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ASIAN JOURNAL O F PUBLIC ADMINISTRATION VOL. 18 , NO 2 (DECEMBER 1996): 168-200

EVOLUTION OF THE PH ILIPPINE HEALTHCARE SYSTEM DURINGTHE LAST FORTY YEARS O FDEVELOPMENT ADMINISTRATION

JOAQUIN L. GONZALEZ III

This article discusses the influence of the evolving development administrationemphases - centralisation and decentralisation to health care delivery in thePhilippines during the last four decades. It shows how prescriptions during the1950s an d 1960 s led to the creation of a centrally planned Philippine health caresystem. The dysfunctions of this centralised system m otivated development admin-istration specia lists to call for decen tralisation in the 1970 s. Initial attemp ts atdecentralisation were mainly functionally and structurally-oriented, that is, thehealth care bureaucracy was reorganised and streamlined to ensure improvedprogramm e implementation especially at the local comm unity level. However, thelimitations of structural decentralisation created the demand for process decen-tralisation efforts an approach which concentrates on more social-behaviouralchanges and active stakeholder participation. Process decentralisation was usednot only to improve implementation but also to ensure sustainability. Governm entalandnon-governm ental organisations of the 1980s andearly 1990s have emphasisedthis dimension of decentralisation as manifested in their projects and programm es.

introductionDevelopm ent adm inistration is an emerging interdisciplinary field ofscholarly research. Although some academics argue that the practiceof development administration could be traced as far back as thehistory of man on this planet, the available literature indicates that the

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Philippine Health Care System

integrated and systematic study of this field began to flourish onlyafter W orld W ar II. Th is was a period in history when most nations,rich and poor, initiated systematic programm es of economic deve lop-ment and social and political change . Being a multidisciplinary field,the study of development administration has evolved with conceptualinfluences from a variety of established disciplines (for example,economics, geography, management, sociology, psychology, politi-cal science, health, biology, and engineering). An analysis of develop -ment administration theory has revolved over three rather distinctapproaches each with its own theoretical underpinnings and eachwith its own concepts of success and failure. Since developmentadministration is closely tied to concepts of political economy, botheconomists and political scientists have played a role in defining thescope and focus of this process.

This article discusses the general theoretical interrelationships ofkey development administration approaches and their impact onPhilippine health care effectiveness during the past forty years. Thesethree concepts are:1. the centralised planning approach;2. the decentralised structural approach; and3. the decentralised process approach.

This article concludes with some conceptual and practical con-straints on which present and future public health care managers andproviders should reflect.Centralised Planning ApproachJustifications for Centralisation1. Economic imperativeBased on the linear growth theories (for exam ple, the Harrod-Dom arM odel and the Rostow M odel), development econom ists argued that

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Asian Journal of Public Adm inistration

planned change was more or less considered to be synonymous withcapital formation. Developm ent experts believed that once capital isaccumulated and reinvested, it would increase production and em-ploym ent, which w ould also raise the incom e-generating capacity ofthe population in general.1The planned economic growth system prescription is supported bydevelopment economist Amartya Sen who identified similar policythemes as the proper approach to the problem of development,including: industrialisation; rapid capital accumulation; mobilisationof underemployed manpower; and planning and an economicallyactive state.2Sen, among others, argued that centralised developm ent throughindustrialisation is definitely important if any Third W orld economyis to accum ulate capital and to emerge from its backwardness. Accord-ing to mainstream development econom ists, capitalist profits are themain source of rapid capital accumulation. If an unlimited supply oflabour is available at a constant wage, then the rate of profits on capitalwould not fall. If any part of the profits is reinvested in productivecapacity, profits w ould grow con tinuously. Capital formation wouldalso grow continuously and development w ould then take place rathernaturally. Moreover, besides rapid capital accumulation, there mustalso be the existence of an en trepreneurial class willing to invest andcontrol accum ulated capital in industrial activities.3 Mainstream writ-ers believe these preconditions must be satisfied to propel a ThirdWorld nation's economic development efforts.

According to these same developm ent w riters, the establishmentof an active state and a system of centralised planning is needed toovercom e the dysfunctions associated w ith "late industrialisation."4Because most Third World countries lack an industrialised sectorrelative to the advanced developed countries, it is believed that astrong state apparatus is needed to protect the interests of the indig-enous capitalist class. Indeed, a large part of the industrialisationprocess would be carried out and financed by the state itself. Yet in thecase of most Third W orld societies, the state was perceived to be m orean instrument of foreign capital and its local surrogates.

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2. Dependency perspectiveAndre G under Frank, Johan G altung, Enzo Faletto, Paul Baran, andFernando C ardoso argued for a Neom arxist perspective for stimulat-ing development. Frank's research findings on Latin America em-boldened him to argue against Sen and the other mainstream develop-ment economists along the following lines:

unde rdevelopm ent and undevelopm ent are two different conceptsbecause the presently developed coun tries were never und erdevel-oped, though they may have been undeveloped;underdevelopment is not an internal condition;the mainstream thesis of a dualist society put forward by ArthurLewis and stages of linear economic growth proposed by WaltWhitman Rostow and Harrod-Domar are false;

- contem porary unde rdevelopm ent is in large part a product of pastand continuing economic, political, and social relations betweenthe underdeveloped satellite and the developed m etropolitan coun-tries; andsatellites have been observed to develop faster w hen their ties withthe metropole (highly developed countries) are weakest.5

Frank concluded that development would be most effective if thesatellite "delink s" itself from the metropo le. For Frank, the m echanicsof how to effectively delink is the main issue in each Third Worldnation because each of them has different degrees of political, eco-nomic, and social links with the metropole. Compared to Frank'sNeomarxist prescription, a classical Marxist would probably seedomestic social revolution as the initial step to delinking.Despite their differences, it seems that development economistsfrom the mainstream, N eomarxist, and classical Marxist perspectivesall agree that a centrally planned economic system is necessary topropel development.

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Asian Journal of Public Administration

3 . Administrative SynthesisIn the 1960s, the goal of development adm inistration all over the worldwas based upon planned economic growth.6 In separate studies,M ontgom ery and Milne noted that if developm ent w as to occur it wassupposed to be manifested as planned changes in the economy (inagriculture or industry, or the capital infrastructure supporting eitherone) and, to a lesser extent, in the social services of the nation-state(especially education and public health).7 Several authors followedwith their own parallel arguments on the need for a centrally planneddevelopment administration. Friedman argued that planned changeshould include two components: the implementation of p rogrammesdesigned to bring about modernity; and changes within an administra-tive system which would increase its capacity to implement suchprogrammes.8

Inayatullah argued that development administiation is supposedto be carried out with a heavy emphasis on planning by publicauthorities in order to succeed in attaining socio-econom ic goals andnation-building.9One of the leading authorities during the 1960s, Fred Riggs arguedthat long-term development changes are the result of collectivedecisions organised in a cohesive plan and implemented through awestern-oriented system of administration.10According to G. Starling, development planners used this capital

accumulation-based economic growth plan to survey current eco-nom ic conditions and the social situation; to evaluate preceding plans;to state new objectives, estimates of growth, suggested measures toraise growth rate; and produce a revised programme of governmentexpenditures.11Predominant Management SystemAs implied by the discussion above, the most common developmen tmanagement system prescribed by development experts to comple-ment this economic objective w as the utilisation of strong centralisedcontrol and supervision over all development endeavours through thenation-state 's adm inistrative bureaucracy. The centralisation of gov-

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em inent refers to the dom inant role taken by the central, as opposed tothe local, administrative units (for example, m unicipalities and villagecom munities). Cen tralisation manifests itself in the governm entalbureaucracy adopting the roles of revenue collector, distributor offinancial aid to local units, creator of standards to be followed by localgovernments, and implementor of services throughout its territorialjurisdiction by means of central government officials. Strong execu-tive leadership frequently complements these centralisation traits.12Development administrators believed that using this centralised man-agement system would enable countries, which had just gainedindependence from their colonial masters, to harness their scarceresources towards the goal of acquiring much needed capital. Inaddition, centralisation of control was prescribed by internationalfinancial institutions as part of their assistance package towardsmodernisation. Policy-makers in these international financial institu-tions thought comprehensive national planning orchestrated by thestate would direct the resource-allocation of the country into appropri-ate investmen t a reas. Some of the investment areas they had in m indwere: export-oriented industrialisation, import-substitution industri-alisation, agricultural exports, and raw materials export.13

Centralisation in the PhilippinesA centrally planned economic system was already in place in thePhilippines as early as the 1600s. The Spaniards were the first toestablish an administrative system that unified the Philippine Islands.Through the traditional hacienda system, the Spaniards establishedmassive plantations that produced coffee, sugar, and spices for con-sumption in Europe. Spain utilised this economic system to exploit theresources of the Philippines until the late 1800s.

After losing the Spanish-American W ar, Spain w as forced to cedethe Philippines to the United States under the Treaty of Paris in 1898.The Am ericans continued the concept of a centrally planned econo micsystem, focusing how ever on their own interests. The A mericans sawthe Philippines as a source of raw materials and a market for A meri-can- finished products. In addition, the Philipp ines was established asa base for penetrating the growing Asian markets in China, Japan,173


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India, and the Middle East. The U nited States lost the Philippines toJapan during the Second World War. Under the Japanese , the centrallyoriented econom ic system in the Philippines w as again used to channelmuch needed resources to another nation.On July 4,1 946, in accordance with the provisions of the Tydings-McDuffie Independence Act, the Philippines was granted independ-ence by the United States of Am erica. Filipino adm inistrators foundthemselves faced with responsibilities far greater than they hadenvisioned. The Second World War had left the Philippines withsevere economic and physical destruction. Within months after thedeclaration of independence, Filipinos found themselves requestingdevelopment assistance from the United States.In 1950, the Philippines asked the United States to send a surveymission "to recomm end m easures that will enable the Philippines tobecome and to remain self-suppo rting."14 In response to this request,the American government sent a team of elite consultants headed byDaniel Bell. The Bell mission provided a very d ismal picture of theeconom ic and political realities of the Philippines. The Bell m issionmade numerous recommendations in response to this post-War situ-ation. Following the logic of the current thought on administrativereform, they recommended the revival and enhancement of the cen-tralised administrative system, which was established before thegranting of independence. The Bell mission noted that the Philippinesinherited from their American colonisers a "reasonably well-organ-ised administration and a well-trained civil se rvice," but the war andthe disarray that followed made it difficult to restore the administrativeefficiency it used to enjoy.15 A centralised administrative bureaucracyrecommended by the Bell mission would facilitate the political andeconomic rebuilding of the country. Based on these recommenda-tions, the Philippines adapted a planned economy heavily gearedtowards the exportation of agricultural products and raw materials.The trade-off for development financing to the Philippines was theestablishment of American military bases in selected strategic loca-tions around the country.

Politically, the Philippines responded to the Bell mission recom-mendations by establishing the Government Survey and Reorganisa-tion C omm ittee (GSRC) under the Philippine Republic Act No. 997.174


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The G SRC was tasked w ith the recentralisation of the administrativebureaucracy based on the specifications it had before the Japaneseoccupation of the Philippines. The G SR C conducted evaluations andmade organisational adjustments to governm ent agencies pertainingto agriculture and natural resources, commerce and industry, eco-nomic planning, education and culture, health, labour, public worksand communications, revenue system and statistics, and allied re-search.

This marriage between centralisation and planned developmentwas clearly manifested in the high priority given to the reorgan isationof the National Economic Council,16 the central planning body of thePhilippine government.17 The prescriptions of development expertsfor reforming the Philippine administrative system clearly reflectedthe dominant trend in Am erican public adm inistration, w hich was thecreation of a W eberian notion of bureaucracy. In addition, the GS RCsubdivided the country into eight geographic regions: Region I(Dagupan City); Region II (Tuguegarao, Cagayan); Region III (Ma-nila); Region IV (Naga City); Region V (Iloilo City); Region VI (CebuCity); Region VII (Zamboanga C ity); and Region VIII (Davao City).The guiding principles of the National Economic Council were usedas the main blueprint for developm ent planning in the various regiona ldevelopment bodies that were created. These regional developmententities were the Mindanao Development Authority and the CentralLuzon Cagayan Valley Authority (both organised in 1961); theHundred Islands Conservation and Development Authority (1963);the Panay Development Authority (1964); the San Juanico StraitsTourist Development Authority (1964); the Mountain Provinces De-velopment Authority (1964); the Mindoro Development Board, theBicol Development Company, and the Catanduanes DevelopmentAuthority (1965); and the Laguna Lake Development Authority(1966).18 Each was highly centralised and structured to reflect thelogic of modern public administration theory.

The recommendations for the establishment of a reorganisedcentral administrative structure affected all government departmentsincluding the Department of Health. Based on this planned deve lop-men t model prescribed by the Bell mission and adapted into law by thePhilippine legislature, the Department of Health established a system175


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of hospital-based health care administered by and accountable to thehead office in Manila.A major part of this centralisation plan was the creation ofPresidential Sanitary Divisions which sought to extend the adminis-trative grasp of policy-m akers to a num ber of presidentially selectedrural areas. M anila-trained public health professionals w ere quick toreject local health systems in the rural areas as primitive and ineffec-tive labelling traditional village-level healers as "quacks" whooften did more harm than good through their "herbal concoctions and

cures." The D epartment of Health presented alternatives to the tradi-tional health system by dispatching medical professionals who pre-scribed drugs manufactured in the W est. Unfortunately, as thepopulation grew, the demand for health services also expanded. TheDepartment of Health then found itself unable to keep up with thedemand for more medical professionals and western medicine be-cause people with even minor ailments travelled great distancesdemanding to see a doctor in the government hospital. On top ofbedside duties, public health professionals in this centralised healthcare system were also laden with adm inistrative responsibilities likeplanning, budgeting, and personnel managem ent.19

In the late 1950s, Presidential Sanitary Divisions were slowlyreplaced and renam ed Rural Health Units (RHU ). Rural Health U nitswere established in every municipality. The Department of Healthintroduced the health team approach in each Rural Health Unit.Distinct but complimentary roles were assigned to a Rural Health U nitteam composed of a public health doctor, a public health nurse, andparaprofessionals (for exam ple, midw ives and sanitary health inspec-tors). This new system authorised public health nurses andparaprofessionals to deal with simple cases requiring immediateattention and to educate the community on healthy habits and prac-tices.20The public health physician was required to deal only with the

most demanding and difficult cases aside from his administrativeduties.Further consolidation of the Department of H ea lth's control overthe adm inistration of rural health care services w as implem ented in thereorganisation of 1958. Instead of creating more autonomous units,

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the reorganisation of 1958 increased the centralised power of thehealth bureaucracy by adding more national-level staff and adminis-trative, regulatory, and advisory bodies. The full implementation ofthe reorganisation plan was completed in the 1960s. Instead ofdecentralising its administrative responsibilities, the reorganisation of1958 further consolidated the supervisory and administrative powersof the Department of Health through bureaucracy-related structuralchanges, that is, creation of new units and removal of offices withduplicating functions.21

With the exception of the creation of regional offices, theseorganisational reforms only reinforced the central planning functionof the Manila-based health bureaucracy. These offices also createdadditional bu reaucratic cond itions for field o perations to pass through .Some of the reforms were changes only in agency name but did notaffect the service-delivery and operation-effectiveness of the office,e.g., the Bureau of Research and Laboratories was renam ed the PublicHealth Research Laboratories same dog, new collar. Even thecreation of regional offices was not enough to bring health care serviceplanning and implementation closer to the people in the villagecommunities. The main beneficiaries of these reforms were politi-cians and bureaucrats who were able to use the newly created positionsin the Manila office as political rewards. Additional organisationalchanges between 1958 and 1969 again reinforced the centralisation ofplanning and administration in the Department of H ealth.22As in the case of previous reforms, organisational changes duringthis centralised development period streamlined the planning opera-tions of the bureaucracy but showed only symbolic concern for fieldoperations. They remained oriented towards the prescriptions ofpublic administration for the use of an effective centralised W eberianbureaucracy.

Outcome of the Central Planning ApproachThis period of planning-oriented development characterised by acentralised and top-to-bottom planning and managem ent process hadlittle effect on people at the village community-level. Based on centralplann ing principles, practitioners and scholars of development admin-

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istration during the 1960s assumed that the careful anticipation of thevillage community's problems and the meticulous application of thecentral government's prescriptions would lead to success. If imple-mentation failed it was blamed on the beneficiaries' negligence infollowing procedures that were carefully described in the initialproject blueprint.23 The people at the national level assumed that theyknew what was best for the people at all levels of the political system ,from the nation-state to the village com munity-level.24 Practitionersof planned development adopted the following simple procedures toproject design:1. identified the mistakes in former blueprints;2. prepared contingencies ahead of time;3. laid out a plan that incorporates the contingenc ies; and4. accomplished the goal.25

Unfortunately, centrally planned developm ent did not lead to theexpected capital accumulation and rapid econom ic growth in a signifi-cant number of less developed countries. One reason was the preva-lence of the self-interest of those adm inistering the econom ic devel-opment plans under the centralised system. Another reason w as thatdifferent interpretations of these national plans led to conflicts overhow to implement development efforts. T he most glaring fact was thatinstead of alleviating the problem of resource inequity, the gapbetween a small rich minority and a larger poor majority widened.Quality health care remained within the reach of only the p rivilegedsegment of the population who lived in metropolitan Manila. Inaddition, the implementation of the central government's develop-ment plans at the local level met heavy resistance especially from thevery people they were supposed to assist. The carefully laid outprogramme and project plans met failure especially when it came tovillage-level implementation.

As demonstrated by development strategies in general and thePhilippine health care experience in particular, the predominantly178


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centralised management approach used during this period did notallow for participation by the lower units in development planning.Th is in effect limited the implementability of developm ent activities.W ithin the Department of H ealth, implementation of health careservices at the village comm unity-level was hampered by the concen -tration of manpower in the central office in Manila and other urbancentres. This arrangement existed notwithstanding the fact that 80 percent of the population lived in the rural areas. The creation of regionaloffices in 1958 did not provide for delegation of functions andauthority. A heavy concentration of administrative du ties and respon-sibilities (for example, appointments, leave matters, promotions,teaching perm its, and overtime services) was still found in the M anilaCentral Office. The health problems of the 1970s were not muchdifferent from the 1950s.Decentralisation Structural EmphasisShift in Focus of Development Adm inistrationDevelopment experts believed that a solution to the dysfunctionsassociated with planned development through a highly centralisedadm inistrative system is to decentralise the bureaucracy. The problemof implementing plans through a centralised development approachhas led to a call for a more decentralised administrative approach todevelopm ent adm inistration. In one of his studies, Denn is Rondinellisummarised a plethora of arguments for a more decentralised ap-proach to planning and implementation, including:1. Decentralisation affords greater authority for deve lopm ent plan-ning and management to officials who are working in the field andhence closer to the problems.2. Decentralisation cuts through the enormous amounts of red tapeand the highly structured procedures.3 . Decentralisation allow s greater representation of various po litical,religious, ethnic, and tribal groups in development decision-making.

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4. Decentralisation increases administrative capability among localgovernm ents and private institutions in the regions and provinces;and5. Decentralisation institutionalises the participation of citizens indevelopment planning and management.26

In order to increase the likelihood of implementation, develop-ment experts of the 1970s concentrated their decentralisation ap-proach on prescribing ways and means aimed at reorienting thestructure and function of the governm ental bureaucracy as evidencedby R ondine lli's enum eration above. This type of decentralisation wasthe same response provided by Am erican public administrators duringthe debureaucratisation efforts of the United States in the 193 0s and1940s.27 A major reorientation of the structural and functional pre-scriptions was supposed to make the administrative system moreeffective in implementing development plans especially at the com-munity level. The reoriented organisational structure should allowparticipation in the decision-making process by field personnel andtarget beneficiaries. This was assumed to be the key to successfulimplementation.

There are basically four major types of structural reorientationsadvanced in the decentralisation literature: deconcentration, delelation,devolution, and privatisation.28 The first three pertain to differenttypes of structural bureaucratic reforms used to decentralise whereasthe fourth refers to non-governmental alternative delivery systems(for exam ple, PV Os , NG Os , IGO s). It was argued that the use of non-governmental entities helps alleviate some of the lesource inadequa-cies of the governmental bureaucracy. These non-traditional, non-hierarchial, non-governmental entities were expected by developmentexperts to increase the prospec ts of project and programm e im plemen-tation because of their simple and flat organisational structure, whichwas conducive to beneficiary involvement in the decision-makingprocedure.Predominant Management SystemDuring the 1 970s, experts and scholars who advocated im plementable

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developm ent assum ed that because planning was always carried out atthe top, development administration problems were the result ofinefficient and ineffective management by higher echelon depart-ments supervising offices at the local levels (for exam ple, departmentsof agriculture or ministries of planning). The participation of themem bers of the bureaucracy, especially those in the field offices, wasmissing. The most common solution was heavily influenced by theexperiences of the western democracies decentralise the highlycentralised planning system of the state.29 Decentralisation as a m eansfor organ isational reorientation (or reorgan isation) w as a solution thatdevelopment administrators learnt from the developed nations, andthey readily adap ted this solution for the eradication of o rganisationalbarriers to development in the less developed countries.

It gradually became evident that development administrationmanagers becam e much m ore effective to the extent that they adopteda more decentralised approach to decision-making and were open tothe various contextual variables often outside their control. Some ofthe contextual variables that projects face are political changes,natural disasters, and economic factors. Project managers with eventhe best laid-out plans could not foresee all the problems related tothese areas: financing, personnel, management, infrastructure, andcommunity participation.30Structural Decentralisation in the PhilippinesDespite the centralisation of planning for effective developmentadm inistration, the Philippines continued to deteriorate politically andeconomically. Graft and corruption permeated Philippine politics.M oreover, the creation of additional personnel positions in the cen traladm inistrative system w as used by politicians as a place for politicalrewards. The centralised economic development plan, which gearedthe economy towards the exportation of raw m aterials, was not enoughto deal with the balance of trade deficits created by the heavyimportation of consumer goods and finished products.

The leading causes of mortality during the 1 950s and 1 960s werepneumonia, tuberculosis, heart disease, gastroenteritis and colitis,disease of the vascular system, avitaminosis and other nutritional181


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deficiencies, accidents, malignant neoplasm, bronchitis and asthma,tetanus, and diseases of early infancy. The leading causes of morbidityduring the 1950s and 1960s were influenza, gastroenteritis and colitis,tuberculosis, pneumonia, m alaria, measles, whooping cough, dysen-tery, malignant neoplasm, tetanus, mental disorder, accidents,bronch itis, heart disease, vitaminosis and other nutritional deficien-cies, and diseases of the vascular system. According to health experts,these diseases and illnesses are easily preven table w ith proper im mu-nisation programmes and improved sanitation.31

On September 9,19 68 , President Marcos signed into law RepublicAct No. 5435. This Act provided for the creation of a PresidentialCom mission on Reorganisation (PCR), a join t executive and leg isla-tive body. The PCR was given the task of developing an IntegratedReorganisation Plan. The final Integrated Reorganisation Plan for theexecutive bureaucracy was to be approved by the President. Unlikeprevious attempts at administrative reorganisation, w hich only furthercentralised decision-making and resource control, the IntegratedReorganisation Plan sought to decentralise the Philippine politicalsystem.The Integrated Reorganisation Plan received critical reviews frommembers of Congress and government administrators despite repre-sentation from the academic, private, and government sectors. Bu-reaucrats objected because the merging and abolition of overlappingand redundant positions would displace many of them. Legislatorswere afraid that the number of political appointments which theycould use as political rewards would be reduced.Upon the declaration of Martial Law on September 21, 1972,President Marcos abolished the Philippine national legislature. Withthe abolition of Congress, President Marcos issued Presidential De-cree No. 1, the first major administrative reform measure undermartial law. Presidential Decree No. 1 mandated a review of theIntegrated Reorganisation Plan for implem entation during the martiallaw period.The 1972 Reorganisation Plans impact was felt mostly at theregional level. Under this reorganisation plan, regional health officeswere established in the newly created regional subdivisions of thecountry. Each region had a designated regional center in the twelve

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major cities of the Philippines. According to Alex Brillantes, "theInter-Agency Com mittee that made the subdivision proposa ls tried todefine relative homogeneous areas, capable of stimulating and sus-taining efforts, not only on the basis of adm inistrative consideration ,but also with respect to geographic, economic, and cultural factors."3 2The reorganisation plan also authorised the regional directors, inline with the policy of decentralisation and within the jurisd iction ofthe regional office, to take final action on matters pertaining tosubstantive and administrative functions of the agency.In an effort to decentralise their administrative and resourcecontrol over village com munity-level units, the Department of Healthin the late 1970s and early 1980s introduced the following pro-grammes: the Restructured Rural Health Care Delivery System(RRHCDS); the Medical Care Program; the Rural Health PracticeProgram me; the Comm unity Med icine Focus of M edical and NursingSchools; and the Community-Based Health Programme.3 3

1. Restructured Rural Health Care Delivery System (RRHCDS)The RRHCDS was implemented in 1975 as part of a World BankPopulation Programme. The most significant contribution of theRRHCDS Programme was the creation of Barangay Health Stations(BHS). Barangay Health Stations are the first line of health careavailable at the village community-level. They are staffed by agovernment-trained midwife and other barangay health workers.Through the financial support of the RR HCD S, the health structureshousing the BHS were also constructed.2. The Medical Care Programme (MEDICARE)According to the primer of the Philippine Medical Care Commission,the M ED ICAR E programm e w as envisioned "to provide the peoplewith a practical means of helping themselves pay for adequate m edicalcare."3 4 This programme assisted in the construction of hospitals inthe far flung a reas of the country. Although its main beneficiaries arelimited to the employed and their families, the MEDICARE Pro-gramme created access to hospital-based health care facilities for therural areas.3 5

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3 . The Rural Health Practice ProgrammeIn order to respond to the growing need for health care in the ruralareas, the Philippine governmen t made rural health service a manda-tory requirement for all medical and nursing graduates before rece iv-ing their professional licences. The volum e of manpow er injected intothe rural areas helped ease the burden on the Department of Health.However, Carino noted that "questions have been raised in otherstudies as to its effectiveness, efficiency, and effects on the mo rale ofregu lar personnel and efficacy as a training tool for underboard nursesand medical doctors."3 64. The Community medicine focus of medical and nursing schoolsPioneered by the Rural Health Programme of the University of theEast-Ramon Magsaysay Memorial School of Medicine in 1964,Philippine medical and nursing schools created programmes thatstressed preventive and social medicine and rural medical practice.These medical and nursing schools emphasised heavy implementa-tion of the pregraduation requirement of rural health practice. Theyalso made curriculum changes that aimed at placing m ore attention onPhilippine medical problems. In addition, a Bachelor of ScienceDegree in Rural Medicine was introduced at the University of thePhilippines-Tacloban City. A rural practice internship at the nearbyCarigara area was the highlight of this programme. The programmecombined features of community-based health care programmes andthe community medicine approach utilised by the regular medicalschools.5. The Community-Based Health Programme (CBHP)In the early 1970s, the CBHP approach was endorsed by both non-governm ental and governmental organisations as their contribution tobringing health care closer to the rural areas. This approach prom otedthe use of multi-function village health workers who administer firstaid, teach health education, provide sanitation attention, and serve asthe frontline staff dealing with people w ith minor ill nesses. Under this

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approach , health w as seen only as a part of an overall village deve lop-ment package. Hen ce, village health workers also facilitated com mu-nity organising and impart incom e-generation skills to members of thevillage community. Victoria B autista enumerated several individualswho promoted pilot projects targeting specific rural areas using theCBHP approach (for example, De La Paz with the Katiwala Pro-gramm e in Davao C ity, Viterbo of Roxas C ity, Macagba of La Union ,Flavier of the Philippine Rural Reconstruction M ovem ent, C ampos ofthe University of the Philippines Com prehensive Community H ealthProgramme, Solon of the Paknaan Cebu Institute of M edicine Project,and Wale of Silliman University).37 In addition, Galvez-Tan notedthat attempts at replicating this programme nationally was prom otedby the Rural Missionaries of the Philippines.38 Other religious groupslike the National Council of Churches in 1977 and the AKAP in 1978followed suite with their own nationwide applications of the CBHPapproach. These groups applied almost similar types of participationapproach towards the institutionalisation of an appropriate healthservice delivery system.Decentralisation Process EmphasisIncluding C oncern for Process in D ecentralisationThe 1970s saw a shift in concentration from planning to the effectiveand improved implementation of the development plan at the lowerunits of the administrative system. Proponents of developm ent adm in-istration discovered that even the best designed development blue-prints were susceptible to failure especially if carried out in a central-ised and autocratic fashion. The completion of developm ent activitiesat the lowest level of jurisdiction became the main focus of thisimplementation-oriented period. The development activity was la-belled a success if the effective start-up of the programme or projectcould be effectively completed.3 9

Management experts in the developed countries learned later thatthe structural and functional changes proposed in structural decen-tralisation were effective only in advancing peripheral changes (forexample, eliminating overlapping activities and duplication of func-18 5


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tions). They did not deal with the issues of effective impact andefficient use of resources.40 It quickly became apparent that a neworganisational structure free from these duplications and overlappingproblem s did not guarantee changes to the dysfunctional behav iour ofpeople inside the central ministries and governmental agencies.Development experts saw that structural decentralisation some-what increased the prospects of project implementation but did notnecessarily ensure the effectiveness or the sustainability of projectsand programmes. Based on the Philippine findings, researchers con-

cluded that it was not enough to create channels for participationbecause the process of interaction was still cooptive, manipulative,and at most only consu ltative. How superiors and subordinates shouldinteract in a genuinely participatory m anner within the decentralisedstructure, as well as how much a governm ent system should interactwith local com munities, was still a major issue. Clearly a concern forthe institutionalisation of behavioural changes and the hum an d imen-sion of decen tralisation required reform both w ithin the administrativesystem and also in the linkage m echanism between bureaucracies andcommunities.Development experts agreed that a social and behavioural modi-fication, or process reorientation, was necessary to complement thestructural aspect of decentralisation. Once the human dimension ofdecentralisation was in place, it was assumed that projects andprogrammes would become more implementable and sustainable.

During this development period, Philippine development expertsassumed that an emphasis in creating a decentralised and participatorystructure would improve planning and increase implementability.Management System Under a Decentralised Process ApproachAs advocated by developm ent experts of the 1980s, process decen-tralisation is the institutionalisation of participatory modifications onthe traditionally non-participatory processes perpetuated by govern-mental bureaucracies. The theoretical descent of process decen tralisa-tion in development management could be traced to the debatebetween the Weberian-inspired school of management and the re-sponse by organisational humanists.

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The Weberian-inspired centralised approach was seriously chal-lenged in theory and practice by authors who subscribed to theorganisational humanist school of managem ent.41 Herbert Simon andRobert Dahl criticised the advocates of the classical approach tomanagem ent for prom oting a "scientific" and value-free paradigm ofdom estic and international administration. Moreover, arguments basedupon Weber's bureaucratic model were also criticised by RobertMerton as having psychosocial dysfunctions.42

The advocates of the human relations school of managementargued that there is no such thing as a rational and value-free approachto management since the interpretations of rationality and valuesvaried from person to person and culture to culture. Structural andfunctional reforms remain successful only in the short run becausestructural and functional reforms pay only lip service to the humanbeings inside the organisational charts and boxes. Project beneficiar-ies are always perceived as a hindrance to developm ent instead of afacilitating force of change. These criticisms and shortcomings oflogical positivism and Weberian-inspired development administra-tion practices were carried over into the implementation decade ofrural development. It was time to propose a more radical change.

Advocates for a more humanist approach to managing organisa-tions lambasted the "principles" advocated by the W eberian-inspiredschool of managem ent as mere "proverbs" and an exercise in Sim on 's"architectonics." 43 The humanist school of management presentedsuch alternatives to the positivist-oriented approaches as managementby objectives (MB O), linking pin, quality c ircles, job redesign, clarityof goals, T-groups, contingency m anagement, m otivation techniques,organisation developm ent (O D), job enrichment, and participativemanagement.44 These techniques are based on the interaction proc-esses and interpersonnal relations of individuals and groups insideorganisations.

Using these human relations school prescriptions involves goingbeyond the structural adjustments advoca ted by Rondinelli and otherdevelopment experts as enumerated in the previous section. Ideally,process decentralisation should be used together with the structuralrearrangem ents and functional redescriptions described earlier. Usingthis combined approach ensures that local units will institutionalise187


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participation. This, combined with a strengthened local resourcemobilisation, would lead to sustainability at the village community-level. Hence, the ultima te goal is to create the appropriate interaction,collaboration, participation, and involvement to complement thereorganised organisational structure.

Development proponents from donor and recipient countriesem ployed approaches patterned after these more hum anist techniquesto help in the effective planning , implem enting, and sustaining of theirdeve lopm ent efforts. B ased on the activities of this period, sustainabledevelopment essentially became human development.These behavioural changes were applied not only in the bureauc-racy but also in the service-delivery field units. The role of thestructurally decentralised grassroots units in policy-making was in-creased through community participation and organisation schemes.Participation as an institutionalised behaviour was assumed to raisethe level of com mitment by the beneficiaries, thus encouraging themto seek w ays and means to sustain the project. Both governmental andnon-governmental groups immersed themselves in making theirprojects participatory not only in structure but also in process.Decentralised Process Approach in the PhilippinesStructural changes in Philippine health care continued until the 1980sbut they were no longer central to decentralisation reforms. Thehighlight of the 1980s was the adoption of primary health care all overthe world. Primary Health Care was essentially a call for sustainablehealth development through behavioural changes (for example, com-munity participation and active beneficiary and proponent collabora-tion). This shifted the em phasis of decentralisation from a structuralfocus to a more process orientation.

In 1977, the Alma Ata conference sponsored by the W orld H ealthOrganisation (WHO) formally mandated the international goal of"Health for A ll by the Year 2000" (HFA). The goal of "Hea lth for Allby the Year 2000" could be traced back to the Constitution of theWorld Health Organisation, which was adopted in 1946. It took theWHO more than thirty years to actually formalise a programme thatdealt with the issue of sustainability. This delayed reaction was similar

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to the OE C D 's late response to sustainability w hich had been in theOEC D Constitution since 1961.45 The international delegates presentat the conference agreed that Primary Health Care was the key toachieving this long-term ob jective. The framers of the HFA Declara-tion envisioned Primary Health Care to be:

an approach that recognises the inter-relationship betweenhealth and overall socio-economic development. It aims toprovide essential health services that are community-based,accessible and sustainable at a cost which the commun ity andthe government can afford through community participationand active involvement. Ultimately, it aims to develop a self-reliant people, capable of achieving an acceptable level ofhealth and well-being.46 (Italics provided).As opposed to prev ious strategies that concentrated on presc ribingstructural decentralisation of the bureaucracy and its parts , this state-

ment clearly implied that health care projects under the PrimaryHealth Care programm e w ere to be grounded on sustainability throughcollaboration, interaction, and involvement at the com mu nity-level.In response to this, the Philippines together with the internationalcom munity of nations redefined their health care approaches tow ardsthe achievement of "Health for All by the Year 200 0."

Primary Health Care and Participation in the PhilippinesThe health problems of the 1960s and the 1970s did not changesignificantly. The leading causes of morbidity in the 1 970s con tinuedto be acute respiratory infections, diarrheal diseases, tuberculosis,malaria, skin infections, and enteritis. The leading causes of mortalityin the 1970s also remained: pneumonia, tuberculosis, bronchitis,diarrhea, health d isease, malignant neoplasms, and accidents.47

Solutions to these health care problems w ere hampered by variousadministrative and resource constraints including the problem ofinsufficient funds; the lack of medical and paramed ical manp ower; theinefficient use of scarce health serv ices availab le; and the lack ofcommunity support for health programmes.189


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With this backdrop in mind, President Marcos issued Letter ofInstruction 949, mandating the implementation of the Primary HealthCare approach throughout the country starting in 1981. PrimaryHealth Care offered a new perspective different from the hospital-based western health care models which proved to be ineffective inless-developed countries like the Philippines. A national coo rdinatingcouncil for primary health care headed by the Depiirtment of Healthand other concerned departments (for exam ple, Food and Agriculture,Social Service, Natural Resources) was immediately established. Thiscoordinating council was duplicated in the different adm inistrativeregions, provinces, municipalities, and villages of the country. In1981, President Marcos declared a new Philippine Republic andordered the implem entation of the revised Integrated ReorganisationPlans of all departments subject to his approval. In addition, hechanged the Philippine adm inistrative system from a presidential to aparliamentary model. Hence, all government departments were re-named ministries.

According to the Minister of Health at that tune, J. Azurin, theadoption of Primary H ealth Care all over the Philippines m oved himto seek im mediate presidential approval of the revised organisationalchart of the Ministry of Health (MOH ) contained in Execu tive O rderNo. 851. M inister Azurin added that this action would accom modateall of the behavioural changes needed to make the MOH moreparticipation-oriented. The most significant change of the 1982 reor-ganisation was at the provincial level with the merging of the Provin-cial Health Office and the Provincial Hospitals.48In the Philippines, the Primary Health C are approach concentratedon the main health problems in the village community, providingprom otive, preventive, curative, and rehabilitative activities. Promo-tive health activities are personal and environmental hyg iene, soundfood and dietary practices, regular physical exercise, and a lessstressed lifestyle. Preventive health activities are occupational health,

immunisation, quarantine, vector control, and disease surveillance.Curative health activities are early diagnosis and treatment of dis-eases, emergency care of the injured, and other applications of medicaltechnology to repair tissue damage brought about by acute or chronicillness or injury. R ehabilitative health activities are the restoration of190


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normal physical, mental and social functions to individu als afflictedwith d isabling injuries and illnesses as well as the extension of servicesto minimise the extent of disability caused by impaired or damagedbody tissues and organs.49 Since these services reflect and evolvefrom the economic conditions and social values of the country and itsvillage communities, they vary by country and com munity. No nethe-less, they include at least the promotion of proper nutrition and anadequate supply of safe water; basic sanitation; maternal and childcare, including family planning; immunisation against major infec-tious diseases; prevention and control of locally endemic diseases;education concerning p revailing health problems and the methods ofpreventing and controlling them; and appropriate treatment for com -mon diseases and injuries.

In order to make Primary Health Care universally accessible inPhilippine village communities as quickly as possible, maximisingcommunity and individual self-reliance for health development wasmandated. Specifically, the attainment of such self-reliance in Philip-pine village com munities required full community participation in theplanning, organisation, and management of Primary Health Care.Such participation was best mobilised through app ropriate education,which w ould enable village com munities to deal with their real healthproblems in ways most suitable to them. Village communities werethus in a position to make sure that the right kind of support wasprovided by the other levels of the national health system. These o therlevels were organised and strengthened so as to support PrimaryHealth Care with technical know ledge, training, guidance and super-vision, logistic support, supplies, information, financing, and referralfacilities, including institutions to which unsolved problems andindividual patients could be referred.

Philippine program me administrators believed that for PrimaryHealth Care to be most effective they had to employ m eans that wereunderstood and accepted by the community, and applied by thecommunity health workers at a cost the community and the countrycould afford. These comm unity health wo rkers, including traditionalpractitioners where applicable, function best if they reside in thecommunity they serve and are properly trained socially and techni-cally to respond to its expressed health needs. 50

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Since Primary Health Care was an integral part of the country'shealth system and of overall econom ic and social developm ent, it hadto be coordinated on a national basis with the o ther levels of the healthsystem as well as with the other sectors that contribute to the coun try' stotal development strategy.51 M utually beneficial linkages as opposedto administrative direction were encouraged by the Primary HealthCare approach.Upon the assumption of pow er in 1986, President Corazon Aquinoimmediately called for another comprehensive reorganisation of thePhilippine adm inistrative system. One of the first pieces of leg islationPresident Aquino issued was Executive Order No. 5. This law recon-stituted and renam ed the Presidential Commission on Reorganisationas the Presidential Commission on Government Reorganisation(PCGR). The five guiding principles of the PCGR were as follows:1. private initiative;2. decentralisation;3 . cost-effectiveness;4. efficiency of frontline-services; and5. accountability.

The PCGR organisation was composed of high calibre Filipinoconsu ltants from both the private and public sectors. These consult-ants were divided into survey teams headed by a coordinator. ThePCGR had a policy group and a special studies group. These groupswere in charge of standardising, collating, and compiling all thesurvey team 's findings. The final approval of the each departm entalreorganisation plan was left solely in the hand of President Aquino.This w as due to the absence of a legislature, which was abolished afterthe coup d'etat facilitated by Fidel Ramos and Juan Ponce Enrile. Theabsence of a legislature also gave the Chief Executive the power tocarry out the reforms without opposition from the other politicalbranches of government.

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The scope of the PCGR's mandate as defined under ExecutiveOrder No. 5 was encom passing. It involved the overall reorganisationof the administrative branch, governm ent-owned and controlled cor-porations, and local government. Never in the history of Philippinegovernment restructuring has a single entity been accorded thismassive task of reorganisation. U nder President Aqu ino, the depart-ment model of government was again revived.This reorganisation furthered the cause of process-orien ted decen-tralisation by constitutionally encouraging Primary Health Care through

collaboration , interaction, and involvem ent from the nationa l-level tothe village community-level. The changes instituted under the 1987Reorganisation of the Department of Health were:1. the creation of the Com munity Health Service and Field Epidemi-

ology Training Programm e;2. the development of a simplified and realistic health informationsystem;3 . the computerisation of the main Department of Health for greaterefficiency of services;4. the creation of an NG O coordinating desk within the Departmen t;5. the rationalisation of the Health Department's procurement sys-tem;6. the developm ent of legislative liaison; and7. the strengthening of the District Health Office, Rural Health Units,and Barangay Health Stations.

Following the general guidelines of Primary Health Care's "sus-tainable health development through participation mandate," moredefinite and specific operating principles and approaches towardsprocess decentralisation were produced by the Aquino administra-tion.52193


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Conclusion: Some Theoretical and Practical ConstraintsTheoretical ConstraintsAfter examining the experiences of the bureaucracy4evel applicationof structural and process decentralisation in a number of countries,including the United States, the Philippines, Peru, South Korea, andVenezuela, policy-m akers adm it that there is an inherent difficulty inintroducing behavioural reorientation to governm ent reforms. Hencethe more manoeuvrable structural decentralisation techniques are stilllikely to predominate.

One argument against the interface of OD and other humanist-oriented management approaches with decentralisation efforts aretheir "application constraints in the public sector." Some publicadministrationist claim that these techniques are better suited to thebusiness or profit-oriented sector where their success is more easilyidentified and can be more readily proven. Robert Golembiewskienum erates some structural, habitual, and managem ent constraints tothe application of process decentralisation techniques to the publicsector.53 Other developm ent managem ent writers simply contend thatpublic bureaucracies have an "organisational imperative," whichdictates that government bureaucrats advocate the status quo and aredisposed towards systems maintenance.Some public adm inistration experts argue that the organ isational

humanists may have simply provided a more sophisticated array oftechniques for administrators in securing more compliance from thebureaucracy and the local units.54 Hence, decentralisation is actuallya recentralisation technique because the more predominant theme isstill taken from classical management theory and centralisation.Indeed, it is an irony that some of the techniques like manipulation,cooptation, and intervention have actually emerged from the alterna-tive school to centralisation thought the human relations school ofmanagement.Practical ConstraintsDespite some positive changes, the problem of resources for health

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care delivery at the rural areas continues to be demonstrated by theactual number of barangays in the Philippines as opposed to thenum ber of Barangay Health S tations. Seven years after the implemen -tation of Primary Health Care in the Philippines, the total number ofbarangays in the country is 45,000 , while the combined total of R uralHealth Un its (1,991) and Barangay H ealth Stations (7,991) rem ains atonly 9,982. This means that over 35,000 barangays (78 per cent) stilldo no t have imm ediate access to health care services. A large num berof these barangays, which do not have readily available health care, arelocated in the most remote and depressed areas of the country. ThePhilippine Department of Health admits that it does not have thenecessary resources to fill this gap. The national governm ent spend ingon health during the presidencies of Aquino and Ram os has increasedover the years but still remains below the World Health Organisationexpectation for countries like the Philippines.

Hence, whenever the Departmen t of Health and nongovernmentalorganisations receive additional funding from local or internationalsources, they seek to establish much needed health care projects w hichtarget those village communities still in need of health care services.This accounts for the evolution of two distinct sets of start-up imple-mentation flow of resources to the village com munities in the 1980swhich provided greater concern for community participation amuch needed and distinct process decentralisation objective.These alternative local and international donor-suppo rted projects

are not enough when the overall rural health picture is examined.Nevertheless they offer hope for village communities which do nothave any health care services at all. Keeping in mind the conceptualand practical pitfalls discussed in this article, the issue of thenonsustainability or sustainability of projects that will enhance thehealth care delivery and development should now be the focus ofconcern for current and future Philippine policy-makers.

NOTES1. E.D . Dom ar, Essays in the Theory of Economic Growth (Oxford: Oxford

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University Press, 1957); R.F. Harrod, Towards a Dynamic Economics (London:Macmillan Press, 1948); and W.W. Rostow, The Process of Economic Growth(Oxford: Clarendon Press, 1960).2. A. Sen, "Development: Which Way Now ," inC.Wilber, The Political Econom yof Development and Underdevelopment (New York: Random House, 1988).3 . A. Lew is, "Econom ic D evelopment with Unlimited Supplies of Labour," in A.Agarwala, Economic of Under development (New York: Oxford University Press,1958).4. A. Gerschenkron, Economic Backwardness in Historical Perspective (Cam-bridge: Harvard University Press, 1962).5. A.G. Frank, "The Development of Underdevelopment," in R. Rho des, Imperi-alism and Underdevelopment (New York: Monthly Review Press, 1970).6. A. W aterston, Development Planning: Lessons of Experience (Baltimore,Maryland: Johns H opkins Press, 1969).7. See J.Mon tgom ery, "A Royal Invitation: Variations on Three Classic The mes,"in J. Montgomery and W. Siffin, eds., Approach es to Developm ent- Politics,Administration, and Change (New York: McGraw-Hill, 1966) and R.S. Milne,Planning or Progress: The Administration ofEconom ic Planning in the Philippines(Manila: Institute of Pub lic Adm inistration, University of the Philippines, 1960).8. J. Friedman, A Spatial Framework for Rural Development: Problems ofOrganisation and Implemen tation (Los Angeles, California: University of Califor-nia Press), p. 254.9. Inayatullah, ed., Rural Organisations and Rural Development: Some AsianExperiences (Kuala Lumpur, M alaysia: Asian & Pacific Development Administra-tion C entre, 1978 ), p. 278.10. See F. Riggs, Frontiers of Development Administration (Durham, NorthCarolina: Duk e University Pres s, 1971) and F. Rig gs, "Bureaucracy and Dev elop-ment Adm inistration," Philippine Journal of Public Adm inistration 21 (1977): 35 -50.11. G. Starling, Managing the Public Sector (Homewood, Illinois: Dorsey Press,1982), p. 18 8.12. I. Sharkansk y, Public Administration: Policy-making in Government A gencies(Chicago, Illinois: Rand McN ally, 1978), pp. 46-7 .13. See M. Blomstrom and B. Hettne,Development Theory in Transition (London:Zed Books Ltd, 1984).14. J. Endriga, "Stability and Change: The Civil Service in the Philippines,"Philippine Journal of Public Adm inistration 29 (198 5): 145.15. D. Bell,U.S. Econom ic Survey Mission's Rep ort (Manila Philippine Boo k Co.,1950).16. The NEC was later renamed the National Economic Development Authority(NED A), the governmen t's overall economic planning arm.17. J.L. Gonzalez and L. Deapera, "A Review of Philippine Reorganisation,"Philippine Jou rnal of Public Adm inistration 31 (1987): 257-70.18. A.B. Brillantes, "Decentralization in the Philippines: An Overview," Philip-

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pine Journal of Public Administration 31 (1987): 131 -48. See also P.D. Tapales,Devolution and Empowerment (Quezon City: University of the Philippines Press,1993).19. L. Carino, "Policy Directions for Health in the 1980s," Philippine Journal ofPublic Administration 25 (1981): 192-206.20. Carino , "Policy Directions for H ealth in the 198 0s," p. 193 .21 . Aside from J.C. Azurin, Primary Health Care: Innovations in the PhilippineHealth System 1981 1985 (Manila: J.C. Azurin Foundation, 1988), the authorexamined various inter-office communications pertaining to the Department ofHealth's 1958 reorganisation.22. The National Nu trition Prog ramme w as later integrated into the budget respon-sibility of the Department of Health.23 . See B .M . Gross, Action Under Planning: The Guidance of Economic Develop-ment (New York: M cGraw -Hill, 1967) and S. Padilla, ed., Tugwell's Thoughts onPlanning (Puerto Rico: University of Puerto Rico Press, 1975).24. See H.W. Wickwar, The Modernization of Administration in the Near East(Beirut: Kyatas, 1962); R. Gom ez, The Peruvian Administrative System (Boulder,Colorado : University of Colorado Press, 1 969); H. Lee and A. Sam onte, Adminis-trative Reform s in Asia (Manila: Eastern Regional Organization for Public Admin-istration, 1970); R. Groves, Action Under Planning: The Guidance of EconomicDevelopment (New Y ork: McGraw -Hill, 1967); and D. My ers, ed., Venezuela: TheDemocratic Experience (New York: Praeger, 1977).25. R.P. Misra, Local-level Planning and Development (New Delhi: SterlingPublishers, 1 983 ), p. 75 .26. G.S. Chcema and D. Rondinelli, eds., Decentralization and Development.Policy Implementation in Developing Countries (Beverly Hills, California: SagePublications): 14-15. Similar arguments are presented in D . Ron dinelli, "Adm inis-trative Decentralisation and Econom ic Development: Th e Suda n's Exp eriment w ithDevolution," Journal of Modern African Studies 19 (1981): 596-624 and D.Ron dinelli, et al., Decentralization in Developing Countries: A Review of RecentExperience (Washington, DC: World Bank, 1984).27. See L. Gulick and L. Urwick, Paper on the Science of Administration (NewYork: McGraw -Hill, 1937) where the autho rs outlined the following functional jobsof the executive in iheir famous P OS DC OR B, which stands for planning , organis-ing, staffing, directing, coordinating, reporting, and budgeting. Gulick and Urwickargued that these seven principles of good management should be the basis forreorganising the executive bureaucracy. Another author, L. Brownlow, et al.,"Report of the President's Committee on Administrative Management," in U.S.Government, Adm inistrative Manag ement in the Government of the United States(Washington, D C: USG PO , 1937) argued that reorganisations have to address theissue of a strong executive and a large bureaucracy. Reorganisation princ iples haveto be developed a ndapplied successfully to decentralise the organisation. M oreover,L. Mcrriam, in Reorganization of the National Government: What Does it Involve?(Washington, DC: The Brookings Institution, 1939) argued that reorganisations

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should eliminate functions and activities of the bureaucracy which are no longeressential or justifiable. Eliminating or curtailing these would lead to substantialreductions in expenditure. Other al ternat ive s tructural arrangements todebureaucraticise w ere contained in the proposals of W. Bennis, "Organisation ofthe Future," Personnel Ad ministration 24 (1967 ). These involve the use of m ore"organic-adaptive structures." A. Toffler, in Future Shock (New York: Bantam,1971) also prescribed the use of "adhocracies." Other writers called for almostsimilar structural adjustments like a flexible structure, a flat structure , a project teamapproach, a matrix organisation, or a committee system [see P. Drucker, ThePractice of Management (New York: Harper and Row , 1958 )].28. Rondinelli, et al., Decentralization in Developing Countries: A Review ofRecent Experience, p. 67 . Similar arguments are presented by D. Conyers, "Decen-tralisation and Development: A Framework for Analysis," Community Develop-ment Journalll (198 6): 88 -100; S. Gregory and J. Smith, "Decentralisation No w,"Community Development 21 (1986): 101-6; M. Khan, "The Proce ss of Decentrali-sation in Bangladesh, Community Development Journal 21 (1986): 116-25; R.Shields and J. W ebber, "Hackney Lurches Lo cal," Comm unity D evelopment Jour-nal21 (1986): 133-40; P. Sills, etal. , "Decentralisation: CurrentT rends and Issues,"Comm unity Development Journal 21 (1986): 84-87; M. Taylor, et al., "For Wh oseBenefit? Decentralising Hou sing Services in Tw o Cities," Community DevelopmentJournal 21 (1986): 126-32; W. Boyer and M . Byong A hn, "Local Gov ernment andDevelopment Administration: A Case of Rural South K orea," Planning and Admin-istration 2 (1989): 21-29; and D. Rondinelli, "Decentralising Public Services inDeveloping Countries: Issues and Opportunities," Journal of Social, Political an dEconomic Studies 14 (1989): 77-98 .29. See R. Polenberg, Reorganizing Roosevelt's Government: The ControversyOver Executive Reorganization 1936-1939 (Cambridge: Massachusetts: HarvardUniversity Press, 1966).30. J. Pressman and A. Wildavsky, Implementation: How Great Expectations areDashedin Oakland (Berkeley, California: U niversity of California P ress, 197 3)an dG. Honadle, "Implementation Analysis," International Development Administra-tion (New York: Praeger, 1977).3 1. United Nations, Demographic Yearbook (New York: United Nations, 1964,1965, and 1977) and World H ealth O rganization, World Health Statistics (Genera:World Health Organization, 1977).32. Brillantes, "Decentralization in the Philippine s," p. 14 1.33 . See Carino, "Policy Direction for Health in the 198 0s;" and A zurin, PrimaryHealth Care.34. Philippine Medical Care Comm ission, The Medicare Program of the Philip-pines (Quezon City: PMC C, 1974), p. 1.35. Ca rino, "Policy Direction for Health in the^l980 s."36. Carino, Ibid, p. 194; see also M. Reforma, The Rural health Practice Program:An Evaluation of the R ural Service Requirements for Health P rofessionals (Manila:University of the Philippines-College of Public Ad ministration, 1978).

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37. V. Bautista, "Structures and Interventions in the Philippine Health ServiceDelivery Syslcm : State of the Art," in Philippine Institute of Deve lopm ent S tudies,Survey of Philippine Development Research III (Manila: Philippine Institute ofDevelopment Studies, 1989).38. J. Galvez-Tan, "Primary Health Care: Health in the Hands of the People,"Health Policy Development Consultation Series (Quezon City: Health ActionInformation Network, 1986).39. Sec P. Agarwal, "Some Aspects of Plan Implementation," Indian Journal ofPublic Administration 24 (1973): 218-40. J. Mon tgomery, Technology and CivicLife: Making and Implementing Development Decisions (Cambridge: Massachu-setts, 1974); G. Iglcsias, Implementation: The Problem of Achieving Results(Manila: Eastern R egional Organization for Public Adm inistration, 1976); and J.Cohen and N . Uphoff, Rural Development Participation: Concepts and Measuresfor Project Design Implementation (Ithaca, New York: Cornell Un iversity, 1977).40. L. Hammcrgrcn, Deve lopment and the Politics of Adm inistrative Reform(Boulder, Colorado: Westview Press, 1983); J.L. Gon zalez, "A H istorical Survey ofReorganization in the Philippines," Praxis 2 (1988): 45-63 and J.L. Gonzalez,"Philippine and U .S. Adm inistrative R estructuring: Sam e Basic Prob lem ," Philip-pine Journal of Public Administration 24 (1990): 295-99.41 . For instance, E. Ma yo, The Hum an Problems of an Industrial Civilization (NewYork: Macm illan Comp any, 1933); H. Simon , "Proverbs of Adm inistration," PublicAdministration Review 6 (1946): 53-67 and R. Dahl, "The Science of PublicAdministration: Three Problems," Public Administration Review 7 (1947): 1-11.42. R. Mcrton, Reader in Bureaucracy (Chicago , Illinois: Free Pres s, 1952 ), p. 3 6.43 . See C. Barnard, The Function of the Executive (Cambridge, Massachusetts:Harvard University Press, 1938); A. Maslow, "A Theory of Motivation," Psycho-logical Review 50 (1943): 370-96. P. Appleby, Policy and Administration (Corgy,Alabama: The University if Alabama Press, 1949); C. Argyris, Personality andOrganization (New York: Harper and Row, 1957); H. Simon, AdministrativeBehavior (New York: Macmillan, 1957); D. McGregor, The Human Side ofEnterprise (New Y ork: McG raw-H ill, 1960); R. Blake and J. Mouton, The Mana-gerial Grid (New York: Gulf Publishing, 1964); F. Herzberg, Work and the Natureof Man (New York: Thomas Crowell, 1966).44. See P. D rucker, The Practice of Management (New York: Harper and Row,1954); D. Dem ing, Com pany O rganization for Packaging Efficiency (New York:American Foundation for Management Research, 1962); R. Likert, The HumanOrganization (New York: McGraw-H ill, 1967); M. Sashkin, A M anage r's Guide toParticipative Managem ent (New York: Am erican Managem ent Association, 1984);R. Golembiewski and E. Eddy, eds., Organization Development in Public Adm in-istration (New York: Marcel Dekker, 1978); W. Ouchi, Theory Z (Reading,M assachusetts: Addison-W esley, 1981); P. Block, The Empowered Manager (SanFrancisco, California, 1987); F . Herzberg, "M otivation to W ork," in RussianAcademy of Sciences, Journal of Sociological Studies (Moscow: Academy ofSciences, 1990): 32-46.

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45. It wa s only after the 1985 Brundtland Co nference that the OECD addressed thisimportant development issue. For more information about the 1 mplementation of thePHC in the Philippines see Executive O rder No. 851; Letters of Instruction No. 949;and Presidential Decree No. 1397.46. Azurin, Primary Health Care, p. 58.47. M inistry of Health, An Overview of the Ministry of Health (Manila: M inistry ofHealth, 1978) and Ministry of Health, Annual Report (Manila: Ministry of H ealth,1979).48 . Azurin, Primary Health Care, p. 35.49. /Wd., pp. 40-1.50. M inistry of Health, Revised Training Module on the Five-Impact Programsforthe Training of Bar an gay Health Wo rkers (Manila: Ministry of Health, 1 985).51 . Ibid.52. See Department of Health, Annual Report (Manila: Department of Health,1988), p. 5.53 . R. Golembiewski, Humanizing Public Organizations (Maryland: LomondPub lications, 198 5), p . 5.54. R. Denhardt, Theories ofPublic Organization (Pine Grove, California: Broo ks/Cole, 1984).

Joaquin L. Gonzalez III is Fellow at the Department of Political Science, the NationalUniversity of Singapore. He is grateful to Edith R. Borbon, Elise B. G onzalez, colleagues atthe National University of Singapore, the University of the Philippines, De La SalleUniversity, the University of Utah, the World Bank, and an an onymou s referee for theirvaluable comments, suggestions, and encouragement.

phil lip pine health system

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