By Marcus Tutert, University of Toronto
On November 22nd 2013, the fourth strongest typhoon ever recorded struck the Philippines, leaving devastation in its wake. Over a million residents have been left homeless while the death toll has climbed to over 5,000. In addition to this, a lack of effective healthcare provision from the Philippine government has left the region exceedingly vulnerable in the aftermath. Over the past couple of years, the Philippine policy of decentralization has left the country’s healthcare provision under the jurisdiction of smaller organizations. This policy was initiated because larger central bodies have historically lacked accountability and responsiveness. This article will explore this decentralization of healthcare within the Philippines, examine its potential strengths and address its most significant failings and how they contributed to the ineffective national typhoon response. Following that, the article will comment on the challenges involved with improving systems of care within developing nations as a whole, while assessing possible alternatives proposed by the global health community.
In the Wake of Typhoon Haiyan: Examining the Decentralization of Health Care Within the Philippines
The primary concern overall is the degree of autonomy within the decentralized system.
The pre-existing vulnerabilities in the system are an assortment of both geographic conditions and inadequate governmental oversight. The former is an immutable reality that creates dangerous conditions for the inhabitants of the Philippines. As an archipelago located in the Southeast region of Asia, the Philippines are composed of coastal lowlands, which are susceptible to harsh floods, torrential storms and typhoons.1 These natural phenomena strongly affect the population, resulting in adverse health effects such as illness from water contamination, increased spread of infectious diseases, and malnutrition.2
The pre-existing vulnerabilities in the system are an assortment of both geographic conditions and inadequate governmental oversight. A recent “Health Systems Review” done by the World Health Organization (WHO) in 2011 cited several critical issues related with the breadth of healthcare provided by the government to various sectors of the population.3 Large income inequalities have an impact on the geographic layout of urban housing. This layout forces those with low incomes to not only live in less developed housing, but also to reside in far more vulnerable regions.4 This is a substantial contributing factor to the high health inequity between income levels in the nation.5 Furthermore, populations living in vulnerable regions often require the most substantive health treatments, creating a large strain on the health care system. This arrangement leads to the adoption and development of new health practices that are limited to populations living in more developed regions.3
To remedy the vulnerabilities that exist within the healthcare system, the Philippine government has shifted to a far more decentralized form of health care. As a result, the formerly centralized operating branch known as the Department of Health (DOH) has begun to shift focus away from its formerly overarching public health mandate. Instead, the mandates are being assigned to specific Local Government Units (LGU) throughout the affected regions.6 In addition, the LGUs and the DOH now form a hierarchy of several specific task chains that collaborate with the private sector to produce further specialized and independent units. Some examples include Health Regulation Units and Rural Health Units.5 In addition to being in charge of local health systems, LGUs are responsible for enforcing and creating new policies and mandates that improve specific aspects of the overall health care system.7
In theory, the decentralization of a country such as the Philippines creates a far more fluid system. These organizations are better able to respond to local needs and are able to craft more specific policies. In particular, the Philippine system of decentralization was created to foster increasing amounts of autonomy for each LGU. This system allows each unit to retain an increased surplus of revenue that they can then put towards various health mandates10. These financial surpluses are critical. For example, they allowed the local government expenditures to increase by 10.7% in 1993 (during the process of decentralization), as documented by a recent study.5
It is also critical to note that significant problems stemmed from the decentralization of the nation’s healthcare systems. When such a high degree of autonomy is present in each of the newly formed groups, it is difficult to observe national policy. The LGUs began to make decisions based on what they felt was best for their own units rather than what is best for the country as a whole. For instance, in a study done by “Health Policy Planning,” it was demonstrated that each LGU possessed unique target goals that often remained mutually exclusive to the needs of the country itself.8 Furthermore, these goals are often tied to commercial profit. An important example of this arose when an LGU targeted the agricultural sector and other commercial marketing avenues to maximize profits. The decision went against the overarching mandates that food security for related LGU’s are of the utmost importance.5
Many solutions have been proposed not only to fix these problems in the Philippines but also to apply this concept of decentralization in a better form to other developing countries in similar circumstances. The primary concern overall is the degree of autonomy within the decentralized system. To remedy this issue, a more central organization body can be used to keep the agents more accountable for their actions and to establish broader operating mandates.7
This Philippine method of decentralizing the healthcare system can also be analyzed and evaluated as a possible model for other developing countries. However, a host of other potential problems may arise in its application. In countries outside the Philippines, the transference of power from a DOH to the LGUs may not be as effective, leading to delay in governmental action. For example, a study done in Ghana and Uganda found that the logistical issues and transference of power in these two states was difficult to overcome in the new system.5
A report by the European Observatory–a world-wide organization that examines health policy’s and mandates–suggests specific solutions to the problems of decentralization.7 With regards to the purview of smaller organizations, one accessible solution is to ensure that they maintain a strong relation with the central authorities. An alternative solution is a far more reduced form of recentralization. Systems should continue with a larger central body while limiting both the amount of LGU groups present along with the power they contain. This alternative strategy suggests that a complete decentralization of the system may not be ideal in the long term, and that the discretion of these smaller organizations must be reviewed and often times limited.
The process of decentralization is a long-term movement that fosters better individual health while allowing for a more fluid and dynamic response system when done effectively. Although there are issues with decentralization, the Philippine system is making steady strides towards an improved health care system, ensuring the safety and health of its citizens into the future.
- Perez R, Amadore L, Feir R. 1999. Climate Change Impacts and Responses in the Philippines Coastal Sector. Climate Research. 12: 97-107.
- Ahern M, Kovats, R, Wilkinson P, Few R, Matthies F. 2005. Global Health Impacts of Floods: Epidemiological Evidence. Epidemiologic Reviews. 27: 36-46.
- Romauldez A, Frances J, Flavier J, Quimbo S, Hartigan-Go K, Lagrada L, David L. 2011. Phillipines Health System Review. Health Systems in Transition. 1(2).
- Tran T, Tran P, Tuan T. 2012. Review of Housing Vulnerability: Implications for Climate Resilient Houses. Discussion Paper Series.
- Bossert T, Beauvais J. 2002. Decentralization of Health Systems in Ghana, Zambia,Uganda and the Philippines: a Comparative Analysis of Decision Space. Health Policy Planning. 17(1): 14-31
- Healy V., Gorgolon L, Sandig E. 2003. Overview of Devolution of Health Services in Philippines. Rural and Remote Health. 3(2): 220.
- Bankauskaite V, Vrangbaek K, Saltman I Decentralization in Health Care: Strategies and Outcomes. Maidenhead: Open University Press, 2007.
- Legaspi P. 2010. The Changing Role of Local Government Under a Decentralized State: The Case of the Philippines. Public Management Review. 3(1): 131-139.