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Decentralisation, accountability and SRH services: lessons from Philippines.

This case study in the Philippines explores the potential and limitations of one model of decentralisation--devolution of powers to local bodies--in strengthening accountability to communities with regards to sexual and reproductive health (SRH) services. The Philippines government embarked on devolution of health and social services after the passing of the Local Government Code of 1991. As part of the devolution in health services, 95 per cent of its facilities, 60 per cent of its personnel and 45 per cent of the budget was transferred from the Department of Health to local government units (LGUs) at provincial, city and municipality levels. To oversee the functioning of health services in decentralised units, local health boards were set up in each unit, comprising the Governor or Mayor as its chairperson, Municipal Health Officer as vice chairperson, the local councillor for health, a representative of the Department of Health and a representative of a health NGO.

Local government expenditures increased by 51.9 per cent in 1993 when compared to the pre-devolution period, with 66 per cent being allocated for the health sector. Though this amount in principle is untied, a significant proportion goes for salaries of health workers. The Local-Government Assistance and Monitoring Service (LGAMS) was set up within the Department of Health to monitor LGU health programmes and provide technical assistance. The LGAMS was also supposed to augment resources of LGUs, if they agreed to implement national health programmes, including the Reproductive Health Programme (1). However, there were no incentives or punitive measures to ensure that units complied with the agreements.

Impact of Devolution on SRH Services

Researchers have observed that the implementation of reproductive health programmes has suffered because of decentralisation (2). Provision of a wide range of contraceptives by local clinics depended on attitudes of members elected to LGUs at different levels. This in turn led to high rates of unsafe abortions. While emergency obstetric care has been on the priority list of many LGUs, in practice such services have been affected because of weakening referral systems as different levels of healthcare are being managed by different elected bodies. Access to diagnosis and management of HIV/AIDS is still limited and unequally distributed across rich and poor areas.

Men's sexual and reproductive health needs are often not prioritised by LGUs. By and large, curative care was given more priority over preventive care by most LGUs. Another area of concern is the LGUs' preoccupation with being re-elected. They are fearful of promoting any policy or programme that goes against the interests of the Church, as this institution still influences voting patterns of communities. There has also been little effort to build capacities of local health boards and LGUs on their roles and responsibilities as elected members as well as on sexual and reproductive health and rights issues.

The potential role that NGOs could play to promote sexual and reproductive health and rights (SRHR) within the process of devolution is illustrated through the experience of the Development of People's Foundation in Davao city (3) which strengthened SRH services in the area by providing research and capacity building support to LGUs, and by putting pressure on LGUs from outside by building advocacy skills of NGOs and community women.

This case illustrates that the devolution model of decentralisation offers potential for strengthening accountability with respect to SRH services when adequate powers and resources are devolved to LGUs, inequities between resources of LGUs in resource-poor and resource-rich areas are addressed by governments and when incentives are provided to LGUs to provide essential SRH services. At the local level, it is important that women and marginalised groups are proportionately represented in these bodies, members of elected bodies are aware of their roles and responsibilities and sensitive to issues of SRHR, and citizens are in a position to put external pressure on local bodies to provide comprehensive SRH services.

* Endnotes

(1) The Reproductive Health Programme of the Philippines includes services to improve contraceptive choice and access, MCH and nutrition, prevention and management of abortion complications, prevention and treatment of RTIs, including HIV/AIDS/STDs, education and counselling on sexuality and sexual health, detection and treatment of breast and reproductive tract cancers, men's and adolescent reproductive health, care and counselling for victims of violence against women and prevention and treatment of infertility and sexual disorders

(2) Tadiar, F.M. 2000. Reproductive health programmes under health reform: The Philippines case. International Council on Management of Population Programmes, Malaysia. Available at pp 14

(3) This effort is part of a broader strategy (called Gender Watch) of the Foundation to monitor the implementation of the 'Women's Development Code of Davao City' which was passed by city council in 1997. (Pacaba-Deriquito,

* Ranjani Krishnamurthy, Independent Researcher on gender, health and poverty and Member of the Coordinating Team, Initiative for Sexual and Reproductive Rights in Health Reforms (South Africa), 12, Srinivasamurthi Avenue, Adyar, Chennai, 600 020 India. Tel: 91 44 24902960 Email:
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Title Annotation:Policy
Author:Krishnamurthy, Ranjani
Publication:Arrows For Change
Geographic Code:9PHIL
Date:Dec 1, 2003
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