Zff Lhb Monograph

Abstract

The decentralization of basic social services in 1992 prompted local chief executives to assume the responsibility of providing these services, including health, to their constituents. It aims to improve the delivery of services by empowering local leaders and giving them the mandate to undertake decision-making to immediately respond to local needs. The decentralization was envisioned to bring governance closer to the people.

The Local Government Code (LGC) of 1991 set up various mechanisms to ensure support for the decentralization and responsiveness of the local health system. This included institutionalization of local health boards (LHB) at every level of the local government unit (LGU). The LHB is regarded as an avenue for wider community participation at the local level. Community-based organizations can become members of the LHB and take part in the decision-making process. The LHB also assists the LGU, particularly the Sangguniang Bayan, in crafting health ordinances and resolutions, as well as in preparing health budgets.

However, after almost two decades of implementation, not all LGUs have been able to institutionalize their LHBs. Evidence shows varying outcomes of decentralization, with some LGUs faring better and being more responsive than others. Some had no organized LHBs, while others had functional and effective LHBs. Still, there were others that organized their LHBs, but only on paper. The study1 on the status of LHBs supported positive correlation between the functionality of local health boards and some indicators of LGU responsiveness such as community consultations, health initiatives, and the allotment of budget for health, among others.

This study is part of the situational analysis for an intervention that intends to ensure the presence of a supportive policy environment in the local health system. The analysis examines the functionality of LHBs in the Zuellig Family Foundation’s (ZFF) Cohorts 1 and 2 partner-municipalities at the onset of the partnership. The Foundation envisions the LHBs as a critical institution to support the reforms that can be instituted in the municipalities and as a catalyst of a more responsive policy environment. The analysis also explores the difference in the possible outcomes between municipalities with functional and non-functional LHBs in terms of percentage of budget allocated for health, adequacy of health workers, and the provision and amount of barangay health worker honorarium.

1 Ramiro, Laurie S., Fatima A. Castillo, Tessa Tan-Torres, Cristina E. Torres, Josefina G. Tayag, Rolando G. Talampas, and Laura Hawken (2001). Community participation in local health boards in a decentralized setting: Cases from the Philippines. Oxford University Press.

Datu Paglas municipal health officer, Dr. Tina Almirante (in white shirt) leads the LHB members during the municipal health summit.

Local Health Board 1

DecentralizationThe decentralization of basic social services in 1992 intends to empower both the LGUs

and the community. It gives local leaders the mandate to undertake local decision-making and respond according to local health needs. Devolved functions of LGUs, including provision and financing of basic health services, are intended to ensure a responsive local health delivery system as well as community participation and accountability. For the community, various mechanisms are enshrined in the LGC to ensure greater participation, including the institutionalization of the LHB. The table below enumerates the basic functions devolved to various institutions of the LGU.

Devolved Health Functions based on the Implementing Rules and Regulations of the Local Government Code of 19912

Functions Local Government Units (LGUs)

Provision 1. Barangays – Health services through the maintenance of barangay health stations 2. Municipalities – Implementation of programs and projects such as: •primaryhealthcare •maternalandchildcare •communicableandnon-communicablediseasecontrolservices •accesstosecondaryandtertiaryhealthservices •purchaseofmedicines,medicalsupplies,andequipment •constructionandmaintenanceofclinics,healthcenters,andother health facilities 3. Provinces – Health services through hospitals and other tertiary health services 4. Cities – All health services and facilities provided by municipalities and provinces

Financing 1. Funds for basic services and facilities shall come from the share of LGUs in the proceeds of national taxes (IRA and national wealth), other local revenues, and transfers from the national government, national government agencies (NGAs) and government owned & controlled corporations (GOCC). 2. NGAs affected by devolution or the next higher LGU may augment basic services and facilities assigned to a lower LGU

Participation Local Health Board

and A LHB is established in each LGU composed of the local chief executive Accountability as chair, the local health officer as vice chair, the Sangguniang Panlalawigan/ Sangguniang Bayan chair of the committee on health, a representative from Non-Government Organizations or the private sector, and the Department of Health-Representative. The LHB shall propose to the local Sangguniang Bayan an annual health budget, and serve as an advisory committee on health matters to the local Sanggunian and other local health agencies.

2 Bautista, A. B. (1993). Rules and regulations implementing the Local Government Code of 1991 with related laws and concept of decentralization. Mandaluyong City: National Bookstore.

2 Zuellig Family Foundation

With the authority given to local government units comes greater accountability, as embodied in the concept of closer governance. Local governments now have the responsibility of providing health services to their respective communities. Through decentralization, the Rural Health Unit (RHU) is administratively and financially under the Municipal Mayor while government provincial and district hospitals are under the Provincial Governor. The Department of Health (DOH), however, maintains specialty hospitals, regional hospitals and medical centers. It also operates regional field offices known as Centers for Health Development (CHD) in every region, which has a provincial health team made up of representatives to the local health boards and retained personnel involved in managing selected priority health problems. 3

“At the local level, citizens can more easily learn of the activities and programs that their local leaders have promoted and supported, discern how much effort they have devoted to improving public services, and confirm whether they have delivered on campaign promises. In other words, the information that citizens need to make judgments is more readily accessible under decentralization.” 4

The responsibilities devolved to LGUs demand greater leadership and management competencies. This poses imperatives for local chief executives to exercise good governance to ensure efficiency and efficacy. They are expected to optimize the various support mechanisms provided by the LGC to ensure smooth transition of authority and responsibility from the national to the local governments. These support mechanisms are intended to complement the skills and expertise of local chief executives in carrying out devolved functions. A case in point is an LHB intended to guide and provide technical support on health to the local chief executive and other local decision-making authorities.

Autonomous Region in Muslim Mindanao The case is relatively different in the Autonomous Region in Muslim Mindanao (ARMM).

Functions of the DOH-National are devolved to the Autonomous Regional Government (ARG) through Executive Order 133 series of 1993. The ARG finances the operations of the Department of Health-ARMM (DOH-ARMM) where health service provision is centralized. DOH-ARMM administers, manages and implements the public sector health programs. The Integrated Provincial Health Office (IPHO) and Rural Health Units, as well as health personnel, are all under the DOH-ARMM. However, there are no clear guidelines on the role of LGUs in the delivery of health programs and services.

While there is EO 133, there also exists the Muslim Mindanao Autonomy Act (MMA) No. 25 that mandates LGUs to provide basic health services, which is similar to the provision in the LGC of 1991. EO 133 and MMA 25 have conflicting provisions made worse by the absence of implementing rules and regulations that define the ARMM health system. 5 This situation impedes the efficient delivery of health services in ARMM.

The centralized structure of the delivery of public sector health programs has resulted to the growing indifference and lack of ownership of health challenges among LGUs in the ARMM. Some LGUs tend to depend solely on the DOH-ARMM for health service delivery. While some consider health as their last priority, there are also LGUs that played critical roles in effective health service delivery.

3 Ronquillo, Kenneth, Fely Marilyn Elegado-Lorenzo, Rodel Nodora (2005). Human Resources for Health Migration in the Philippines: A Case Study and Policy Directions. Paper for ASEAN Learning Networks for Human Resources for Health (August 2-5, 2005) Bangkok, Thailand.4 Campos, J. E. and J. S. Hellman (2005). Governance gone local: Does decentralization improve accountability? R.White and P. Smoke (eds.) East Asia Decentralizes: Making Local Government Work. Washington, DC: The World Bank. pp. 237-252.5 Department of Health; Autonomous Region of Muslim Mindanao and Department of Health-ARMM (2008). ARMM-Wide Investment Plan for Health (AIPH).


The Role of the Local Health Board

One of the mechanisms enshrined in the LGC to ensure the effective implementation of decentralization is the establishment of the Local Health Board in every province, city or municipality. 6 The LHB is envisioned to provide technical expertise and guidance to the LGUs. Composed of representatives from the public and non-government sectors, the LHB serves as a venue for greater stakeholder participation.

The LHB is regarded as the “government’s intended mechanism for broader community participation in health decision-making in the country”. 7 The LHB is composed of the local chief executive as the chairman, the local health officer as the vice-chairman, with the Sanggunian Committee on Health chairman, a representative from the DOH, and a representative from the private sector or non-governmental organizations as members.

Section 102-105 of the LGC specifically mandates the LHB to propose to the Sanggunian concerned the annual budgetary allocations for the operation and maintenance of health facilities and services; to serve as an advisory committee to the Sanggunian; and to create committees which shall advise local health agencies on personnel selection and promotion, bids and awards, grievances and constraints, personnel discipline, and budget review, among others. (Local Government Code, Section 102-105) .

6 Local Government Code (1991). Section 102-105. 7 Ramiro, Laurie S., Fatima A. Castillo, Tessa Tan-Torres, Cristina E. Torres, Josefina G. Tayag, Rolando G. Talampas, and Laura Hawken (2001). Community participation in local health boards in a decentralized setting: cases from the Philippines. Oxford University Press.

Mayor Datu Abdulkarim Langkuno addressing his constituents during Paglat’s community health summit.


The LGC also set provisions for conducting regular meetings and quorums. The provision requires at least one meeting a month, or as often as necessary. The quorum is constituted by the majority of the members while the affirmative vote of the majority of the members is necessary to approve proposals. Regular meetings ensure that members are up-to-date and informed of the health situation, issues, and current status of programs and projects.

The abovementioned functions of the LHB are critical in local health system development. The LHB serves as an avenue where the LGU and local health officers can sit together to discuss and address health concerns of their constituents. Local health officers and community representatives are given the opportunity to air out health issues and consequently, provide feedback to the community. The LHB also serves as an accountability mechanism that ensures checks and balances on the local chief executive’s decision-making power.

In a comparative study conducted in 2001, there were more community participation, fund-raising activities, health initiatives and higher per capita health expenditure in LGUs with functioning LHBs than in LGUs with non-functional LHBs. (Ramiro et. al. 2001) Moreover, in the case of ARMM, the LHB serves as the link between the DOH-ARMM and its institutions on one hand and the local governments on the other (refer to Figure 1). The LHB serves as a venue to get LGUs involved in discussing and addressing local health needs of the community.

Figure 1. ARMM Public Health System

Assessment of Functionality The study assessed the functionality of LHBs in the Zuellig Family Foundation Cohorts

1 and 2 partner-municipalities at the onset of the partnership. The research is part of the situational analysis for an intervention to create a supportive policy environment in the local health system where the LHB shall serve as the critical mass that will advocate and support health reforms initiated by health leaders.


The assessment is based on the “Local Governance Performance Management System”, which was developed by the Department of the Interior and Local Government (DILG) to self-assess LGU performance. The performance indicators of functionality include:

Performance Indicators

•CompositionisinaccordancewithSec.102ofRANo.7160,ortheLocal Government Code of ARMM, in the case of ARMM LGUs

•theLHBhassubmittedanannualhealthplanandbudgettotheSanggunian•theLHBhasservedastheadvisorycommitteetotheSanggunianonhealthmatters•theLHBhascreatedcommitteesthatwouldadviselocalhealthofficesorunitson

personnel selection, promotion and discipline, grievance and complaints, bids and awards, budget review and other related matters

•theLHBholdsmeetingsatleastonceamonth

The analysis showed that 11 out of the 22 local health boards can be considered functional. These include two from Cohort 1 and nine from Cohort 2. Functionality is measured based on the averaged rating of the municipality on the performance indicators mentioned above. Of the five criteria, most of the functional LHBs were able to get high ratings on composition and regular meetings. Only three, however, were able to submit annual health plans and budgets to their Sanggunian. Eight LHBs were able to serve as advisory committees to the Sanggunian on health matters, while eight others were able to create functional committees. The findings indicate that despite their functionality, areas for improvement remain, particularly in terms of performing their functions.

LHBs in eleven of the municipalities were rated as non-functional. Ten had formal documents stating their composition based on the LGC, yet were rated low based on compliance to its mandate and functions. Their LHBs existed merely on paper.

“Only 11 of the 22 LHBs were found to be functional.”

Functionality and OutcomePart of the analysis also explores the possible outcome of functional local health boards

particularly in terms of the percentage of budget allocated to health, the adequacy of rural health workers, and the provision of BHW honorarium. In general, functional LHBs showed positive impacts on local health system development. LGUs with functional LHBs tended to have relatively higher percentage of budget allocated for health. There was also positive correlation between functioning LHBs on one hand, and the adequacy of rural health workers and provision of higher honorarium among BHWs, on the other.


The results reveal that generally, the average percentage of health budget of LGUs with functional LHBs are higher than those with non-functional LHBs. The average percentage of budget allocated for health of LGUs with functional LHBs was 10.27% of the total budget compared to 8.73% in LGUs with non-functional LHBs. Municipal health officers said that LHB meetings and budget deliberations in the LHBs enable the mayors and SB on health chairmen to recognize the importance and implications of addressing health concerns. It also builds their awareness on the need for health programs that will be implemented in the municipalities; thus, they provide relatively higher financial support for health. Moreover, LHB meetings discussing budget allocations for health enable MHOs to lobby for the support of other LHB members.

“The average percentage of health budget of municipalities with functional LHBs are higher than those with non-functional LHBs.”

Aside from its impact on budget allocation, LHBs also play a vital role in addressing various issues at the local level. The LHB is mandated by the LGC to create committees that can provide advice on issues such as health personnel selection, promotions and disciplinary action, grievances and complaints. Through this mechanism, rural health workers are given the opportunity to air their concerns about their work conditions, such as the inadequacy in the number of providers and the lack of BHW honorarium.

The research showed that municipalities with functional LHBs tended to have more rural health workers computed based on provider-to-population ratio. Figure 2 illustrates that average healthcare provider index 8 increases as LHB rating for functionality increases. A statistical test on the correlation validated the significant interaction (sig=0.017) of the two variables at the 0.05 level. Disaggregating the data, midwife-to-population ratio and BHW-to-household ratio indicate the same correlation. It is observed that municipalities with functional LHBs have relatively adequate number of midwives and BHWs compared to municipalities with non-functional LHBs (see Figure 3). A statistical test showed that the cumulative average of midwives, BHWs and average provider in municipalities with functional LHBs were significantly higher than those in LGUs with non-functional LHBs.

“Municipalities with Functional LHBs have relatively adequate number of providers than those with non-functional LHBs.”

8 Average healthcare provider index calculates the adequacy of selected rural health workers (doctors, nurses, midwives and BHWs) computed based on the provider to population/household ratio. Index closer to one indicates more adequate number of selected rural health workers compared to index closer to zero.


Figure 2.

Figure 3.

Indicators Adequacy of selected Significance rural health workers

Municipalities with Municipalities with Functional LHBs Non-functional LHBs

Midwife to population 0.7396 0.5279 0.015BHW to household 0.8582 0.6069 0.043Average provider 0.7203 0.5650 0.013to population/ household index

The study also indicated a positive correlation between the frequency of regular meetings of the LHB and the average amount of BHW monthly honorarium. Statistical analysis revealed that on the average, the BHW monthly honorarium is relatively higher in municipalities with more frequent LHB meetings 9 (See Figure 4). This particular test excludes four municipalities

9 Statistical test shows that correlation is significant (0.031) at 0.05 level.


from ARMM since incentives and compensation of health personnel come from the DOH-ARMM. Municipal health officers acknowledge the value of regular meetings as a venue to raise and address contentious issues that would have been neglected. Commonly neglected issues include rural health worker benefits and incentives. In this case, frequent meetings enable the BHWs to voice out their needs and sentiments to the local chief executives and other authorities.

Figure 4. 10

Crucial Enabling Factors for Functional LHBs

The research also revealed various insights on the functionality and dynamics of the local health board in their respective municipalities. Based on the situational analysis, crucial enabling factors for the LHB were found to include shared mission, vision and commitment; presence of local champions; holding of regular meetings; individual perception of the LHB and each member’s roles; and the interpersonal relationships of members.

ShARed MiSSion, ViSion And CoMMitMentBased on the key informant interview conducted with LHB members, the recognition of

shared vision and mission among LHB members helped in setting their commitment and passion for work. In areas where the LHB is inactive, there seemed to be no clear vision and mission, or it existed only on paper or on some plaque at the Municipal Health Office.

Also, the MHO seemed detached from the LGU, as if it was an entirely independent entity. As a consequence, the LGU lacked ownership of health issues and simply left these to the MHO. These were visible in most of the cases in this study where the MHO and his/her staff carried the burden of responding to the health needs of the community.

10 LHBs are rated 1, 3, 5 according to frequency of regular meeting. (1-less than quarterly; 3-Semi-monthly/ Quarterly; 5- Monthly)


PeRCePtion oF the LhB And MeMBeRS’ RoLeSThe LHB members’ perception of their roles and the LHB itself is crucial in ensuring active

participation in the LHB. Predictably, mayors with functional LHBs perceive it as an important mechanism to gain support from his constituents. As a venue for greater participation, the LHB established their credibility as empowering the community and encouraging the participation of other stakeholders. In the same way, the MHO and the DOH-Rep felt empowered with the ability to provide technical support, as they were frequently consulted on health issues. The other members appreciated their perceived high involvement in decision-making. On the other hand, members of non-functional LHB regarded it as another layer of bureaucracy with mandated functions but no police power.

LoCAL ChAMPionSThe presence of local champions also drives a responsive health system where leaders

push for improvements in health service delivery. Often, these local health leaders are the mayors and/or the municipal health officers who are committed to provide better health services. In the case of a functional LHB, the mayor and/or the MHO initiated the meetings and the establishment of programs. Among inactive LHBs, the mayor’s lack of awareness and ownership and the MHO’s lack of capacity and initiative to persuade and/or call the attention of the mayor contributed to the non-functionality of the LHB and the lack of empowerment of its members.

ReGULAR MeetinGSThe FGDs also revealed that frequency of regular meetings ensured the functionality of

the LHB. Regular meetings kept all members up-to-date and informed of the health situation, issues, and current status of programs and projects. The meetings served as venues for the MHO to persuade and/or call the attention of the Mayor and the SB on Health to support and speed up the process of coming up with ordinances or approving resolutions by influencing other members of the Sanggunian. Citing the case of Dao, the MHO takes advantage of LHB meetings to persuade the Mayor and SB on Health to speed up the process of legislating resolutions by getting other members of the Sanggunian to agree. It also established better interpersonal relationships among LHB members.

inteRPeRSonAL ReLAtionShiP AMonG MeMBeRSThere were also social factors that contribute to the functionality of the LHB, including

good interpersonal relationships that go beyond their role as members of the LHB. Open and frequent formal and informal communication on topics that may go beyond health issues facilitated better relationships among members. This eventually helps quiet members to open up to the dominant member (usually the mayor), who then learns to listen.


Synthesis and RecommendationsGiven the enormous challenges of decentralization, local chief executives need to

maximize enabling mechanisms set by the LGC of 1991 and the MMAA No. 25 (in the case of ARMM) such as the local health board. The study provides cases that support the proposition of various literature on the importance and impact of LHB functionality on local health system development, keeping other things constant. The study shows positive correlation between the functionality of the LHB and key indicators of desirable outcomes, such as a bigger budget allocation for health, adequacy in the number of rural health workers, and provision of BHW honorarium.

Most of the LGUs have taken for granted the institutionalization of the LHB, regarding it as merely another layer of the bureaucracy. However, as literature has shown and as this study suggests, LHBs can have direct and indirect roles in addressing some of the pressing concerns at the local levels. The level of LHB functionality affects the local health system development.

In response to the results of the research, and recognizing the role of the LHB, the Foundation identified the need for an intervention to strengthen LHBs. During validation with LHB members, the need to review the basic mandate and the added value of having a functional and active LHB was suggested. The members of the LHB admitted their lack of awareness and knowledge about their mandate and functions. To address this, the Foundation developed a training intervention designed to help build the capacity of LHB members. The training design is based on the provisions of the Local Government Code on the LHB and on insights and lessons from the case studies of partner municipalities.

Former Sta. Fe Mayor Florante Gerdan (left) discussing health plans with his MHO Dr. Ernesto Robancho, Jr.


SOURCeS:Bautista, A. B. (1993). Rules and regulations implementing the Local Government Code of 1991 with related laws and concept of decentralization. Mandaluyong City: National Bookstore.

Campos, J. E. and J. S. Hellman (2005). Governance gone local: Does decentralization improve accountability?, in R.White and P. Smoke (eds.) East Asia Decentralizes: Making Local Government Work. Washington, DC: The World Bank. pp. 237-252.

Department of Health; Autonomous Region of Muslim Mindanao and Department of Health-ARMM (2008). ARMM-Wide Investment Plan for Health (AIPH).

Ramiro, Laurie S., Fatima A. Castillo, Tessa Tan-Torres, Cristina E. Torres, Josefina G. Tayag, Rolando G. Talampas, and Laura Hawken (2001). Community participation in local health boards in a decentralized setting: cases from the Philippines. Oxford University Press.

Ronquillo, Kenneth, Fely Marilyn Elegado-Lorenzo, Rodel Nodora. (2005) Human Resources for Health Migration in the Philippines: A Case Study and Policy Directions. Paper for ASEAN Learning Networks for Human Resources for Health (August 2-5, 2005) Bangkok, Thailand.

Department of Interior and Local Government. Local Government Code 1991. 1992.

Local Government Code of the Autonomous Region in Muslim Mindanao: Muslim Mindanao Autonomy Act No. 25. “An Act Providing for a Local Government Code of the Autonomous Region in Muslim Mindanao”. Autonomous Region in Muslim Mindanao, Regional Legislative Assembly 1995]. ‘Local Governance Performance Management System’(2005). Department of Interior and Local Government. Bureau of Local Government Supervision, Department of the Interior and Local Government. Quezon City.

Ana Katrina A. GoAuthor

Juan A. VillamorDirector Zuellig Family Foundation InstituteEditor

ernesto D. GarilaoPresidentZuellig Family Foundation Executive Editor-in-chief

Dr. Alberto G. RomualdezUsec. Gerardo BayugoDr. ernesto DomingoDr. Benny ReverenteAdvisory Board Members


Zff Lhb Monograph

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