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The Philippines was one of the signatories to the memorandum adopted by the 1994 International Conference on Population and Development (ICPD), as well as the 1995 Fourth World Conference on Women in Beijing. The Department of Health (DOH) and the Population Commission (PopCom), and delegates from other government and non-government organisations (NGOs) represented the Philippine government in these conferences.

Prior to these conferences, the Philippines passed a law (Local Government Code of 1991 or Republic Act No. 7160), decentralising basic services, including health care and other functions to local governments. Delivery of health services are now managed and controlled by local executive officials at the provincial and municipal levels, under the direct supervision of the Department of Interior and Local Government.

This chapter will describe the features of the local government health sector delivery system as provided by RA 7160, the initiatives and efforts of the DOH to comply with its international agreements, and two examples of projects to integrate reproductive health (RH) programme elements at the provincial and municipal levels. Issues and constraints facing the Philippine RH programme efforts in the devolved set-up will also be discussed. Finally, some recommendations from various sources will be presented.

The Philippine government is accountable to the people for the constitutional provision for health and development of Filipinos, parallel to the principles of ICPD:

Protect and promote the right to health of the people and instill health consciousness among them. Art. II, Sec. 15
Defend 1) the right of spouses to found a family in accordance with their religious convictions and the demands of responsible parenthood 2) the right of children to proper care and nutrition, and special protection from all forms of neglect, abuse, cruelty, exploitation, and other conditions prejudicial to their development. Art. XV, Sec. 3
There shall be priority for the needs of the underprivileged sick, elderly, disabled, women, and children. Art. XII, Sec. 11
Value the dignity of every human person and guarantee full respect for human rights. Art. II, Sec. 11
Recognise the role of women in nation building, and ensure the fundamental equality before the law of women and men. Art. II, Sec. 14
Protect working women by providing safe and healthful working conditions, taking into account their maternal functions, and such facilities and opportunities that will enhance their welfare and enable them to realise their full potential in the service of the nation. Art. XII, Sec. 14
Recognise the sanctity of family life and protect and strengthen the family as a basic autonomous social institution. It shall equally (underscore by author) protect the life of the mother and the life of the unborn from conception. Art. II, Sec. 12
Encourage non-governmental, community-based, or sectoral organisations that promote the welfare of the nation. Art. II, Sec. 23.

The Philippine government and the other signatories of the ICPD have an obligation to strive to make reproductive health accessible to all individuals of appropriate age as soon as possible and no later than 2105.

The Local Government Code of 1991 (RA 7160) had devolved delivery of some basic services, which include health, and social welfare, to the local government units (LGUs). Prior to this, the health care system was under the DOH, which is directly under the office of the Philippine President. Policies and programmes emanating from this office were uniformly implemented all over the Philippines, through regional offices. Under the regional office are various barangay (smallest political unit) health units. City health offices were directly under the central DOH office.

With the devolution, the local government executives were given the power to manage health and other basic services. The DOH is expected to facilitate the delivery of services by providing technical assistance and guidance to the local units. Standards for clinical diagnosis and management, and health facilities, structures, equipment, and supplies, are to be formulated by the DOH and serve to monitor and evaluate provision of services. The DOH still run the regional health facilities, including their hospitals which are of tertiary level in standards, and are the referral centres for cases which cannot be handled by the lower level units or the local government health facilities.

The promotion of the general welfare of the people within their political jurisdiction, is one of the responsibilities of each LGU. The promotion of health and safety, and the enhancement of the right of the people to a balanced ecology, are some of these activities they are expected to perform. Health services and social welfare services in the case of barangay, include maintenance of barangay health station (BHS) and day-care centre. Each barangay serves a population of up to 6,000. A midwife is in charge of a BHS, and is assisted by 6-12 part time volunteers called Barangay Health Workers (BHWs) who each serve 25-30 houses (purok). Another law has been passed regarding the establishment of day-care centres in resident communities and also in workplaces. General hygiene and sanitation, as well as solid waste collections, are also among the responsibilities of the barangay officials.

For a municipality, implementation of programmes and projects on primary health care (PHC), maternal and child-care, communicable and non-communicable disease control services, access to secondary and tertiary health services are some of their functions. Each municipality has one Municipal Health Officer who heads the Rural Health Unit (RHU) for every 25ž100,000 persons. She or he is assisted by paramedical staff (nurses, midwives).

In provinces and cities, health services are provided through hospitals and other tertiary health services. Population development services are under their social welfare sector. This means planning and development processes related to the enumerated actual services to be rendered by staff are under the municipal social welfare programme.

Local health boards are created to serve as advisors and advocates for health matters. The Board members are from the DOH as well as representatives from the private sector or PHCs. Their functions are to propose budgetary allocations for their facilities and services, to advice on administrative policies and procedures needed for their operation and maintenance, and other health issues and concerns. The DOH standards and criteria on technical, administrative, and other matters will serve as guide in their decision-making and recommendations to their local executive and legislative council sangguniang panlalawigan for the province, sangguniang panlungsod for the city, sangguniang bayan for the municipality, sangguniang barangay for the barangay.
Members of these sangguniang are elected by the people and are represented by people from all walks of life. Presidents of leagues of council members are ex-officio members.

The local development councils, which have a multi-sectoral membership, assist their corresponding sangguniang in setting the direction of economic and social development, and in coordinating the development efforts within their jurisdiction. Not less than one-fourth of the membership should come from NGOs which are accredited by the local sangguniang to be chosen from the other NGOs.

Following the 1994 ICPD and the 1995 Fourth World Conference on Women, the DOH created the Reproductive Health Programmes through an administrative order in January 1998. Ten elements were identified to be included as priority health care services under this programme: family planning, maternal and child health (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; breast and reproductive tract cancers and other gynaecological conditions; men's reproductive health; adolescent reproductive health (ARH); violence against women; prevention and treatment of infertility and sexual disorders.

A steering committee was supposed to have been appointed to coordinate and integrate all these activities under what was then designated as the Office of Special Concerns. The planned initial activity was an inventory of all efforts, initiatives, activities on reproductive health, including logistics, research and project-based activities. Based on these, a five-year medium term plan, and an operational plan were to be formulated. However, there was a change in the national leadership within six months of this administrative order. Since then, there have been a lot of changes in structures, and policies. There is no longer an Office of Special Concerns.

The newly designated office for Public Health then formulated the Women's Health and Development Programme (WH and DP) and the Women's Health and Safe Motherhood Programme (WHSMP) and also set a mission for the Reproductive Health Programme.

The WHSMP was established with the goal of institutionalising the women's perspective in programmes and services at all levels of the health care delivery system. Its strategies include capability building (gender sensitivity training and mainstreaming), research, information, education and communication (IEC), advocacy, legislative lobbying and networking with NGOs and women's groups. Initiated in 1995, the WHSMP undertook the role in improving women's health and status through government programmes. The project supported by five donor agencies, assisted the Philippine government in the improvement of women's health, well-being and status. The project has four components and these are Women's Health Service Delivery, Institutional Strengthening, Research and Policy Development and Community Partnerships. All components of the project have a five-year span, which ends in the year 2000 except for the Community Partnership that commenced in September 1997. This component deals with the establishment of partnerships among NGOs, local communities, local governments with the DOH, WH&DP and WHSMP coordinating all foreign assisted projects.

The Reproductive Health Programme's mission is to set, maintain and upgrade health standards; serve as catalyst to enable others to act; ensure that progress is being made to achieve the vision that "by the year 2010, Filipinos of all ages are enjoying the benefits of appropriate, accessible, quality and gender responsive health services" and are empowered to make investments and decisions in a caring and supportive environment.

Service provision in the planned or desired "re-engineering" and changes in policies and programmes at the DOH will include antenatal care, safe delivery, emergency obstetric care, and family planning, as part of the "Family Health Package" which will eventually be integrated with the "Reproductive Health Programme". The impact target will be to reduce maternal mortality ratio from 172 per 100,000 in 1999 to 100 per 100,000 in the next five years. Strategies of the Safe Motherhood Initiative include training, information dissemination, social mobilisation, community participation, promotion of gender sensitivity at all levels, quality assurance schemes, maternal mortality review, upgrading of facilities and equipment for obstetric emergencies, and making quality care accessible.

Another relevant feature of the current plans on health systems reforms is aimed at increasing access to health services, guided by principles of equity and sustainability. Three measures to attain this objective are the financing of women's health programmes through the Philippine Health Insurance Corporation; expansion of the private practice of registered midwives which was recently demonstrated to be feasible through pilot projects undertaken in some provinces; and the funding by DOH of small NGOs to deliver services in partnership with government. There is however still no solid and sound programme for men. Male participation is yet to be strengthened.

Reproductive health as a programme in the DOH has no specific budget of its own. Furthermore, the various elements that should be included are managed by different DOH units. So the MCH/FP and the National AIDS/STD Programmes have their own heads and their own projects. A large portion of their funds come from donor agencies, particularly FP and AIDS/STD.

The following briefly describes the general current situation in the Philippines regarding areas of concern in reproductive health of DOH, which should now be implemented by the LGUs:

There is still a high unmet need among currently married men (45.7 percent) and women (23.5 percent), based on the 1996 FP/RH baseline survey. One study has shown that one in five women reported a desire to space or limit their children but was not using any method to manage her fertility. Access to sterilisation (female and male) and intra-uterine device (IUD) insertion is limited because of the lack of skill and equipment/supplies at the service centres. The attitude of service providers towards sterilisation, IUD and emergency contraception, does not encourage clients to try those options. The promotion of condom as a method or for the prevention of STD/HIVAIDS has been strongly resisted by the Catholic church. In one province, the governor even declared in an administrative order, because of his religious beliefs, that only natural family planning methods would be practised by clients of the public health facilities. The NGOs have to provide all other methods. This province has been known to have high incidence of induced abortion, and to have traditional healers doing the induction.

Doctors at government, private, NGOs at all levels of the health care system provide pre-natal care, delivery services and post-partum care. However, women, particularly from the rural areas and urban slums prefer to go to the registered midwives and the traditional birth attendants (TBAs) because of the lower charges, their quick response to home service and their willingness to accompany the mother to the hospital in case of emergency. But many rural women seek ante-natal care very late in their pregnancy, which hampered early diagnosis of complications. Eighty-five percent of birth occur at home. Nevertheless, hospitals also register high numbers of deliveries and sometimes do not have enough beds for mothers for deliveries.

Most women who suffered from pregnancy complications did not have any or adequate or appropriate pre-natal or labour/delivery care. Iron, iodine, and vitamin A deficiencies are quite high among pregnant and lactating women and over 18 million Filipinos, mostly women, have iron deficiency anaemia. Foetal death rate, which is indicative of mother's health and nutritional status, has been on the uptrend.

Care of the neonate is also inadequate in many health facilities, especially in home deliveries. One out of five Filipino babies are born with low birth weight. A third (32.9 percent) of children 6 years and below are underweight and are stunted in growth (32.7 percent), based on 1993 data.

Child malnutrition has been associated with the decline in breast-feeding. One reason for this decline is the promotion of powdered milk especially in rural areas where midwives and other providers are provided with samples of powdered milk, in spite of the milk code. Health providers are also inadequately informed on the importance of breast-feeding. Moreover, mothers cannot breast-feed for long periods of time because of employment outside their homes. About 18.3 percent of infants up to 3 months of age are not breast-fed. Less than half (47.2 percent) are exclusively breast-fed (National Demographic , 1998).

Although immunisation and vitamin A supplementation are scheduled at the health centres, only 73 percent of infants were fully immunised, while 71 percent received vitamin A supplements in 1998 (National Demographic Health Survey, 1998). However, there has been a significant increase in infants being immunised before their first birthday.

In spite of induced abortion being illegal in the Philippines, and the Catholic Church pursuing a vigorous campaign against it, a lot of studies have shown that it still prevails. In 1993, about 400,000 women were hospitalised because of abortion complications (Perez et al., 1997). One study estimates that the induced abortion rate is 20 to 30 per 1,000 women, aged 15-44 (Reynolds J. et al., 1998). There are no estimates on how many women have died in the community because of unsafe abortion. It is generally believed that physicians and paramedical professionals provide safe abortion to some women. Those with the financial means can afford go to foreign countries for this service.

There are efforts to decriminalise abortion in certain cases of rape and incest. Meanwhile, the Catholic Church is campaigning against the use of contraception as it believes the use of contraceptive methods will lead to promiscuity and abortion. The government budget for family planning has been constrained by these beliefs among lawmakers. Funds for FP is practically all from donor agencies.

Data on reproductive tract infections (RTIs) are not available in the Philippines. A 1998 estimate of STD prevalence from 130 "social hygiene clinics" (where sex workers visited for examinations) revealed that from 1 to 6 percent of these women had various STD infections. Although STDs are reportable diseases, private clinics would not report such cases. Because women with STDs do not recognise symptoms as abnormal, they do not seek help early enough and just self-medicate. The males also self-medicate or they may go to RHUs and private "STD/VD clinics" for treatment.

There were a total of 1,168 new HIV/AIDS cases (from January 1984 to December 1998). It has been reported to have increased by 62 percent between 1997 (117) and 1998 (190). It is estimated that there are actually 35,000 to 40,000 infected with HIV/AIDS in the Philippines. Access to diagnosis and management are still quite limited, only about 300 private and public clinics provided HIV testing and two institutions for Western Blot tests. Care and treatment of AIDS patients is only in Metro Manila. Community-based care is still non-existent, because of lack of facilities and of prevalent discriminatory attitudes.

Republic Act 8504 established the Philippine National AIDS Council (PNAC) as the central advisory, planning, and policy-making body directly under the Philippine President, for the comprehensive and integrated HIV/AIDS prevention and control programme. This body is multi-sectoral/disciplinary with representatives from various relevant government agencies, and NGOs. The plan is to organise similar bodies in partnership with LGUs at all levels.

The same NGOs and other government agencies, have conducted awareness and training activities in sexuality/sexual health. IEC materials that have been produced for these activities are sometimes perceived as pornographic by the religious group. The DECS have adopted modules that have integrated HIV/AIDS concepts, but sexuality and sexual health are still not integrated. Gender sensitivity has not been adequately addressed in the training courses.

Training and utilisation of peer counsellors in school and in entertainment establishments have been done, but these have to be replicated and strengthened in more areas. Face to face, or small group interactions between health educators/service providers and people have been more effective in changing behaviour than large scale mass media campaigns.

Although pap smears are done at many health facilities, the results often are late due to distance of diagnostic laboratories and delay in sending the smears. Although NGOs campaign for prevention and detection of reproductive tract cancers, such screening tests, people are not responding due to cost and misconceptions.

Self-breast examination is not often taught to women clients/patients by health providers. Breast cancer is diagnosed often too late. Other cancers of the reproductive tract are also not detected early enough due to cultural taboos and practices.

Surgery for cancers is available at secondary and tertiary level health facilities, both government and private, but radiotherapy is possible only in a few cities. A good two or more ways -referral system needs to be in place to deal with the situation.

Most FP/RH educators and service providers are women, particularly at the community level, and traditionally, these women are reluctant to approach men. Men need their own clinic session and male staff to listen to their problems. Some NGO programmes have been able to reach men but this area need new innovations and strengthening.

The concept of male reproductive health is still not known by many. Sexual dysfunction highlighted by the media is for the promotion of Viagra. But physicians and other medical professionals usually do not bring up sexuality issues with their male patients, unless they are consulted.

There is a great need for adolescent health and sexuality programmes in the Philippines. NGOs and private health clinics do serve young people, more than the government, which have no special programmes yet for the youth.

Studies have shown that many adolescents are sexually active and engage themselves in high risk behaviours without protecting themselves from unwanted pregnancy or STDs, and do not consult health providers for their problems (Population Institute, 1994). A large majority (74 percent) of the total estimated illegitimate births occur among the 15-24 age group, 21 percent of out-of wedlock births are among the 15-19 years old, at least 20 percent of all maternal deaths are among teenage mothers, fetal deaths are more prevalent among babies born of young mothers who are usually of low birth weight (Institute for Social Studies and Action, 1998).

Various studies, media reports, and other sources, have already been done in the Philippines showing that violence against women is rampant. The DOH has establish the Women and Child Protection Units (WCPU) in all hospitals to provide care and manage victims/survivors of violence. Pilot projects carried out by the Women's Crisis Centre, together with government agencies and NGOs providing legal services, have been implemented in some government hospitals. This include space for WCPU, particularly on a long-term shelter. The Nueva Vizcaya UNFPA-DOH project is planning to initiate this programme in their RH project.

Infertility is a component of the RH programme, which helps couples who want to have children but are unable to. Service providers should be trained to manage these problems, not only male and female factors in infertility, but also menstrual problems and infections in women's reproductive system.

Nueva Vizcaya province has 15 municipalities and 275 barangays. The province has the highest maternal mortality rate in the region and the contraceptive prevalence rate is 35.5 percent, way below the 47.3 percent rate in 1993. Like many of the poor provinces, Nueva Vizcaya faced major problems in the health delivery system, such as lack of medical supplies and commodities and a weak clinical programme which hampered the will to provide adequate health care services.

This project, supported by UNFPA, started in 1997 with the integration of FP, MCH, nutrition, and STD/AIDS as the RH package. Staffs were provided training, and service facilities upgraded, including renovations, equipment, instruments, other logistics to enable the municipalities to provide such services to all who need them. Capacity building of Nueva Vizcaya project would be incrementally strengthened and gradually new elements of RH added into the services package.

To further secure commitment from various sectors, such as stakeholders, service providers, community volunteer workers and the government, a series of orientation sessions on FP/RH were held. Meanwhile, good support from the Governor and a good working relationships among members of the FP/RH Committee (who oversees the RH project), the local government and hospitals, services such as FP, MCH, STD/AIDS were able to be implemented. In some case where such services were already in existence, the Nueva Vizcaya project strengthened their capabilities and quality of their services.

Strategic plans for ARH, violence against women and men's reproductive health are being finalised, school and community-based activities, IEC and counselling through radio programmes, peer education and counselling are some of the strategies.

A review of the Nueva Vizcaya project identified some weaknesses and difficulties in the programme and these were endorsed by the RH Committee:

Functional integration of RH components are still incomplete. These are gender perspectives approaches to services for men, adolescents and unmarried women. Also, the operationalisation for an integrated RH service delivery, especially an effective referral system, is still at its infantile stage and the monitoring and supervision mechanism is still weak.
The review team also mentioned difficulties in expanding services from the traditional RH services to the larger and more specialised services. But, because of the increased awareness on RH, there has been increasing demand for such services. There are also demands for greater flexibility in determining the needs of various communities. The need for relatively specialised RH services to linked more closely vertically with community-based service delivery networks as well as horizontally with other departments/units within the hospital was emphasised.
The review team also found that current RH IEC is lacking and the strategy for RH IEC has not yet been formulated. Special groups such as the commercial sex workers are not reached in the IEC.
It has been noted that intra-agency collaboration is still being explored. The Management Information System has not been able to finalise the computerisation plan due to unforeseen problems.
There was a concern about the sustainability of the management structure which is project-based and which will be dissolved at the end of the project. The team did not see any options developed for either transferring the functions or absorbing them into the mainstream.

Some successes in the project has also been noted, these include:

The birthing centres in two areas are fully functional. It has been noted that there has no maternal deaths for the past two years (since project implementation), and infant mortality rate has gone down to lower than national and regional data. Some communities plan to share cost to pay for services by the birthing centres in order to help the more disadvantaged groups of people in the barangays. The centres also served neighbouring barangays.
A community-based STD clinic has also been established near the area of beer houses and bars. They have been doing Pap smears and providing on-site treatment for STDs. Clients pay a minimum fee for services rendered to them.
Reproductive health IEC materials are produced by and at the DOH with the help of donor agencies.

Some major lessons learnt from this experience, as gathered by the review team are as follows:

Political commitment to reproductive health and responsiveness to gender issues, from among governors, mayors, health managers and providers, are vital for successful planning and implementation of RH programme. It can help legitimise the programme, and that can lead to understanding and acceptance. But without resources, the programme cannot survive.
Decentralisation is a labour-intensive undertaking, especially for a complex programme, like RH. For the programme to succeed, capacity building must be carried out prior to starting the programme.
Most providers, especially at the community and municipal levels, will not be able to offer a complete package of integrated RH services. They will either have to limit their package to a core set of services or refer them to relevant centres. A smaller, "core" Reproductive Health Package of Family Planning, Maternal and Child Health, and Reproductive Tract Infections/STD/HIV/AIDS can be implemented by the BHS, Rural Health Units and NGOs.
Two-way referral network involving district, provincial and private hospitals will be the best way to add services. Regional or teaching hospitals can be consulted for specialised services (e.g., infertility, sexual dysfunction, reproductive tract/breast cancer, HIV/AIDS diagnosis and management, etc.). RH packages that include expensive, and specialised treatments (e.g., for cancer treatment, infertility treatment, AIDS diagnoses) will be too costly to implement.
Men and adolescents are not attending the clinics that were designed for them. Some NGOs do provide services for these two groups of people and the public sector can learn about such programmes from them.
Competent, adequately trained nurses and midwives are able to take on the managerial, supervisory as well as technical roles in the service programme. They and other local health resources should be utilised optimally in the programme.

The Project Review Team concluded that it would take a longer time to determine whether the project will be successful. The team though believes that this is "undoubtedly the most significant UNFPA-supported project" which attempts to operationalise a fully integrated RH service package. But the long-term benefit of the investments in terms of training, equipment, and facility renovation at different levels of the Nueva Vizcaya health system will not be known until after the DOH reorganisation is finalised and operationalised.

Service statistics from LGU health centres show that clients do not utilise these facilities for STD diagnosis and management. Family planning has been integrated with MCH at these clinics. But apparently, FP or MCH clients (mostly women) with signs and symptoms or those at risk of STD either do not complain about these or their complaints are ignored, since the service providers are not trained or experienced in dealing with them.

It is at the "social hygiene clinics" where sex workers employed in establishments are required to regularly report for examination. They are given a "pink slip" which certifies that they had no evidence of STD or RTI. Streetwalkers and other women who solicit money through sex would not go to these clinics, nor would any other women who would be afraid to be labelled or suspected to be a prostitute. They would go to a private doctor or drugstore for medication. Men who suspect that they have STD would also do the same.

The Family Planning Operations Research and Training Programme of the DOH and the Asia and Near East Operations Research and Technical Assistance of the Population Council, Manila, decided to sponsor a project to study the feasibility of integrating RTI management within FP/MCH services of local government health centres. Three different types of communities were selected for the study: twohighly urbanised health centres, three middle-sized city health centres and two from rural setting.

The aim of the intervention study was to strengthen the capacity of local health centres to manage RTI cases, and to analyse the eventual costs of this type of change. The study showed a marked increase in the identification of RTIs among the regular family planning clients in the provincial health centres. There were still difficulties in complying with the case management guidelines and record keeping three months after their care. Another finding was the infrequent presence of physicians in clinics. The other staff were not trained to diagnose and manage these cases. There was no continuity in data collection of activities that were carried out. Three major activities that include training of service providers on RTI case management and of medical technologists on technical skills, upgrading of laboratory facilities and provision of drugs, and community
awareness campaigns with IEC development, were found to be necessary for the integration of RTI management in health centres. Before these activities were undertaken, focus group discussions on local perceptions and behaviours related to RTIs, and later a situational analysis of the local health centres were conducted.

The term "devolution" in the Local Government Code of 1991 refers to the act by which the national government confers power and authority on various LGUs to undertake specific functions and assume certain responsibilities. Even with this code, the local governments are still under the control of the national government because they are within the national laws. The DOH cannot dictate to the LGUs on the types of health service they should provide. It is done through establishing relationships with the local health boards, the local development councils, or the chief executive officials themselves. The regional offices who provide technical assistance and serve as monitors in the utilisation of standards set by the DOH, have not been able to function adequately as these regional offices have been mandated to be phased out.

LGUs, now the executing body of all health programmes, provide the basic services. With this change in the management structure, the staffs need to adjust to the current programme and management. Likewise, the people, other government sectors, NGOs involved in programmes are also required to change their operations, thinking and behaviour. Considerable change is, therefore, involved. There are about 74 regular provinces and 10 provinces in 2 autonomous regions, 79 cities, 1,536 municipalities, more than 42,000 barangay in the Philippines scattered over 7,000 islands. The officials of these units are expected to plan and implement their own health programme. They have been providing traditional services all these years under the DOH and only in 1987, PopCom handed FP over to them.

Therefore, considerable preparation is necessary for effective devolution. Case studies, however, have shown that there was a lack of preparation for the transition from a centralised to a devolved health care system (Update, 1998). The information and education campaign on the vision, mechanics, and implications of devolution on the key players and on the people, was found to be ineffective.

Due to inadequate preparation, the performance of the LGUs varies considerably. There are many governors and mayors who have been quite supportive of the health sector programmes and services. Medical doctors who became public officials of course have a tendency to promote health aspects in their communities. On the other hand, the prevalent interpersonal and political conflicts have affected the functioning of some of the Local Health Boards, particularly on the selection of the members. Government officials have been known to place their own friends on the Board and sometimes put up their own "NGOs" to ensure that their interests would be served. Thus, the needs of the poor and disadvantaged, often does not get attention in these boards.

LGUs have put in considerable efforts in strengthening the management of health programmes. One such initiative is the Local Government Unit Performance Unit Performance Project that provided 15-20 LGUs performance grants each year for the past four years for programme implementation. However, the LGUs have generally not taken advantage of the special capabilities of NGOs and the private sector in contributing to activities for the promotion of health in their areas. NGOs are seen as some kind of competition and NGOs are also critical in viewing public programmes. While the private sector is providing basic and hospital services especially in towns and cities, NGOs serve the marginalised and those who head their services.

The Philippine government, by obligation of the Social Reform and Poverty Alleviation Act, needs to respond to the needs of the poor or marginalised sectors of the population. These groups include the farmers and landless rural workers, fisherfolks, indigenous people, formal and informal sector workers, urban poor, senior citizens, persons with disabilities, disadvantaged women, youth, children, victims of disasters and calamities, migrant workers and members of cooperatives. The Minimum Basic Needs Approach has been adopted in the implementation of the Social Reform Agenda. These needs are
classified into three categories: 1) survival needs Ñ health, nutrition, and water and sanitation; 2) security needs ž income, shelter and peace and order; and 3) empowerment or enabling needs ž basic education and political participation. The BHWs who are already carrying out Social Reform Agenda activities, are also responsible for identifying RH needs of the community. However, this has not been so because they are part-time volunteers and require supervision. BHWs are mostly women community residents who are able to effectively communicate with other women. But men
and adolescents may not feel free to discuss intimate and sexual topics with these women, many of them are known or even related to them. Male clients felt more at ease with health providers or educators who are male and the youth preferred their peer educators.

The UNFPA Project Review Team also cites the following constraints in the implementation of the RH programme in the Philippines: lack of awareness and understanding of RH concepts among policy-makers, executives, managers, providers and the general public; lack of funds for implementation of programmes; absence of organisational capability for the programmes; resistance from the Church, legislators, LGUs, DOH employees and others. Facilitating factors are the support for the ICPD movement, and donor funding for RH but sustainability is the battle cry of all donor agencies as they themselves have problems in securing funds.

The ICPD was held during the term of President Fidel Ramos (1992-98). His
predecessor, President Cory Aquino, a devout Catholic, felt indebted to the Catholic Church for her helping her gain her position. There was a freezing of funds for family planning. But the family planning service was transferred from the PopCom Ñ at a time it was headed by a conservative Secretary of Social Welfare and Development Ñ to the DOH by the Secretary of Health, who favoured the FP programme in the context of MCH. President Ferdinand Marcos had formed PopCom for population control during his presidency.

President Ramos was quite supportive of the ICPD reproductive health thrust. It was also at this time that the Local Government Code of 1991 was signed and gradually implemented. Each LGU would decide on how national policies would be operationalised. The executive branch under President Ramos, had promulgated three policies related to the principles of the ICPD: 1) gender and development; 2) the social reform agenda; 3) the human ecological security. Resources were allocated for the implementation of these policies. However, there has been no significant implementation of these national policies at the local levels. It is felt that the absence of appropriate mechanisms has resulted in low compliance at the lower levels where these policies should be concretised.

One reason for low compliance among local executives is their brief period of incumbency and consequent preoccupation with reelection. They are elected for only three years each term, but can be re-elected up to a maximum of three terms. Subsequently, many local officials aspire to run for a higher government position or to be appointed to one. They are, therefore, reluctant to advocate for any controversial policies or programmes. Many feel that reproductive health would be a sensitive issue, given the Catholic Church's actively campaigned opposition since the ICPD, which they regard as evil and sinful.

The Department of Interior and Local Government was not represented at the ICPD or the Fourth World Conference on Women or other significant UN conferences where reproductive health was discussed. There is still lack of awareness on what reproductive health really means and what elements it encompasses, so there are no advocates for this programme in the LGUs. Furthermore, the Local Government Code divided these elements between the health and social welfare sectors, and the population officer position is optional. So it would be those LGUs who have a good understanding of how RH programme would be beneficial to their constituencies and their political career. The DOH should be able to lead in helping LGUs understand this, and facilitates the development of RH programme.

It was only recently that President Joseph Estrada, the incumbent Philippine President, expressed concern about the population growth of the country. It is hoped that the LGUs would promote reproductive health with the push from the president. The DOH and NGOs concerned with women's health and reproductive rights would do well to capitalise on the President's pronouncement, and prod him to facilitate allocation of resources and support of programmes to promote reproductive health.

As the governance of countries become more complex, administrative institutions have been developed to enable them to perform new functions and to respond to emerging needs and solve public problems (Jong, 1996). It has also been shown that governments have shifted their attention and resources from traditional activities (collecting taxes, maintaining defence forces, etc.) to new programmes for the provision of human services, development of human resources, and solution of complex societal problems.

Resource- and capability-building needs must be addressed for the LGUs to be able to implement the health programmes and provide the services. In addition, there persist cultural-related debates on reproductive rights, sexuality, gender equity, even among the decision- and policy-makers who allocate resources. Right now, the programme depends upon external donor agency support while it initiates efforts for sustainability. Funds and other types of support should be sourced from national, regional, and local bodies, and perhaps, even from international agencies. Continuous advocacy for the programme must be conducted.

The development of a comprehensive RH programme should be undertaken by LGUs Ð one that would put together all the elements that are in the Cairo ICPD-POA. If possible, a one-stop shop facility must be accessible, with quality service rendered by gender-responsive, competent health personnel, planned and implemented with participation of the people themselves. The following are some suggestions for the development of an incremental and public health approach to provide a constellation of services (gathered from an evaluation of the UNFPA Reproductive Health Projects in the Philippines Reynolds, et al., 1998):

Identify/assess the status of available RH services- specify strengths, weaknesses and gaps;
Prepare action plan for addressing the gaps/weaknesses;
Strengthen/establish links among these services (inter- and intra-services or units), with mechanisms for sharing of resources, and developing and maintaining a viable referral system;
Continue to create a better understanding of the social, cultural and behavioural aspects in which RH problems occur;
Regularly monitor and evaluate the services and efforts, and provide technical assistance. Recording and reporting must be timely, accurate, complete, relevant, disseminated, and used for planning and improving services.

Other relevant sectors, including professionals in private practice, in business, the academe, must be involved, particularly because of the multi-social dimensions of public health problems. Theirs must be a sustainable health programme which responds to the needs of individual women in a holistic way. Some measures adopted, which have increased access to clients (Ereneta, 1995), are effective referral systems, extended hours of operation, grouping or related services in one location, community outreach or mobile services and small service outlets.

LGUs are expected to be involved in the development of their particular areas and should address fundamental problems of poverty, inequity, and social justice. "The devolution of basic health services to local government units provides the opportunity to local elective officials to pursue area-based planning", says Victoria Bautista in her article "Alternative Delivery Systems in Health" (Bautista, 1995). A more responsive plan formulation would be developed since the local officials are knowledgeable about the problems of their communities. This is better than a top-down, sectoral, centralist approach where services are planned and implemented, no matter what the conditions are, Bautista remarks. LGUs can learn from experiences of many PHC/community programmes which have been successful in the past, in the development of their RH programmes. Bautista (1995) believes that new modes of health service delivery by LGUs can be established, maintained, and institutionalised, with the implementation of the Local Government Code.

Another helpful feature of the Local Government Code is citizen participation in local development. Bautista cites in the Code, Rule XIII, Article 183 of the Implementing Rules and Regulations (IRR), where barangay development councils (BDCs) are directed to "mobilise people participation and to make citizens involved in the functions of BDCs." Additionally, the IRR also stipulates that NGO representatives should not be less than one-fourth of the fully organised council at the provincial, municipal, and the barangay levels. This way, NGOs have greater opportunities to be able "to supplement or augment the services delivered by government" (Bautista). This is essential in the provision of RH programmes, where NGOs have greater flexibility and autonomy, to be able to reach people who are hard to reach because of the illegality of their work (sex workers or drug users), or because of the sensitivity of their situation Ð adolescents who need family planning methods because of their sexual activities, for example. NGOs are recognised in the Philippine Constitution as vital partners of government for a lot of its development work.

Among the potential problems/apprehensions felt by health sector officials and personnel at the start of the Local Government Code implementation were (Giridhar et al., 1999):

Local decisions may not support and their objectives may not be consistent with the national health programmes like FP/RH programme goals because of inadequate planning and skills, or non-understanding of local health system or situation may lead to unrealistic service delivery objectives and interventions or even non-prioritisation of some health programmes;
Central level may not agree with local priorities and may not be willing to provide augmentation support to these, and national standards on health services may be inappropriate or non-implementable at some local areas;
Local political affiliations/loyalties may inappropriately influence selection and promotion of health staff;
Local level staff may not have the skills to manage finances particularly for the foreign-assisted programmes and weak supervisory skills may result in applying national health programmes health standards of quality care;
Referral systems and outreach activities may discontinue if the local government does not have sufficient funds to cover transportation costs; and
Existing health benefits may not be given to health personnel, especially for the low income municipalities.

Different categories of health personnel in the province of Nueva Vizcaya, however, have also identified some "potential advantages or benefits" of the devolution of health programmes (Giridhar et al., 1999):

Local decisions are made faster with less bureaucratic restrictions.
Local executives have a clearer picture of, and better insight into their own local health situations (they used to rely on national reports), and so appropriate IEC, clinic services, logistics, supervision, other activities can be determined
Health services can be more easily integrated or coordinated and also expanded, with other health and non-health related services and better organised to respond to the total needs of clients. Different agencies now get to know what others are doing. The local mechanisms (local health and development boards, different sangguniang are utilised.
Medicines, medical supplies, instruments and other needs for health service delivery were provided based on their local health situation, and not on what the central or regional offices uniformly purchase or obtain for different areas.
Strategic and area-based planning and programme performance are done together by representatives of various local government agencies and NGOs, with a good deal of sharing of information, experiences, expertise, and views. Opportunities for developing new or innovative activities are, therefore, increased.
LGUs are compelled to seriously address the issue of financial sustainability and maximise local revenue generation.
Staff recruitment can be done within the communities served by the programme.
Local service providers can participate and coordinate their programmes more efficiently because of a feeling of ownership, established performance objectives and accountability for meeting these objectives.

The following is an excerpt from a report of a team of consultants on a field visit regarding the effect of decentralisation on health care delivery system (G. Giridhar et al, 1999):

"The issue of integration, both functional and vertical, and even multi-sectoral, is slowly finding its way into institutionalisation. Health personnel are slowly seeing the broader perspective of health service provision that is client-focussed, and not confined to the traditional fragmented and programme-focussed delivery of health services. The concept of RH approach is now getting rooted and even the governor himself was able to explain [very well] what RH approach is in simple practical manner..."

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Ereneta, Ramon R. (1995). "Panibagong Sigla 2000: New Directions in Public Service Delivery." Public Administration by the Year 2000 (Tapales, P. D. and Pilar, N. N., eds.). Quezon City: University of the Philippines Press.

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Reynolds, J., Iyengar, S., Widyantoro, N., Quintong, J. (1998). Operationalising the Philippine Reproductive Health Programme Ð A Review of Experiences to Date (A Report to the United Nations Population Fund), Manila, Philippines, December 1998.

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