmentOffice, Sangguniang Bayan and Panlalawigan and Integrated Community
Health Services Project (ICHSP)
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Consultation and workshop sponsored by ICHSP for its District HealthComponent (1999)
Consultation with RHO and PHO for financial support (1999)
7. Planning for Implementation
Tour to South Cotabato and Palawan for Health Cooperatives (1999)
Conceptualization of Ambigatton Multipurpose Cooperative for ILHZ support
(1999)
Implementation Stage
8. Activities in support of legal mandates
District Health Board and Provincial Health Board meetings
Accomplishment of activities such as medical missions with the participatingmunicipalities (2001)
Advocacy and sustained implementation of the MOA in spite of political
instability at governors level
9. Development of financing options
Installation of supports systems such as the PhilHealth Indigency Program(2001) and the Ambigatton Multi-purpose Cooperative (2000)
Expansion of support systems by organizing the Bumilgan Multi-purposeCooperative, and the Rizal Barangay Health Workers Multi-purpose
Cooperative
10. Developing pilot and expansion areas
Setting of Chico River District (2000) and the pursuit of the Balbalan-
Bumilgan Health Zones (MOA signed in 1994)
11. Monitoring and Evaluation
ICHSP monitoring and evaluation
Provincial technical team monitoring and evaluation
12. Achievements
District Health Plans
Medical and Surgical Missions
Phil Health Insurance enrollments
Ambigatton Multi-purpose Cooperative and its expansions to other areas
13. Sustainability Updates
Reconvening of the District Health Board where decisions for sustainability
were made. These include the enforcement of the rotation of mayors as hostand chairperson, review and reemphasis on the functions of the DHB,
approval of a better referral tracking system and form, conceptualization of
the MOA to transfer funds of the PHO to Tanudan Municipal Hospital and
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Juan M. Duyan Memorial Hospital based on the Balbalan MOA, scheduled
regular meetings for the board for year 2001 and establishment of a Trust
Fund of the DHB.
In the CVGLJ and Sta. Bayabas District Inter-LGU Health Systems of Negros
Oriental, the following were accomplished:
Preparatory Stage:
1. Identification of convergence area
Gathering of baseline data of the community was done in both CVGLJ DistrictHealth System and in the Sta. Bayabas district. The location of the district
hospitals has become the most important consideration in determining theboundaries of the district catchment areas.
2. Orientation and Training
Inter LGU health conferences were initiated at the provincial level to sell the ideaof health districts to various cities and municipalities.
The district hospital chief and the provincial health office perform socialmarketing functions among targeted LGUs.
3. Action Planning
Health district boards are organized and MOAs are endorsed to SBs ofmember LGUs in the catchment area.
Securing legal mandates for both DHS
Provincial Sangguniang Panlalawigan approved provincial health boardresolution creating the various health districts.
Joint SB Sessions at the municipalities of Bayawan, Basay and Sta. Catalinawere
held (STA.BAYABAS, 2000)
Planning- Workshops on the Implementation of the District Health System
MOA signing
Signing with participating stakeholders of CVGLJ in 1999 and STA.BAYABAS in 2000
Implementation Stage
4. Monitoring and Evaluation
Monitoring is done internally by the health district boards. The St. Goretti Foundation is the external monitor for Sta. Bayabas and
BIARSP is the external monitor for CVGLJ.
From the consolidated experiences of the different case study ILHZs, we can derivecritical steps in the formation of ILHZs that need to be undertaken to ensure their
viability and sustainability. These include:
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1. Undertaking extensive and meticulous pre-implementation preparation of ILHZ
stakeholders.
2. Deciding on effective organizational structures and arrangements that areeffective and feasible relative to site characteristics.
3. Securing enduring functional linkages and mandates among key stakeholders to
forge strong working relationships and teamwork.4. Finalizing and securing commitments for resource support, and networking of
services.
5. Massive social marketing to disseminate the concept, the ILHZ system, itsmission, vision and objectives to generate widespread community buy-in and
participation.
6. Conducting joint management sessions among local government and health
managers to oversee ILHZ operations.7. Developing local health financing options to ensure sustainability of ILHZ
operations
8. Phased and province-wide dissemination of the ILHZ
9. Monitoring and evaluation of the pilot and expansion areas
First, an extensive and meticulous pre-implementation preparation seems to be
extremely valuable. In this step, valuable strategic plans to determine the direction of
ILHZ organization efforts can be carefully laid out. More detailed annual operational
plans can also be hatched to determine vital contributions of key stakeholders.
Proposals for external funding may also be crafted at this time. Most importantly, thisperiod will allow process champions to secure necessary mandates to legitimize ILHZ
organization and to ensure its sustainability over time.
A second important step is making decisions on effective organizational
structures and arrangements that are required by context of the area to ensurethe feasibility of initiating the inter-local health zone system as well as its
sustainability over time. There were several examples of this step as a keydeterminant of success of ILHZ over time. In Bulacan, Cotabato and Bayawan, it was
decided early that the District Health Board needs to be chaired by the Provincial
Governor to ensure that the participation of the Mayors of the componentmunicipalities would be coordinated more effectively and so that provincial support
can be facilitated. In Pampanga, it was decided to experiment with CHD3s model 2
that required one Mayor to lead the district health board on a rotation basis. There is aneed to examine and decide on other organizational arrangements such as the
inclusion of an external funding agency such as AUSAID and USAID into the formal
organization of the ILHZ. Identification of key partners and clear delineation of theirroles and functions in the ILHZ is vital to ensure that organizational arrangementswill be made to work. The identification of key partners especially NGOs and POs is
also important to ensure that networking to ensure quality health care provision is
feasible.
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Third, securing enduring and functional linkages and mandates between health
managers at the DOH, the local health managers and the local government
managers is important to forge strong working relationships and teamwork to
facilitate a robust and integrated health operations system. At South Cotabato, the
provincial health office exerted great effort in securing necessary mandates fromdifferent administrative levels namely, the national, regional, the provincial, and the
municipal levels, to ensure that the LAHDZ system will withstand political changes
and upheavals. Among mandates secured that assured enduring and functionallinkages were: EO 205 at the national level establishing national Inter-local Health
Zones; Provincial Executive Order 99-08 establishing the IHS creation of Local Area
Health Development Zones (LAHDZ); Provincial Development Council resolution
for adoption and full implementation of the Integrated Health System (IHS); LAHDZ2 MOA among the participants of the LAHDZ 2; and Local Health Board Resolution
No. 1 endorsing adoption of the integrated health system, issuance of Provincial
Executive Order and signing of MOAs . While other case study areas were not able to
develop as extensive inter-local policies, there were vital key mandates developed inall areas except Pampanga, such as the MOA among component municipalities and
the provincial government to formalize their commitment of participating in IHLZdevelopment.
As the mandates were secured, the support of local government executives wassimultaneously won, as local government executives perceived that they had no
choice but to follow national legislation mandates. At the same time, local
government managers and health managers at different levels had to work on this
common task so team building eventually was facilitated. Working on securing thenecessary mandates provided a focus that bound them together in the preparatory
stages of setting up the IHLZs.
A fourth step that is related to securing mandates is finalizing agreements and
securing commitments for resource support, financial and human resource
arrangements, and networking with other agencies and organizations including
NGOs and POs. In this process, counterpart-funding commitments were secured
from local government executives as initial or continuing commitments.
Massive social marketing comprised the fourth critical step in ILHZ formation .
In Pampanga and Bulacan, CHD 3 went to such lengths as developing Power Pointpresentations for local government executives and government managers to convince
them on the importance of setting up and supporting ILHZs. These were instrumentalin winning over the governors and mayors and supporting ILHZ development. These
events were likewise utilized to communicate advantages and disadvantages of setting
up health districts as well as conveying that financial incentives were available to thelocal areas that were willing to initiate and operate ILHZs. Sustained social marketing
was also identified as valuable in the implementation phase. South Cotabato used tri-
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media- radio, local newspapers and other printed materials to disseminate information
about the progress of the LAHDZ system. They developed a weekly radio program
where the Provincial Health Officer (PHO) discussed issues and addressed problemsand criticism of health care delivery.
In this case, health managers were able to address tensions stemming from local
health care delivery as expressed by the recipients of care. The success of Dr.
Fidencio Aurelia in securing community participation in health care financing wasalso a vital output of social marketing. It is envisioned that this step will be priceless
in securing widespread community participation and buy-in to improve the utilization
and quality of local health systems. An important outcome is the fostering of
community empowerment and ownership of the health system such that thecommunity will realize that they have an important stake in the success or failure of
their local health system.
Joint planning sessions conducted to oversee implementation of ILHZ operations
were likewise identified as vital to ensure full integration of health operations
into local government operations. These means that regular, well attended meetings
were organized to ensure that health operations among participating local
governments synchronized well. These sessions also provided oversight in the
networking of the component municipalities to facilitate information and resourcesharing. This step was successfully demonstrated in all the ILHZ case study areas.
Development of financing options was an important component fully developed
in some of the ILHZ study areas but underdeveloped or non-existent in others. In
Negros Oriental, the Peso for Health was successful in mobilizing community interestand support for local health development while setting up health financing options for
the area. The financing decisions moreover facilitated the development of autonomy
and independence in supporting and maintaining local health system operations. In
Kalinga, a cooperative pharmacy was set up as well as a community-based healthcooperative. Moreover, all the areas participated in the PhilHealth Indigent Program.
The sixth important step in ILHZ formulation would be phased and province-wide dissemination of the ILHZ. Although not many of the new ILHZ pilot areas
have reached this phase, this seems to be an important step to ensure deliberate andcontrolled expansion of ILHZ areas. In this step learning from other mature ILHZ
implementation areas would be beneficial before implementing the ILHZ system full
blast. Some ILHZ managers like those in Kalinga visited other areas that wereidentified as successful models of ILHZ, in this case, South Cotabato before it fully
implemented the system in their area. South Cotabato developed only one
convergence zone that could be used as a model that may be utilized for pilot testing
new strategies, training, and a source of a wealth on information about success and
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failure factors in ILHZ formation. For areas like Negros Oriental that had models of
District Health Systems since 1985, this step was experienced in the development of
the Sta. Bayabas District System as an expansion area of CGLVJ District HealthSystem.
A final step would be monitoring and evaluation of the pilot and expansionareas. With full implementation, monitoring and evaluation of activities is a necessity
that would allow IHLZ areas to learn from the experiences of the pilot and expansion
areas that would allow them to replan and introduce changes more systematically.While none of the areas was able to demonstrate the achievement of this step, the
Province of Kalinga was able to refine the ILHZ models that it introduced in the area
so that the cultural requirements of indigenized systems were respected and upheld.
3.3 Health Operations: Organization, Composition of Services, and Patterns of
Utilization
Health Services and their Support Subsystems
The BHS usually provides health services that include symptomatic or definitive
management of common illnesses (e.g., antipyretics for fever, analgesics forheadaches, Chemotheraphy for TB) and preventive/promotive services in relation to
the DOH programs (e.g., EPI) through the Barangay Health Workers (BHWs) and
Rural Health Midwives (RHMs). The rural health unit (RHU) main health centers,services include simple laboratory examinations (e.g., urinalysis, fecalysis) and dental
services provided by medical technologists and dentists correspondingly.
At the District Hospitals, there are pharmacy, laboratory and x-ray services asidefrom in-patient and out-patient services. The in- and out-patient services are
classified into general medicine, pediatrics, minor and surgery and obstetrics-
gynecology including Caesarian operations and D & Cs. Only the District Hospital inArayat provides rehabilitation services through a tie-up with a private foundation
serving students of physical therapy schools.
Some of the hospitals in the case study sites were licensed as primary hospitals as
Norala in South Cotabato and Guihulngan in Negros Oriental while others wererecognized as secondary hospitals such as in Bayawan, Negros Oriental and Tabuk,
Kalinga. However, the Tabuk hospital is also a provincial hospital and caters topatients outside of the catchment areas. In the same manner, those in the catchment
areas do not utilize some of these facilities. They go to the nearest hospital (e.g.,
residents of Mexico, Pampanga go to the nearer regional hospital in San Fernandorather than to the farther DH in Arayat. The residents of Rizal, Kalinga on the other
hand, go to another district hospital and not to the designated core referral hospital,
the provincial hospital in Tabuk).
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The BHS, RHUs and hospitals manage a mix of communicable and non-
communicable diseases especially in the urbanized areas of the districts. Such a mix
is characteristic of communities in development transition.
Integrative Planning and Development Mechanisms
There are varying degrees of participation in planning in the five areas, ranging from
a non-integrated (i.e., the district hospital and each RHU come up with their ownplans) operational planning in Pampanga, to the integrated strategic planning in the
LAHDZ of South Cotabato through the involvement of Provincial Technical
Advisory Groups (PTAGs) and area coordinators, and to the annual planning of the
Linawa Zone with participation by the mayors and municipal health committeemembers in addition to those in the health system. In Bulacan, the DOH
representative consolidates the municipal plans and the resulting plan is approved by
the district health board headed by the Governor. In Negros Oriental, strategic
planning occurs from the BHS/RHU and DH levels to the ILHZ level.
Policy Making Processes and Mechanisms
In terms of the organizational structure and management processes, the ILHZ district
health board is the unifying and coordinating body composed of representatives fromdifferent agencies and organizations that contribute to the health zone operation:
Provincial LGU representative, Sangguniang Panlalawigan (SP) representative to the
health zone, Integrated Provincial Health Office (IPHO) representative, MunicipalLGU representative, Association of Barangay Captains (ABC) President, DOH
representative, Health insurance organization representative, Chief of Hospital,
Municipal Health Officer (MHO) and, Non-government organization (NGO) /Peoples Organization (PO) representative.
The ILHZ district health board has financial and policy-making functions to
supplement existing LGU policies. New ILHZ policies are presented and approved bythe Provincial Health Board and the Sangguniang Panlalawigan. It also approves the
integrated health work and financial plan.
The ILHZ Technical Management Committee (TMC) is composed of the technical
staff from the RHU and hospital personnel and assisted by the administrative staff
designated by participating LGUs on a part-time or full-time basis. Other membersmay include the DOH representative or a patient representative.
Usually, the first policy governing the ILHZ is the MOA between the stakeholders
(GOs: health and political; and NGOs). In general, policymaking is vested in the
District Health Boards.
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In South Cotabato, policy making is multi-level, from the Sangguniang Bayan, the
LAHDZ Board and the Expanded Provincial Health Development Board asexemplified by the process they utilized to change provincial hospital pricing.
In Pampanga which still does not have a completed MOA, its sole policy is withregard to the referral system and the decongestion of the district hospital.
In Bulacan, an example of a policy is the focus on the malnutrition problem leading toULHS-wide planning and implementation on nutrition improvement including
income-generating activities at various levels.
Policymaking in Negros is vested in the various health boards which havemultisectoral representation. A technical management committee made up of health
workers at various levels is formed to provide inputs to the board which acts on their
recommendation.
Financing and Budgeting Mechanisms
Certain mechanisms have been put in place in support of the local health systems.
Negros Oriental is one of the few provinces that have allowed public hospitals to keep
their income held in trust by the Provincial treasurer. Aside from the regular budgetallocation from the province, the income earned by hospitals from user fees are
plowed back to the hospital for their maintenance and operating expenses.
Up to the present, user fees are remitted to the provincial treasurer and an accountant
is assigned to keep records and keep track of all hospital remittance forwarded to the
Provincial Treasurer. The hospital makes periodic requests for release of funds and abudget sub-allotment is prepared and approved by the Sangguniang Panlalawigan.
Each hospital has its own board that decides how the funds are to be spent.
The creation of hospital boards also prepared various sectors of Negros Orientalsociety for participation in district health boards. The hospital board has multi-
sectoral members and is given policy making as well as financing functions. It
approves the work and financial plan prepared by the hospital staff and disbursementby the province is in accordance with the approved plan and budget.
Negros Oriental stands head and shoulders above the other ILHZ that were studied in
terms of community health financing.Their ILHZ board established a common healthfund from the LGU appropriation of member municipalities in the catchment area, in
addition to other funds from other sources like foreign funding. They may also tap
into a health insurance fund, DOH grants, community financing fund and otherprivate sector contribution.
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All funds are deposited to the ILHZ account and disbursed in accordance with the
integrated work and financial plan. The common health fund is deposited under one
collaborating LGU as agreed upon by participating LGUs and managed by the ILHZTechnical Management Committee. The ILHZ Health Board and the Technical
Management Committee (TMC) maintains separate books of account and keep
financial records available anytime for monitoring and auditing by an authorizedagency. The TMC submits a financial statement and narrative report.
In CVGLJ, the health district board maintains a common health fund derived from
BIARSP funds and contributions from participating municipalities. The CVGLJdistrict has been registered with the Securities and Exchange Commission and the
board has opened a bank account for the common fund. (See Appendix 9 for the
Articles of Incorporation of the CVGLJ ILHS)
In Sta. Bayabas, all areas agreed to put up a common health fund. The amounts
pledged reflect the financial position of each of the three towns with Bayawan,
recently converted into a city paying the highest contribution, Sta. Catalina next andBasay, a fourth class municipality and the poorest among the three paying the least.
The District Health Board met to decide on how the common fund should be
allocated among the 7 components of the Sta Bayabas ILHS. Of these components,the Peso for Health Program gets the highest percentage for funding.
Both Bayawan and Guihulngan have the local Peso for Health insurance scheme andtrust funds for health coming from a variety of sources (e.g., LGU, health insurance,
revolving drug funds). It also has separate district and hospital board budgeting.
Kalinga has similar mechanisms (multi-purpose cooperative pharmacy and trust
fund). It also has inter-LGU sharing of resources for medical missions (e.g., human
resources, transportation, fuel).
On the other hand, there is no health insurance in South Cotabato but there is anintegrated budgeting at the LAHDZ. There is an on-going Indigency Health Insurance
Program through the PhilHealth in certain municipalities of South Cotabato, Kalinga,
Bulacan and Pampanga.
Referral Processes and Mechanisms
Referrals are usually shunted from one primary level of care to a secondary of tertiary
level. In CHD of Central Luzon, there is a uniform referral system, with multi-colored forms that is implemented in the ULHS of Bulacan and Pampanga. InKalinga, the referral chain is not generally followed. Referrals are dictated by
proximity (e.g., skipping the RHU because the district hospital or the provincial
hospital is geographically accessible). In South Cotabato, a two-way referral system,the integrating factor in the health information system, is in place. Here, the LAHDZ
is the focus for development. The referral system addresses problems such as
underdeveloped health services as in the downgraded hospital license of the Norala
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district hospital, lack of coordination with private practitioners and confusion among
the community members regarding points of access to health care. Such a two-way
referral system is also operational in Negros Oriental such that people know whichservices are available in the existing health facilities. A common problem is the lack
of back referrals.
Human Resources Management
Generally, the HRM functions belong to the respective LGUs (i.e., the provincialgovernment for the DH staff and the municipal government for the RHU staff).
Oftentimes, politics play a part in recruitment and selection, promotion and
performance evaluation. There are also inadequacies in staff development especially
for the non-medical personnel and insufficient career path. Some incentives such asawards are provided, however, as exemplified by the provincial government of
Bulacan. There are also complaints of inadequate remuneration such as the absence
of hazard pay and among LGUs, the higher salaries of MHOs/RHPs than the mayors.
There are still many DHs and RHUs with incomplete staffing. Such problems resultin low morale and low levels of motivation. As far as human resources for the ILHZ
are concerned, Negros Oriental and South Cotabato are two areas with specificstaffing for a district health system. The former has the Management Committee
while the latter has the PTAGs and the area coordinators.
Management Information System
The FSHIS started by the DOH is still in place. In CHD No.3, the lack of staff for
ULHS operations contributes to the difficulty of having a MIS. Thus, data from theRHUs bypass the ULHS and go straight to the PHO resulting in the absence of
planning at the district level. In the ICHSP areas of South Cotabato and Kalinga, this
is being developed. In the former, the LGUs contribute in the procurement ofhardware. Presently, networking is not yet completed despite the presence of
computers. In Negros Oriental, it was noted that there is better information sharing
with the use of computers. However, in general, information has yet to be generated
for better decision making at the ILHZ.
The most developed health services subsystems are the planning and development as
well as the policymaking subsystems. All case study areas have three- year strategicplans both at the provincial and local levels. They also have corresponding annual
operating plans. Most of these plans are crafted during joint planning meetings of the
District Health Boards. Due to the short implementation phase of Pampanga, thesejoint planning meetings were not as evident there. However, it must be noted that
integration of health operations into local health system operations is no yet complete.
Policymaking subsystems are operating at high levels. They are able to churn out
important supportive policies for ILHZ implementation. At the same time the more
mature systems like South Cotabato and Negros Oriental have been shown to
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influence central DOH and the executive and legislative branches of government to
craft policies that would support inter-local health systems.
The least developed sub systems are the management information and human
resource development systems. The ICHSP project has provided funding for South
Cotabato and Kalinga for investments in the development of local health informationsystems that would integrate both field health services and hospital services to each
other. While the initial hardware has been procured, the software development has not
been completed yet. These areas are hopeful though that this system can be developedin the near future. Human resource development has also lagged behind the other sub
systems.
Organization of Health Services
As previously described, health operations in the study areas are clustered
geographically around core referral hospitals at the District level. While thefunctional capabilities and resultant services of the district core referral hospitals
varied, they were all expected to be capable of providing secondary hospital services.There were a number of problems associated with this. First, not all areas clearly
delineated the essential services provided at the primary secondary and tertiary levels
that should be provided. South Cotabato did this well by designating primary,
secondary and tertiary health packages that should be provided at different levels ofcare. The other case study sites assumed that this was already done and thus
exhibited more overlaps and gaps in their service delivery. Second, not all core
referral hospitals were shown to be capable of delivering secondary hospital services.In the case of South Cotabato, the Norala District Hospital was downgraded by the
PHIC to a primary hospital. Hence, the services that the District hospital overlapped
with those provided by the RHU. The same was true in the Guihulngan DistrictHospital. Hence, in Norala because there was no secondary hospital capability, people
had no choice but to go to private hospitals or go to the distant provincial hospital.
However, when Provincial hospitals provide only secondary hospital services, then
tertiary services will have to be availed of in a more distant Regional hospital as whathappened in the Kalinga experience.
Patterns of Health Services Utilization
In all the study areas, the most accessible health care facility identified in this study isthe Barangay Health Station followed by the private hospital and the RHU as reported
by Table 4. The district hospital and provincial hospital are perceived to be the fourth
and fifth most accessible health facility respectively. However, reported healthseeking and health facility utilization behaviors show preference for private
practitioner and private hospital over BHS, RHU and self-medication. Please see
Tables 5 and 6. The results from these two tables seem to correlate well with each
other and validate the preferences indicated by these two measures. One set of
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responses were answers to What do you do when you or any family member fall
sick? The other responses were in reply to the query, What health facility do you
usually go to?
These responses were matched with what they said were what common health
services they sought as shown in Table 7. Respondents indicated that they mostlyutilized the following ranked services: check-ups/consultation/ BP checks all in first
rank, immunizations in second rank, followed up by family planning, maternal care
and free or refill of medicines. Moreover, Table 8 shows that the family healthproblems that they seek consultation for are best addressed at the BHS and RHU
levels.
Common health services that the respondents utilize for their most common familyhealth problems are all provided in the BHS and RHU but why do the respondents go
to private hospitals and physicians? Perhaps, the perception that private physicians
and hospitals are more complete and capable of providing needed services is still
dominant. Conversely, even if some public health facilities are accessible, they areperceived as incapable of providing quality care due to lack of medicines, necessary
equipment and personnel. This perception surfaced during the focus groupdiscussions.
Responses on satisfaction of respondents with health services provided at the
reference health facility was shown in Table 9 to be positive, i.e. 79% of allrespondents indicating that they were satisfied with health services. However, there
was a sizable proportion of respondents (20%) who either did not respond, had
inapplicable responses or indicated that they were only sometimes satisfied. Theinvestigators construe these responses as negative. True to the Filipino behavior of
not wanting to offend or displease others, these responses may have been masked to
soften their expression of dissatisfaction.
In addition, all district hospitals were expected to have technical supervisory
responsibilities over RHUs, but it seemed that it was not clear to all of them that they
should also be operating district health offices with organized technical staff to do thejob. The District Hospitals that were able to do this included Kalinga and South
Cotabato while the rest merely functioned as secondary health care referral centers.
Perhaps the reason for this is that the core referral hospital in Tabuk for the LinawaHealth Zone is also the provincial hospital that houses the technical staff. In South
Cotabato, the Provincial Hospital acted as core referral hospital for LAHDZ 3 that
was not included in the case study sites. For this LAHDZ, the technical supervisionfrom the District Hospital was evident. But it was not so for LADHZ 2 that the
Norala District Hospital was supposed to technically oversee. In the latter case, the
District hospital merely acted as a referral unit. While technical supervision waslacking in the other areas, the critical role of the DOH representative was highlighted
by this situation. In Bulacan where the DOH representative was very active and on
top of all IHLZ developments, he was able to discharge the technical oversight that
was necessary in the local areas. He thus linked the Provincial DOH technical staff
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capabilities with the needs of the developing BULHS. In other areas, the DOH
representatives did not actively figure in providing this link.
3.4 Organograms
The different models of ILHZs, as shown in Appendix 6, present us with varyingcomplexities of organizational structures in terms of: the number of structures
working within the framework of an integrated health system; the expanded
membership found at the provincial level and, the functions and powers inherent toeach structure.
Comparing the District Health Board of the different ILHZs shows stark differencesin the chairmanship of the board and composition of members. In some models like
the ILHZs in Bulacan and Negros, the Governor heads the board. On the contrary, the
LAHDZ board found in South Cotabato has designated the Sangguniang
Panlalawigan member as the chairperson of the board. A different case was alsoobserved in the Linawa Zone Health Board in Kalinga and the AULHS District
Health Board in Arayat. The chairmanship is rotated among the mayors involved in
the catchment area of the district health system.
District Health Board membership also varied depending on the institutional context
of each ILHZ. Some models of the ILHZ are jumpstarted with the help of a foreignfunding agency such as the BIARSP and AusAID through ICHSP. Hence, their board
membership included external agency representatives as board members. Those that
are locally initiated either by the regional health offices and/or by key persons in thehealth sector also had representation in the district health board.
The Guihulngan Model was locally initiated but was also heavily supported by a
foreign funding agency BIARSP. The membership to the board, was thus, madeavailable to the representative of the foreign funding agency. It also included a
Department of Agrarian Reform representative since BIARSP targets agrarian
communities as its beneficiaries.
The Kalinga Model, on the other hand, is also backed by AusAID through the ICHSP
that helped implement the subsystems of the district health system. This, however,has not affected the composition of the Linawa Zone Health Board and has
conserved its membership to the mayors of participating municipalities, SP and SB
board representatives, loc