Decentralisation and its Implications for Reproductive Health: The Philippines Experience

Figures & data

Table 1 Division of health sector responsibilities following devolution

Government level	Responsibility
Central and Regional DOH	– Health policy setting
	– Regulation and quality assurance
	– Training and technical supervision
	– Retained hospitals (tertiary referral care)
	– Funding and technical assistance for national disease control and health service programmes associated with international agreements
	– Monitoring local government performance
Provinces	– Provincial and district hospital services (primary and secondary referral care)
Cities	– Hospitals in highly urbanised areas, excluding National Capital Region (secondary referral care)
Municipalities	– Primary health care functions, including delivery of nationally retained disease control and health service programmes
	– Supervision of barangay health stations
Barangays	– Outreach functions, including services provided at barangay health stations

Table 2 Reproductive health implications of devolution

Aspects of health system	Unintended consequences of devolution	Implications for reproductive health services
Delivery of services	– Fragmentation of referral care	– Safe motherhood services adversely affected
	– National government unable to influence local decision-making	– Provision of family planning services is a national priority but not implemented by some local governments
Financing of services	– Non-earmarked transfer of funds	– Some local governments did not invest in priority health areas such as family planning
		– Resource allocation not based on revenue- generating capacity at local level	– Income inequities exacerbated–access to reproductive health services of those in greatest need suffered
	– Curative care bias of government spending not addressed	– Under-funding of preventive reproductive health care
Institutional capacity	– Reorganisation of roles and responsibilities–central and local	– Centre did not provide vision for comprehensive reproductive care to local levels
		– Rapid nature and scope of devolution exacerbated institutional constraints at local level	– Local level unable to effectively manage reproductive health services
Health personnel	– Low morale of health workers	– Quality of reproductive care adversely affected
		– Increase in workload of front-line workers	– Midwives unable to meet the reproductive health care needs of the population they serve
Quality of care	– Loss of integrity of referral care; under-funding of preventive care; low personnel morale; increase in workload of midwives	– Negative implications for quality of care
		– Cuts in travel for training	– Reproductive health skills eroded
	– Supervision by district teams discontinued	– No technical support or quality guidance for devolved workers
Local representation	– Local level susceptible to strong conservative pressures	– Traditionally controversial areas such as family planning and STDs targeted for cuts
		– Local representation of women in decision-making capacities low	– Limited voice for women in decisions taken on reproductive health services
	– Large number of local governments units responsible for service delivery	– Enormous efforts needed to build support for reproductive health care services

Figure 1 Nurse providing antenatal care, Bangkok, 2002