Asian Journal of Public Administration Vol

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

EVOLUTION OF THE PHILIPPINE HEALTH

CARE SYSTEM DURING

THE LAST FORTY YEARS OF

DEVELOPMENT ADMINISTRATION

JOAQUIN L. GONZALEZ IIIThis article discusses the influence of the evolving development administration emphases - centralisation and

decentralisation to health care delivery in thePhilippines during the last four decades. It shows how

prescriptions during the1950s and 1960s led to the creation of a centrally planned Philippine health care system.

The dysfunctions of this centralised system motivated development administrationspecialists to call for

decentralisation in the 1970s. Initial attempts atdecentralisation were mainly functionally and structurally-oriented,

that is, the health care bureaucracy was reorganised and streamlined to ensure improved programme

implementation especially at the local community level. However, the limitations of structural decentralisation

created the demand for process decentralisation effortsan approach which concentrates on more social-

behavioural changes and active stakeholder participation. Process decentralisation was used not only to improveimplementation but also to ensure sustainability. Governmental andnon-governmental organisations of the 1980s

andearly 1990s have emphasised this dimension of decentralisation as manifested in their projects and

programmes.

Introduction

Development administration is an emerging interdisciplinary field of scholarly research.

Although some academics argue that the practice of development administration could be tracedas far back as the history of man on this planet, the available literature indicates that the

integrated and systematic study of this field began to flourish only after World War II. This was

a period in history when most nations, rich and poor, initiated systematic programmes ofeconomic development and social and political change. Being a multidisciplinary field, the study

of development administration has evolved with conceptual influences from a variety of

established disciplines (for example, economics, geography, management, sociology,psychology, political science, health, biology, and engineering). An analysis of development

administration theory has revolved over three rather distinct approaches each with its own

theoretical underpinnings and each with its own concepts of success and failure. Since

development administration is closely tied to concepts of political economy, both economists andpolitical scientists have played a role in defining the scope and focus of this process.

This article discusses the general theoretical interrelationships of key developmentadministration approaches and their impact on Philippine health care effectiveness during the

past forty years. These three concepts are:

1. the centralised planning approach;

2. the decentralised structural approach; and

3. the decentralised process approach.

This article concludes with some conceptual and practical constraints on which present and

future public health care managers and providers should reflect.

Centralised Planning Approach

Justifications for Centralisation

1. Economic imperative


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Based on the linear growth theories (for example, the Harrod-Domar Model and the Rostow

Model), development economists argued that planned change was more or less considered to be

synonymous with capital formation. Development experts believed that once capital isaccumulated and reinvested, it would increase production and employment, which would also

raise the income-generating capacity of the population in general. The planned economic growth

system prescription is supported by development economist Amartya Sen who identified similar policy themes as the proper approach to the problem of development, including:

industrialisation; rapid capital accumulation; mobilisation of underemployed manpower; and

planning and an economically active state.

Sen, among others, argued that centralised development through industrialisation is definitely

important if any Third World economy is to accumulate capital and to emerge from its

backwardness. According to mainstream development economists, capitalist profits are the mainsource of rapid capital accumulation. If an unlimited supply of labour is available at a constant

wage, then the rate of profits on capital would not fall. If any part of the profits is reinvested in

productive capacity, profits would grow continuously. Capital formation would also growcontinuously and development would then take place rather naturally. Moreover, besides rapid

capital accumulation, there must also be the existence of an entrepreneurial class willing toinvest and control accumulated capital in industrial activities.3 Mainstream writers believe these

preconditions must be satisfied to propel a Third World nation's economic development efforts.

According to these same development writers, the establishment of an active state and a system

of centralised planning is needed to overcome the dysfunctions associated with "lateindustrialisation."

Because most Third World countries lack an industrialised sector relative to the advanced

developed countries, it is believed that a strong state apparatus is needed to protect the interestsof the indigenous capitalist class. Indeed, a large part of the industrialisation process would be

carried out and financed by the state itself. Yet in the case of most Third World societies, thestate was perceived to be more an instrument of foreign capital and its local surrogates.

2. Dependency perspective

Andre Gunder Frank, Johan Galtung, Enzo Faletto, Paul Baran, and Fernando Cardoso argued

for a Neomarxist perspective for stimulating development. Frank's research findings on Latin

America emboldened him to argue against Sen and the other mainstream developmenteconomists along the following lines: underdevelopment and undevelopment are two different

concepts because the presently developed countries were never underdeveloped, though they

may have been undeveloped; underdevelopment is not an internal condition; the mainstream

thesis of a dualist society put forward by Arthur Lewis and stages of linear economic growth proposed by Walt Whitman Rostow and Harrod-Domar are false; - contemporary

underdevelopment is in large part a product of past and continuing economic, political, and

social relations between the underdeveloped satellite and the developed metropolitan countries;and satellites have been observed to develop faster when their ties with the metropole (highly

developed countries) are weakest.5


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Frank concluded that development would be most effective if the satellite "delinks" itself from

the metropole. For Frank, the mechanics of how to effectively delink is the main issue in each

Third World nation because each of them has different degrees of political, economic, and sociallinks with the metropole. Compared to Frank's Neomarxist prescription, a classical Marxist

would probably see domestic social revolution as the initial step to delinking. Despite their

differences, it seems that development economists from the mainstream, Neomarxist, andclassical Marxist perspectives all agree that a centrally planned economic system is necessary to

propel development.

3. Administrative Synthesis

In the 1960s, the goal of development administration all over the world was based upon planned

economic growth.6 In separate studies, Montgomery and Milne noted that if development was to

occur it was supposed to be manifested as planned changes in the economy (in agriculture orindustry, or the capital infrastructure supporting either one) and, to a lesser extent, in the social

services of the nation-state (especially education and public health).7 Several authors followed

with their own parallel arguments on the need for a centrally planned developmentadministration. Friedman argued that planned change should include two components: the

implementation of programmes designed to bring about modernity; and changes within an

administrative system which would increase its capacity to implement such programmes.

Inayatullah argued that development administiation is supposed to be carried out with a heavy

emphasis on planning by public authorities in order to succeed in attaining socio-economic goals

and nation-building. One of the leading authorities during the 1960s, Fred Riggs argued thatlong-term development changes are the result of collective decisions organised in a cohesive

plan and implemented through a western-oriented system of administration. According to G.

Starling, development planners used this capital accumulation-based economic growth plan tosurvey current economic conditions and the social situation; to evaluate preceding plans; to state

new objectives, estimates of growth, suggested measures to raise growth rate; and produce a

revised programme of government expenditures.

Predominant Management System

As implied by the discussion above, the most common development management system

prescribed by development experts to complement this economic objective was the utilisation ofstrong centralised control and supervision over all development endeavours through the nation-

state's administrative bureaucracy. The centralisation of goveminent refers to the dominant role

taken by the central, as opposed to the local, administrative units (for example, municipalitiesand village communities). Centralisation manifests itself in the governmental bureaucracy

adopting the roles of revenue collector, distributor of financial aid to local units, creator of

standards to be followed by local governments, and implementor of services throughout its

territorial jurisdiction by means of central government officials. Strong executive leadershipfrequently complements these centralisation traits.

Development administrators believed that using this centralised management system wouldenable countries, which had just gained independence from their colonial masters, to harness

their scarce resources towards the goal of acquiring much needed capital. In addition,

centralisation of control was prescribed by international financial institutions as part of theirassistance package towards modernisation. Policy-makers in these international financial

institutions thought comprehensive national planning orchestrated by the state would direct the


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resource-allocation of the country into appropriate investment areas. Some of the investment

areas they had in mind were: export-oriented industrialisation, import-substitution

industrialisation, agricultural exports, and raw materials export.13

Centralisation in the Philippines

A centrally planned economic system was already in place in the Philippines as early as the

1600s. The Spaniards were the first to establish an administrative system that unified thePhilippine Islands. Through the traditional hacienda system, the Spaniards established massive

plantations that produced coffee, sugar, and spices for consumption in Europe. Spain utilised this

economic system to exploit the resources of the Philippines until the late 1800s. After losing theSpanish-American War, Spain was forced to cede the Philippines to the United States under the

Treaty of Paris in 1898. The Americans continued the concept of a centrally planned economic

system, focusing however on their own interests. The Americans saw the Philippines as a sourceof raw materials and a market for American- finished products. In addition, the Philippines was

established as a base for penetrating the growing Asian markets in China, Japan, India, and the

Middle East. The United States lost the Philippines to Japan during the Second World War.Under the Japanese, the centrally oriented economic system in the Philippines was again used to

channel much needed resources to another nation. On July 4,1946, in accordance with the provisions of the Tydings-McDuffie Independence Act, the Philippines was granted

independence by the United States of America. Filipino administrators found themselves facedwith responsibilities far greater than they had envisioned. The Second World War had left the

Philippines with severe economic and physical destruction. Within months after the declaration

of independence, Filipinos found themselves requesting development assistance from the UnitedStates. In 1950, the Philippines asked the United States to send a survey mission "to recommend

measures that will enable the Philippines to become and to remain self-supporting."14 In response

to this request, the American government sent a team of elite consultants headed by Daniel Bell.The Bell mission provided a very dismal picture of the economic and political realities of the

Philippines. The Bell mission made numerous recommendations in response to this post-War

situation.

Following the logic of the current thought on administrative reform, they recommended the

revival and enhancement of the centralised administrative system, which was established before

the granting of independence. The Bell mission noted that the Philippines inherited from theirAmerican colonisers a "reasonably well-organised administration and a well-trained civil

service," but the war and the disarray that followed made it difficult to restore the administrative

efficiency it used to enjoy.15 A centralised administrative bureaucracy recommended by the Bellmission would facilitate the political and economic rebuilding of the country. Based on these

recommendations, the Philippines adapted a planned economy heavily geared towards the

exportation of agricultural products and raw materials. The trade-off for development financing

to the Philippines was the establishment of American military bases in selected strategiclocations around the country.

Politically, the Philippines responded to the Bell mission recommendations by establishing theGovernment Survey and Reorganisation Committee (GSRC) under the Philippine Republic Act

No. 997.


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The GSRC was tasked with the recentralisation of the administrative bureaucracy based on the

specifications it had before the Japanese occupation of the Philippines. The GSRC conducted

evaluations and made organisational adjustments to government agencies pertaining toagriculture and natural resources, commerce and industry, economic planning, education and

culture, health, labour, public works and communications, revenue system and statistics, and

allied research. This marriage between centralisation and planned development was clearlymanifested in the high priority given to the reorganisation of the National Economic Council, the

central planning body of the Philippine government. The prescriptions of development experts

for reforming the Philippine administrative system clearly reflected the dominant trend inAmerican public administration, which was the creation of a Weberian notion of bureaucracy. In

addition, the GSRC subdivided the country into eight geographic regions: Region I (Dagupan

City); Region II (Tuguegarao, Cagayan); Region III (Manila); Region IV (Naga City); Region V

(Iloilo City); Region VI (Cebu City); Region VII (Zamboanga City); and Region VIII (DavaoCity).

The guiding principles of the National Economic Council were used as the main blueprint for

development planning in the various regional development bodies that were created. Theseregional development entities were the Mindanao Development Authority and the Central Luzon

Cagayan Valley Authority (both organised in 1961); the Hundred Islands Conservation andDevelopment Authority (1963); the Panay Development Authority (1964); the San Juanico

Straits Tourist Development Authority (1964); the Mountain Provinces Development Authority

(1964); the Mindoro Development Board, the Bicol Development Company, and the

Catanduanes Development Authority (1965); and the Laguna Lake Development Authority(1966). Each was highly centralised and structured to reflect the logic of modern public

administration theory. The recommendations for the establishment of a reorganised central

administrative structure affected all government departments including the Department ofHealth. Based on this planned development model prescribed by the Bell mission and adapted

into law by the Philippine legislature, the Department of Health established a system of hospital-

based health care administered by and accountable to the head office in Manila. A major part ofthis centralisation plan was the creation of Presidential Sanitary Divisions which sought to

extend the administrative grasp of policy-makers to a number of presidentially selected rural

areas. Manila-trained public health professionals were quick to reject local health systems in therural areas as primitive and ineffective labelling traditional village-level healers as "quacks"

who often did more harm than good through their "herbal concoctions and cures." The

Department of Health presented alternatives to the traditional health system by dispatching

medical professionals who prescribed drugs manufactured in the West. Unfortunately, as thepopulation grew, the demand for health services also expanded. The Department of Health then

found itself unable to keep up with the demand for more medical professionals and western

medicine because people with even minor ailments travelled great distances demanding to see adoctor in the government hospital. On top of bedside duties, public health professionals in this

centralised health care system were also laden with administrative responsibilities like planning,

budgeting, and personnel management. In the late 1950s, Presidential Sanitary Divisions wereslowly replaced and renamed Rural Health Units (RHU). Rural Health Units were established in

every municipality. The Department of Health introduced the health team approach in each Rural

Health Unit. Distinct but complimentary roles were assigned to a Rural Health Unit team


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composed of a public health doctor, a public health nurse, and para professionals (for example,

midwives and sanitary health inspectors). This new system authorised public health nurses and

paraprofessionals to deal with simple cases requiring immediate attention and to educate thecommunity on healthy habits and practices.

The public health physician was required to deal only with the most demanding and difficult

cases aside from his administrative duties. Further consolidation of the Department of Health'scontrol over the administration of rural health care services was implemented in the

reorganisation of 1958. Instead of creating more autonomous units, the reorganisation of 1958

increased the centralised power of the health bureaucracy by adding more national-level staff andadministrative, regulatory, and advisory bodies. The full implementation of the reorganisation

plan was completed in the 1960s. Instead of decentralising its administrative responsibilities, the

reorganisation of 1958 further consolidated the supervisory and administrative powers of theDepartment of Health through bureaucracy-related structural changes, that is, creation of new

units and removal of offices with duplicating functions.With the exception of the creation of

regional offices, these organisational reforms only reinforced the central planning function of theManila-based health bureaucracy. These offices also created additional bureaucratic conditions

for field operations to pass through. Some of the reforms were changes only in agency name butdid not affect the service-delivery and operation-effectiveness of the office, e.g., the Bureau of

Research and Laboratories was renamed the Public Health Research Laboratories same dog,new collar. Even the creation of regional offices was not enough to bring health care service

planning and implementation closer to the people in the village communities. The main

beneficiaries of these reforms were politicians and bureaucrats who were able to use the newlycreated positions in the Manila office as political rewards. Additional organisational changes

between 1958 and 1969 again reinforced the centralisation of planning and administration in the

Department of Health.

As in the case of previous reforms, organisational changes during this centralised development

period streamlined the planning operations of the bureaucracy but showed only symbolic concernfor field operations. They remained oriented towards the prescriptions of public administrationfor the use of an effective centralised Weberian bureaucracy.

Outcome of the Central Planning Approach

This period of planning-oriented development characterised by a centralised and top-to-bottom

planning and management process had little effect on people at the village community-level.Based on central planning principles, practitioners and scholars of development administration

during the 1960s assumed that the careful anticipation of the village community's problems and

the meticulous application of the central government's prescriptions would lead to success. If

implementation failed it was blamed on the beneficiaries' negligence in following procedures thatwere carefully described in the initial project blueprint.23 The people at the national level

assumed that they knew what was best for the people at all levels of the political system, from

the nation-state to the village community-level.24 Practitioners of planned development adoptedthe following simple procedures to project design:

1. identified the mistakes in former blueprints;

2. prepared contingencies ahead of time;3. laid out a plan that incorporates the contingencies; and


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4. accomplished the goal.

Unfortunately, centrally planned development did not lead to the expected capital accumulationand rapid economic growth in a significant number of less developed countries. One reason was

the prevalence of the self-interest of those administering the economic development plans under

the centralised system. Another reason was that different interpretations of these national plans

led to conflicts over how to implement development efforts. The most glaring fact was thatinstead of alleviating the problem of resource inequity, the gap between a small rich minority and

a larger poor majority widened. Quality health care remained within the reach of only the

privileged segment of the population who lived in metropolitan Manila. In addition, theimplementation of the central government's development plans at the local level met heavy

resistance especially from the very people they were supposed to assist. The carefully laid out

programme and project plans met failure especially when it came to village-levelimplementation. As demonstrated by development strategies in general and the Philippine health

care experience in particular, the predominantly centralised management approach used during

this period did not allow for participation by the lower units in development planning. This ineffect limited the implementability of development activities. Within the Department of Health,

implementation of health care services at the village community-level was hampered by theconcentration of manpower in the central office in Manila and other urban centres. This

arrangement existed notwithstanding the fact that 80 percent of the population lived in the ruralareas. The creation of regional offices in 1958 did not provide for delegation of functions and

authority. A heavy concentration of administrative duties and responsibilities (for example,

appointments, leave matters, promotions, teaching permits, and overtime services) was stillfound in the Manila Central Office. The health problems of the 1970s were not much different

from the 1950s.

Decentralisation Structural Emphasis

Shift in Focus of Development Administration

Development experts believed that a solution to the dysfunctions associated with planneddevelopment through a highly centralised administrative system is to decentralise the

bureaucracy. The problem of implementing plans through a centralised development approach

has led to a call for a more decentralised administrative approach to development administration.In one of his studies, Dennis Rondinelli summarised a plethora of arguments for a more

decentralised approach to planning and implementation, including:

1. Decentralisation affords greater authority for development planning and management toofficials who are working in the field and hence closer to the problems.

2. Decentralisation cuts through the enormous amounts of red tape and the highly structured

procedures.

3. Decentralisation allows greater representation of various political, religious, ethnic, and tribalgroups in development decisionmaking.

4. Decentralisation increases administrative capability among local governments and private

institutions in the regions and provinces; and5. Decentralisation institutionalises the participation of citizens in development planning and

management.


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In order to increase the likelihood of implementation, development experts of the 1970s

concentrated their decentralisation approach on prescribing ways and means aimed at reorienting

the structure and function of the governmental bureaucracy as evidenced by Rondinelli'senumeration above. This type of decentralisation was the same response provided by American

public administrators during the debureaucratisation efforts of the United States in the 1930s and

1940s.27 A major reorientation of the structural and functional prescriptions was supposed tomake the administrative system more effective in implementing development plans especially at

the community level. The reoriented organisational structure should allow participation in the

decision-making process by field personnel and target beneficiaries. This was assumed to be thekey to successful implementation. There are basically four major types of structural

reorientations advanced in the decentralisation literature: deconcentration, delelation, devolution,

and privatisation.28 The first three pertain to different types of structural bureaucratic reforms

used to decentralise whereas the fourth refers to non-governmental alternative delivery systems(for example, PVOs, NGOs, IGOs). It was argued that the use of nongovernmental entities helps

alleviate some of the lesource inadequacies of the governmental bureaucracy. These non-

traditional, nonhierarchial, non-governmental entities were expected by development experts to

increase the prospects of project and programme implementation because of their simple and flatorganisational structure, which was conducive to beneficiary involvement in the decision-making

procedure.

Predominant Management System

During the 1970s, experts and scholars who advocated implementable development assumed that

because planning was always carried out at the top, development administration problems werethe result of inefficient and ineffective management by higher echelon departments supervising

offices at the local levels (for example, departments of agriculture or ministries of planning). The

participation of the members of the bureaucracy, especially those in the field offices, wasmissing. The most common solution was heavily influenced by the experiences of the western

democracies decentralise the highly centralised planning system of the state.29

Decentralisation as a means for organisational reorientation (or reorganisation) was a solutionthat development administrators learnt from the developed nations, and they readily adapted this

solution for the eradication of organisational barriers to development in the less developed

countries. It gradually became evident that development administration managers became muchmore effective to the extent that they adopted a more decentralised approach to decision-making

and were open to the various contextual variables often outside their control. Some of the

contextual variables that projects face are political changes, natural disasters, and economic

factors. Project managers with even the best laid-out plans could not foresee all the problemsrelated to these areas: financing, personnel, management, infrastructure, and community

participation.

Structural Decentralisation in the PhilippinesDespite the centralisation of planning for effective development administration, the Philippines

continued to deteriorate politically and economically. Graft and corruption permeated Philippine

politics. Moreover, the creation of additional personnel positions in the central administrativesystem was used by politicians as a place for political rewards. The centralised economic

development plan, which geared the economy towards the exportation of raw materials, was not

enough to deal with the balance of trade deficits created by the heavy importation of consumergoods and finished products. The leading causes of mortality during the 1950s and 1960s were


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pneumonia, tuberculosis, heart disease, gastroenteritis and colitis, disease of the vascular system,

avitaminosis and other nutritional deficiencies, accidents, malignant neoplasm, bronchitis and

asthma, tetanus, and diseases of early infancy. The leading causes of morbidity during the 1950sand 1960s were influenza, gastroenteritis and colitis, tuberculosis, pneumonia, malaria, measles,

whooping cough, dysentery, malignant neoplasm, tetanus, mental disorder, accidents, bronchitis,

heart disease, vitaminosis and other nutritional deficiencies, and diseases of the vascular system.According to health experts, these diseases and illnesses are easily preventable with proper

immunisation programmes and improved sanitation. On September 9,1968, President Marcos

signedinto law Republic Act No. 5435. This Act provided for the creation of a PresidentialCommission on Reorganisation (PCR), a joint executive and legislative body. The PCR was

given the task of developing an Integrated Reorganisation Plan. The final Integrated

Reorganisation Plan for the executive bureaucracy was to be approved by the President. Unlike

previous attempts at administrative reorganisation, which only further centralised decision-making and resource control, the Integrated Reorganisation Plan sought to decentralise the

Philippine political system.

The Integrated Reorganisation Plan received critical reviews from members of Congress andgovernment administrators despite representation from the academic, private, and government

sectors. Bureaucrats objected because the merging and abolition of overlapping and redundantpositions would displace many of them. Legislators were afraid that the number of political

appointments which they could use as political rewards would be reduced. Upon the declaration

of Martial Law on September 21, 1972, President Marcos abolished the Philippine national

legislature. With the abolition of Congress, President Marcos issued Presidential Decree No. 1,the first major administrative reform measure under martial law. Presidential Decree No. 1

mandated a review of theIntegrated Reorganisation Plan for implementation during the martial

law period.

The 1972 Reorganisation Plans impact was felt mostly at the regional level. Under this

reorganisation plan, regional health offices were established in the newly created regionalsubdivisions of the country. Each region had a designated regional center in the twelve major

cities of the Philippines. According to Alex Brillantes, "the Inter-Agency Committee that made

the subdivision proposals tried to define relative homogeneous areas, capable of stimulating andsustaining efforts, not only on the basis of administrative consideration, but also with respect to

geographic, economic, and cultural factors."The reorganisation plan also authorised the regional

directors, in line with the policy of decentralisation and within the jurisdiction of the regional

office, to take final action on matters pertaining to substantive and administrative functions ofthe agency. In an effort to decentralise their administrative and resource control over village

community-level units, the Department of Health in the late 1970s and early 1980s introduced

the following programmes: the Restructured Rural Health Care Delivery System (RRHCDS); theMedical Care Program; the Rural Health Practice Programme; the Community Medicine Focus

of Medical and Nursing Schools; and the Community-Based Health Programme.

1. Restructured Rural Health Care Delivery System (RRHCDS)The RRHCDS was implemented in 1975 as part of a World Bank Population Programme. The

most significant contribution of the RRHCDS Programme was the creation of Barangay Health

Stations (BHS). Barangay Health Stations are the first line of health care available at the villagecommunity-level. They are staffed by a government-trained midwife and other barangay health


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workers. Through the financial support of the RRHCDS, the health structures housing the BHS

were also constructed.

2. The Medical Care Programme (MEDICARE)

According to the primer of the Philippine Medical Care Commission, the MEDICARE

programme was envisioned "to provide the people with a practical means of helping themselvespay for adequate medical care."This programme assisted in the construction of hospitals in the

far flung areas of the country. Although its main beneficiaries are limited to the employed and

their families, the MEDICARE Programme created access to hospital-based health care facilitiesfor the rural areas.

3. The Rural Health Practice Programme

In order to respond to the growing need for health care in the rural areas, the Philippinegovernment made rural health service a mandatory requirement for all medical and nursing

graduates before receiving their professional licences. The volume of manpower injected into the

rural areas helped ease the burden on the Department of Health. However, Carino noted that"questions have been raised in other studies as to its effectiveness, efficiency, and effects on the

morale of regular personnel and efficacy as a training tool for underboard nurses and medical

doctors."

4. The Community medicine focus of medical and nursing schools Pioneered by the Rural Health

Programme of the University of the East-Ramon Magsaysay Memorial School of Medicine in

1964, Philippine medical and nursing schools created programmes that stressed preventive andsocial medicine and rural medical practice. These medical and nursing schools emphasised heavy

implementation of the pregraduation requirement of rural health practice. They also made

curriculum changes that aimed at placing more attention on Philippine medical problems. Inaddition, a Bachelor of Science Degree in Rural Medicine was introduced at the University of the

Philippines-Tacloban City. A rural practice internship at the nearby Carigara area was the

highlight of this programme. The programme combined features of community-based health careprogrammes and the community medicine approach utilised by the regular medical schools.

5. The Community-Based Health Programme (CBHP)

In the early 1970s, the CBHP approach was endorsed by both nongovernmental andgovernmental organisations as their contribution to bringing health care closer to the rural areas.

This approach promoted the use of multi-function village health workers who administer first

aid, teach health education, provide sanitation attention, and serve as the frontline staff dealingwith people with minor ill nesses. Under this approach, health was seen only as a part of an

overall village development package. Hence, village health workers also facilitated community

organising and impart income-generation skills to members of the village community. Victoria

Bautista enumerated several individuals who promoted pilot projects targeting specific ruralareas using the CBHP approach (for example, De La Paz with the Katiwala Programme in Davao

City, Viterbo of Roxas City, Macagba of La Union, Flavier of the Philippine Rural

Reconstruction Movement, Campos of the University of the Philippines ComprehensiveCommunity Health Programme, Solon of the Paknaan Cebu Institute of Medicine Project, and

Wale of Silliman University).37 In addition, Galvez-Tan noted that attempts at replicating this

programme nationally was promoted by the Rural Missionaries of the Philippines.38 Otherreligious groups like the National Council of Churches in 1977 and the AKAP in 1978 followed


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suite with their own nationwide applications of the CBHP approach. These groups applied

almost similar types of participation approach towards the institutionalisation of an appropriate

health service delivery system.

DecentralisationProcess Emphasis

Including Concern for Process in DecentralisationThe 1970s saw a shift in concentration from planning to the effective and improved

implementation of the development plan at the lower units of the administrative system.

Proponents of development administration discovered that even the best designed developmentblueprints were susceptible to failure especially if carried out in a centralised and autocratic

fashion. The completion of development activities at the lowest level of jurisdiction became the

main focus of this implementation-oriented period. The development activity was labelled a

success if the effective start-up of the programme or project could be effectively completed.Management experts in the developed countries learned later that the structural and functional

changes proposed in structural decentralisation were effective only in advancing peripheral

changes (for example, eliminating overlapping activities and duplication of functions). They did

not deal with the issues of effective impact and efficient use of resources. 40 It quickly becameapparent that a new organisational structure free from these duplications and overlapping

problems did not guarantee changes to the dysfunctional behaviour of people inside the centralministries and governmental agencies. Development experts saw that structural decentralisation

somewhat increased the prospects of project implementation but did not necessarily ensure the

effectiveness or the sustainability of projects and programmes. Based on the Philippine findings,

researchers concluded that it was not enough to create channels for participation because the process of interaction was still cooptive, manipulative, and at most only consultative. How

superiors and subordinates should interact in a genuinely participatory manner within the

decentralised structure, as well as how much a government system should interact with localcommunities, was still a major issue. Clearly a concern for the institutionalisation of behavioural

changes and the human dimension of decentralisation required reform both within the

administrative system and also in the linkage mechanism between bureaucracies andcommunities.

Development experts agreed that a social and behavioural modification,or process reorientation, was necessary to complement the

structural aspect of decentralisation. Once the human dimension of

decentralisation was in place, it was assumed that projects and

programmes would become more implementable and sustainable.During this development period, Philippine development experts

assumed that an emphasis in creating a decentralised and participatory

structure would improve planning and increase implementability.Management System Under a Decentralised Process Approach

As advocated by development experts of the 1980s, process decentralisation

is the institutionalisation of participatory modifications onthe traditionally non-participatory processes perpetuated by governmental

bureaucracies. The theoretical descent of process decentralisation

in development management could be traced to the debate

between the Weberian-inspired school of management and the response


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by organisational humanists.186

Philippine Health Care System

The Weberian-inspired centralised approach was seriously challenged

in theory and practice by authors who subscribed to the

organisational humanist school of management.41 Herbert Simon and

Robert Dahl criticised the advocates of the classical approach tomanagement for promoting a "scientific" and value-free paradigm of

domestic and international administration. Moreover, arguments based

upon Weber's bureaucratic model were also criticised by RobertMerton as having psychosocial dysfunctions.42

The advocates of the human relations school of management

argued that there is no such thing as a rational and value-free approachto management since the interpretations of rationality and values

varied from person to person and culture to culture. Structural and

functional reforms remain successful only in the short run because

structural and functional reforms pay only lip service to the human

beings inside the organisational charts and boxes. Project beneficiariesare always perceived as a hindrance to development instead of a

facilitating force of change. These criticisms and shortcomings oflogical positivism and Weberian-inspired development administration

practices were carried over into the implementation decade of

rural development. It was time to propose a more radical change.Advocates for a more humanist approach to managing organisations

lambasted the "principles" advocated by the Weberian-inspired

school of management as mere "proverbs" and an exercise in Simon's"architectonics."43 The humanist school of management presented

such alternatives to the positivist-oriented approaches as management

by objectives (MBO), linking pin, quality circles, job redesign, clarityof goals, T-groups, contingency management, motivation techniques,organisation development (OD), job enrichment, and participative

management.44 These techniques are based on the interaction processes

and interpersonnal relations of individuals and groups insideorganisations.

Using these human relations school prescriptions involves going

beyond the structural adjustments advocated by Rondinelli and otherdevelopment experts as enumerated in the previous section. Ideally,

process decentralisation should be used together with the structural

rearrangements and functional redescriptions described earlier. Using

this combined approach ensures that local units will institutionalise187

Asian Journal of Public Administration

participation. This, combined with a strengthened local resourcemobilisation, would lead to sustainability at the village communitylevel.

Hence, the ultimate goal is to create the appropriate interaction,

collaboration, participation, and involvement to complement the

reorganised organisational structure.


13/22

Development proponents from donor and recipient countries

employed approaches patterned after these more humanist techniques

to help in the effective planning, implementing, and sustaining of theirdevelopment efforts. Based on the activities of this period, sustainable

development essentially became human development.

These behavioural changes were applied not only in the bureaucracybut also in the service-delivery field units. The role of the

structurally decentralised grassroots units in policy-making was increased

through community participation and organisation schemes.Participation as an institutionalised behaviour was assumed to raise

the level of commitment by the beneficiaries, thus encouraging them

to seek ways and means to sustain the project. Both governmental and

non-governmental groups immersed themselves in making theirprojects participatory not only in structure but also in process.

Decentralised Process Approach in the Philippines

Structural changes in Philippine health care continued until the 1980s but they were no longercentral to decentralisation reforms. The

highlight of the 1980s was the adoption of primary health care all overthe world. Primary Health Care was essentially a call for sustainable

health development through behavioural changes (for example, community

participation and active beneficiary and proponent collaboration).

This shifted the emphasis of decentralisation from a structuralfocus to a more process orientation.

In 1977, the Alma Ata conference sponsored by the World Health

Organisation (WHO) formally mandated the international goal of"Health for All by the Year 2000" (HFA). The goal of "Health for All

by the Year 2000" could be traced back to the Constitution of the

World Health Organisation, which was adopted in 1946. It took theWHO more than thirty years to actually formalise a programme that

dealt with the issue of sustainability. This delayed reaction was similar188


to the OECD's late response to sustainability which had been in the

OECD Constitution since 1961.45 The international delegates present

at the conference agreed that Primary Health Care was the key toachieving this long-term objective. The framers of the HFA Declaration

envisioned Primary Health Care to be:

an approach that recognises the inter-relationship between

health and overall socio-economic development. It aims toprovide essential health services that are community-based,accessible and sustainable at a cost which the community and

the government can afford through community participation

and active involvement. Ultimately, it aims to develop a selfreliant

people, capable of achieving an acceptable level of

health and well-being.46 (Italics provided).As opposed to previous strategies that concentrated on prescribing


14/22

structural decentralisation of the bureaucracy and its parts, this statement

clearly implied that health care projects under the Primary

Health Care programme were to be grounded on sustainability throughcollaboration, interaction, and involvement at the community-level.

In response to this, the Philippines together with the international

community of nations redefined their health care approaches towardsthe achievement of "Health for All by the Year 2000."

Primary Health Care and Participation in the Philippines

The health problems of the 1960s and the 1970s did not changesignificantly. The leading causes of morbidity in the 1970s continued

to be acute respiratory infections, diarrheal diseases, tuberculosis,

malaria, skin infections, and enteritis. The leading causes of mortality

in the 1970s also remained: pneumonia, tuberculosis, bronchitis,diarrhea, health disease, malignant neoplasms, and accidents.47

Solutions to these health care problems were hampered by various

administrative and resource constraints including the problem of

insufficient funds; the lack of medical and paramedical manpower; theinefficient use of scarce health services available; and the lack of

community support for health programmes.189


With this backdrop in mind, President Marcos issued Letter of

Instruction 949, mandating the implementation of the Primary HealthCare approach throughout the country starting in 1981. Primary

Health Care offered a new perspective different from the hospitalbased

western health care models which proved to be ineffective inless-developed countries like the Philippines. A national coordinating

council for primary health care headed by the Depiirtment of Health

and other concerned departments (for example, Food and Agriculture,Social Service, Natural Resources) was immediately established. Thiscoordinating council was duplicated in the different administrative

regions, provinces, municipalities, and villages of the country. In

1981, President Marcos declared a new Philippine Republic andordered the implementation of the revised Integrated Reorganisation

Plans of all departments subject to his approval. In addition, he

changed the Philippine administrative system from a presidential to aparliamentary model. Hence, all government departments were renamed

ministries.

According to the Minister of Health at that tune, J. Azurin, the

adoption of Primary Health Care all over the Philippines moved himto seek immediate presidential approval of the revised organisational

chart of the Ministry of Health (MOH) contained in Executive Order

No. 851. Minister Azurin added that this action would accommodateall of the behavioural changes needed to make the MOH more

participation-oriented. The most significant change of the 1982 reorganisation

was at the provincial level with the merging of the ProvincialHealth Office and the Provincial Hospitals.48


15/22

In the Philippines, the Primary Health Care approach concentrated

on the main health problems in the village community, providing

promotive, preventive, curative, and rehabilitative activities. Promotivehealth activities are personal and environmental hygiene, sound

food and dietary practices, regular physical exercise, and a less

stressed lifestyle. Preventive health activities are occupational health,immunisation, quarantine, vector control, and disease surveillance.

Curative health activities are early diagnosis and treatment of diseases,

emergency care of the injured, and other applications of medicaltechnology to repair tissue damage brought about by acute or chronic

illness or injury. Rehabilitative health activities are the restoration of190


normal physical, mental and social functions to individuals afflicted

with disabling injuries and illnesses as well as the extension of services

to minimise the extent of disability caused by impaired or damagedbody tissues and organs.49 Since these services reflect and evolve

from the economic conditions and social values of the country and itsvillage communities, they vary by country and community. Nonetheless,they include at least the promotion of proper nutrition and an

adequate supply of safe water; basic sanitation; maternal and child

care, including family planning; immunisation against major infectious

diseases; prevention and control of locally endemic diseases;education concerning prevailing health problems and the methods of

preventing and controlling them; and appropriate treatment for common

diseases and injuries.In order to make Primary Health Care universally accessible in

Philippine village communities as quickly as possible, maximising

community and individual self-reliance for health development wasmandated. Specifically, the attainment of such self-reliance in Philippine

village communities required full community participation in the

planning, organisation, and management of Primary Health Care.Such participation was best mobilised through appropriate education,

which would enable village communities to deal with their real health

problems in ways most suitable to them. Village communities were

thus in a position to make sure that the right kind of support wasprovided by the other levels of the national health system. These other

levels were organised and strengthened so as to support Primary

Health Care with technical knowledge, training, guidance and supervision,

logistic support, supplies, information, financing, and referralfacilities, including institutions to which unsolved problems and

individual patients could be referred.Philippine programme administrators believed that for Primary

Health Care to be most effective they had to employ means that were

understood and accepted by the community, and applied by the

community health workers at a cost the community and the countrycould afford. These community health workers, including traditional


16/22

practitioners where applicable, function best if they reside in the

community they serve and are properly trained socially and technically

to respond to its expressed health needs.50191


Since Primary Health Care was an integral part of the country's

health system and of overall economic and social development, it hadto be coordinated on a national basis with the other levels of the health

system as well as with the other sectors that contribute to the country' stotal development strategy.51 Mutually beneficial linkages as opposed

to administrative direction were encouraged by the Primary Health

Care approach.

Upon the assumption of power in 1986, President Corazon Aquinoimmediately called for another comprehensive reorganisation of the

Philippine administrative system. One of the first pieces of legislation

President Aquino issued was Executive Order No. 5. This law reconstitutedand renamed the Presidential Commission on Reorganisation

as 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 Filipino

consultants from both the private and public sectors. These consultantswere divided into survey teams headed by a coordinator. The

PCGR had a policy group and a special studies group. These groups

were in charge of standardising, collating, and compiling all thesurvey team's findings. The final approval of the each departmental

reorganisation plan was left solely in the hand of President Aquino.

This was due to the absence of a legislature, which was abolished afterthe coup d'etatfacilitated by Fidel Ramos and Juan Ponce Enrile. The

absence of a legislature also gave the Chief Executive the power to

carry out the reforms without opposition from the other political

branches of government.192


The scope of the PCGR's mandate as defined under Executive

Order No. 5 was encompassing. It involved the overall reorganisationof the administrative branch, government-owned and controlled corporations,

and local government. Never in the history of Philippinegovernment restructuring has a single entity been accorded this

massive task of reorganisation. Under President Aquino, the department

model of government was again revived.

This reorganisation furthered the cause of process-oriented decentralisationby constitutionally encouraging Primary Health Care through


17/22

collaboration, interaction, and involvement from the national-level to

the village community-level. The changes instituted under the 1987

Reorganisation of the Department of Health were:1. the creation of the Community Health Service and Field Epidemiology

Training Programme;

2. the development of a simplified and realistic health informationsystem;

3. the computerisation of the main Department of Health for greater

efficiency of services;4. the creation of an NGO coordinating desk within the Department;

5. the rationalisation of the Health Department's procurement system;

6. the development of legislative liaison; and

7. the strengthening of the District Health Office, Rural Health Units,and Barangay Health Stations.

Following the general guidelines of Primary Health Care's "sustainable

health development through participation mandate," more

definite and specific operating principles and approaches towardsprocess decentralisation were produced by the Aquino administration.52

193Asian Journal of Public Administration

Conclusion: Some Theoretical and Practical Constraints

Theoretical Constraints

After examining the experiences of the bureaucracy4evel application

of structural and process decentralisation in a number of countries,

including the United States, the Philippines, Peru, South Korea, andVenezuela, policy-makers admit that there is an inherent difficulty in

introducing behavioural reorientation to government reforms. Hence

the more manoeuvrable structural decentralisation techniques are stilllikely to predominate.One argument against the interface of OD and other humanistoriented

management approaches with decentralisation efforts are

their "application constraints in the public sector." Some publicadministrationist claim that these techniques are better suited to the

business or profit-oriented sector where their success is more easily

identified and can be more readily proven. Robert Golembiewskienumerates some structural, habitual, and management constraints to

the application of process decentralisation techniques to the public

sector.53 Other development management writers simply contend that

public bureaucracies have an "organisational imperative," whichdictates that government bureaucrats advocate the status quo and are

disposed towards systems maintenance.

Some public administration experts argue that the organisationalhumanists may have simply provided a more sophisticated array of

techniques for administrators in securing more compliance from the

bureaucracy and the local units.54 Hence, decentralisation is actuallya recentralisation technique because the more predominant theme is


18/22

still 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 alternativeschool to centralisation thought the human relations school of

management.

Practical ConstraintsDespite some positive changes, the problem of resources for health194


care delivery at the rural areas continues to be demonstrated by theactual number of barangays in the Philippines as opposed to the

number of Barangay Health Stations. Seven years after the implementation

of Primary Health Care in the Philippines, the total number ofbarangays in the country is 45,000, while the combined total of Rural

Health Units (1,991) and Barangay Health Stations (7,991) remains at

only 9,982. This means that over 35,000 barangays (78 per cent) still

do not have immediate access to health care services. A large number

of these barangays, which do not have readily available health care, arelocated in the most remote and depressed areas of the country. The

Philippine Department of Health admits that it does not have thenecessary resources to fill this gap. The national government spending

on health during the presidencies of Aquino and Ramos has increased

over the years but still remains below the World Health Organisationexpectation for countries like the Philippines.

Hence, whenever the Department of Health and nongovernmental

organisations receive additional funding from local or internationalsources, they seek to establish much needed health care projects which

target those village communities still in need of health care services.

This accounts for the evolution of two distinct sets of start-up implementationflow of resources to the village communities in the 1980swhich provided greater concern for community participation a

much needed and distinct process decentralisation objective.

These alternative local and international donor-supported projectsare not enough when the overall rural health picture is examined.

Nevertheless they offer hope for village communities which do not

have any health care services at all. Keeping in mind the conceptualand practical pitfalls discussed in this article, the issue of the

nonsustainability or sustainability of projects that will enhance the

health care delivery and development should now be the focus of

concern for current and future Philippine policy-makers.NOTES

1. E.D. Domar,Essays in the Theory of Economic Growth (Oxford: Oxford

195Asian Journal of Public Administration

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," in C. Wilber, The Political Economy

of Development and Under development(New York: Random House, 1988).


19/22

3. A. Lewis, "Economic Development 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 (Cambridge:

Harvard University Press, 1962).5. A.G. Frank, "The Development of Underdevelopment," in R. Rhodes,Imperialism

and Underdevelopment(New York: Monthly Review Press, 1970).6. A. Waterston,Development Planning: Lessons of Experience (Baltimore,

Maryland: Johns Hopkins Press, 1969).

7. See J.Montgomery, "A Royal Invitation: Variations on Three Classic Themes,"

in J. Montgomery and W. Siffin, eds.,Approaches to Development- Politics,

Administration, and Change (New York: McGraw-Hill, 1966) and R.S. Milne,

Planning for Progress: The Administration of Economic Planning in the Philippines

(Manila: Institute of Public Administration, University of the Philippines, 1960).

8. J. Friedman,A Spatial Framework for Rural Development: Problems of

Organisation and Implementation (Los Angeles, California: University of California

Press), p. 254.

9. Inayatullah, ed.,Rural Organisations and Rural Development: Some Asian

Experiences (Kuala Lumpur, Malaysia: Asian & Pacific Development Administration

Centre, 1978), p. 278.

10. See F. Riggs,Frontiers of Development Administration (Durham, NorthCarolina: Duke University Press, 1971) and F. Riggs, "Bureaucracy and Development

Administration,"Philippine Journal of Public Administration 21 (1977): 35-50.

11. G. Starling, Managing the Public Sector(Homewood, Illinois: Dorsey Press,

1982), p. 188.

12. I. Sharkansky,Public Administration: Policy-making in Government Agencies

(Chicago, Illinois: Rand McNally, 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 Administration 29 (1985): 145.

15. D. Bell, U.S. Economic Survey Mission's Report(Manila Philippine Book Co.,

1950).16. The NEC was later renamed the National Economic Development Authority

(NEDA), the government's overall economic planning arm.

17. J.L. Gonzalez and L. Deapera, "A Review of Philippine Reorganisation,"

Philippine Journal of Public Administration 31 (1987): 257-70.

18. A.B. Brillantes, "Decentralization in the Philippines: An Overview,"Philip-196


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 of

Public Administration 25 (1981): 192-206.

20. Carino, "Policy Directions for Health in the 1980s," p. 193.21. Aside from J.C. Azurin,Primary Health Care: Innovations in the Philippine

Health System 1981 1985 (Manila: J.C. Azurin Foundation, 1988), the author

examined various inter-office communications pertaining to the Department of

Health's 1958 reorganisation.

22. The National Nutrition Programme was later integrated into the budget responsibility

of the Department of Health.

23. See B .M. Gross,Action Under Planning: The Guidance of Economic Development

(New York: McGraw-Hill, 1967) and S. Padilla, ed., Tugwell's Thoughts on

Planning(Puerto Rico: University of Puerto Rico Press, 1975).


20/22

24. See H.W. Wickwar, The Modernization of Administration in the Near East

(Beirut: Kyatas, 1962); R. Gomez, The Peruvian Administrative System (Boulder,

Colorado: University of Colorado Press, 1969); H. Lee and A. Samonte,Administrative

Reforms in Asia (Manila: Eastern Regional Organization for Public Administration,

1970); R. Groves,Action Under Planning: The Guidance of Economic

Development(New York: McGraw-Hill, 1967); and D. Myers, ed., Venezuela: The

Democratic Experience (New York: Praeger, 1977).25. R.P. Misra,Local-level Planning and Development(New Delhi: Sterling

Publishers, 1983), p. 75.

26. G.S. Chcema and D. Rondinelli, eds.,Decentralization and Development.

Policy Implementation in Developing Countries (Beverly Hills, California: Sage

Publications): 14-15. Similar arguments are presented in D. Rondinelli, "Administrative

Decentralisation and Economic Development: The Sudan's Experiment withDevolution,"Journal of Modern African Studies 19 (1981): 596-624 and D.

Rondinelli, et al.,Decentralization in Developing Countries: A Review of Recent

Experience (Washington, DC: World Bank, 1984).

27. See L. Gulick and L. Urwick,Paper on the Science of Administration (New

York: McGraw-Hill, 1937) where the authors outlined the following functional jobs

of the executive in iheir famous POSDCORB, which stands for planning, organising,

staffing, directing, coordinating, reporting, and budgeting. Gulick and Urwick

argued 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,Administrative Management in the Government of the United States

(Washington, DC: USGPO, 1937) argued that reorganisations have to address the

issue of a strong executive and a large bureaucracy. Reorganisation principles have

to be developed andapplied successfully to decentralise the organisation. Moreover,

L. Mcrriam, inReorganization of the National Government: What Does it Involve?

(Washington, DC: The Brookings Institution, 1939) argued that reorganisations197


should eliminate functions and activities of the bureaucracy which are no longer

essential or justifiable. Eliminating or curtailing these would lead to substantial

reductions in expenditure. Other alternative structural arrangements todebureaucraticise were contained in the proposals of W. Bennis, "Organisation of

the Future,"Personnel Administration 24 (1967). These involve the use of more

"organic-adaptive structures." A. Toffler, inFuture Shock(New York: Bantam,1971) also prescribed the use of "adhocracies." Other writers called for almost

similar structural adjustments like a flexible structure, a flat structure, a project team

approach, a matrix organisation, or a committee system [see P. Drucker, The

Practice of Management(New York: Harper and Row, 1958)].

28. Rondinelli, et al.,Decentralization in Developing Countries: A Review of

Recent Experience,p. 67. Similar arguments are presented by D. Conyers, "Decentralisation

and Development: A Framework for Analysis," Community Development

Journalll(1986): 88-100; S. Gregory and J. Smith, "Decentralisation Now,"Community Development21 (1986): 101-6; M. Khan, "The Process of Decentralisation

in Bangladesh, Community Development Journal21 (1986): 116-25; R.Shields and J. Webber, "Hackney Lurches Local," Community Development Journal21

(1986): 133-40; P. Sills, etal., "Decentralisation: CurrentTrends and Issues,"Community Development Journal21 (1986): 84-87; M. Taylor, et al., "For Whose

Benefit? Decentralising Housing Services in Two Cities," Community Development

Journal21 (1986): 126-32; W. Boyer and M. Byong Ahn, "Local Government and

Development Administration: A Case of Rural South Korea,"Planning and Administration

2 (1989): 21-29; and D. Rondinelli, "Decentralising Public Services in

Developing Countries: Issues and Opportunities,"Journal of Social, Political and

Economic Studies 14 (1989): 77-98.


21/22

29. See R. Polenberg,Reorganizing Roosevelt's Government: The Controversy

Over Executive Reorganization 1936-1939 (Cambridge: Massachusetts: Harvard

University Press, 1966).

30. J. Pressman and A. Wildavsky,Implementation: How Great Expectations are

Dashedin Oakland(Berkeley, California: University of California Press, 1973)andG. Honadle, "Implementation Analysis,"International Development Administration

(New York: Praeger, 1977).31. United Nations,Demographic Yearbook(New York: United Nations, 1964,

1965, and 1977) and World Health Organization, World Health Statistics (Genera:

World Health Organization, 1977).

32. Brillantes, "Decentralization in the Philippines," p. 141.

33. See Carino, "Policy Direction for Health in the 1980s;" and Azurin,Primary

Health Care.

34. Philippine Medical Care Commission, The Medicare Program of the Philippines

(Quezon City: PMCC, 1974), p. 1.

35. Carino, "Policy Direction for Health in the^l980s."

36. Carino,Ibid,p. 194; see also M. Reforma, The Rural health Practice Program:An Evaluation of the R ural Service Requirements for Health Professionals (Manila:

University of the Philippines-College of Public Administration, 1978).198

Philippine Health Care System37. V. Bautista, "Structures and Interventions in the Philippine Health Service

Delivery Syslcm: State of the Art," in Philippine Institute of Development Studies,Survey of Philippine Development Research III(Manila: Philippine Institute of

Development 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 of

Public Administration 24 (1973): 218-40. J. Montgomery, Technology and Civic

Life: Making and Implementing Development Decisions (Cambridge: Massachusetts,

1974); G. Iglcsias,Implementation: The Problem of Achieving Results

(Manila: Eastern Regional Organization for Public Administration, 1976); and J.

Cohen and N. Uphoff,Rural Development Participation: Concepts and Measuresfor Project Design Implementation (Ithaca, New York: Cornell University, 1977).

40. L. Hammcrgrcn,Development and the Politics of Administrative Reform

(Boulder, Colorado: Westview Press, 1983); J.L. Gonzalez, "A Historical Survey ofReorganization in the Philippines,"Praxis 2 (1988): 45-63 and J.L. Gonzalez,

"Philippine and U.S. Administrative Restructuring: Same Basic Problem,"PhilippineJournal of Public Administration 24 (1990): 295-99.

41. For instance, E. Mayo, The Human Problems of an Industrial Civilization (New

York: Macmillan Company, 1933); H. Simon, "Proverbs of Administration,"Public

Administration Review 6 (1946): 53-67 and R. Dahl, "The Science of Public

Administration: Three Problems,"Public Administration Review 7 (1947): 1-11.

42. R. Mcrton,Reader in Bureaucracy (Chicago, Illinois: Free Press, 1952), p. 36.43. See C. Barnard, The Function of the Executive (Cambridge, Massachusetts:

Harvard University Press, 1938); A. Maslow, "A Theory of Motivation,"PsychologicalReview 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,Administrative

Behavior(New York: Macmillan, 1957); D. McGregor, The Human Side of

Enterprise (New York: McGraw-Hill, 1960); R. Blake and J. Mouton, The Managerial

Grid(New York: Gulf Publishing, 1964); F. Herzberg, Work and the Nature

of Man (New York: Thomas Crowell, 1966).

44. See P. Drucker, The Practice of Management(New York: Harper and Row,1954); D. Deming, Company Organization for Packaging Efficiency (New York:


22/22

American Foundation for Management Research, 1962); R. Likert, The Human

Organization (New York: McGraw-Hill, 1967); M. Sashkin, A Manager's Guide to

Participative Management (New York: American Management Association, 1984);

R. Golembiewski and E. Eddy, eds., Organization Development in Public Administration

(New York: Marcel Dekker, 1978); W. Ouchi, Theory Z (Reading,Massachusetts: Addison-Wesley, 1981); P. Block, The Empowered Manager(San

Francisco, California, 1987); F. Herzberg, "Motivation to Work," in RussianAcademy of Sciences,Journal of Sociological Studies (Moscow: Academy of

Sciences, 1990): 32-46.

199


45. It was only after the 1985 Brundtland Conference that the OECD addressed this

important development issue. For more information about the 1 mplementation of thePHC in the Philippines see Executive Order No. 851; Letters of Instruction No. 949;

and Presidential Decree No. 1397.

46. Azurin,Primary Health Care,p. 58.

47. Ministry of Health,An Overview of the Ministry of Health (Manila: Ministry of

Health, 1978) and Ministry of Health,Annual Report(Manila: Ministry of Health,

1979).

48. Azurin,Primary Health Care,p. 35.

49. /Wd., pp. 40-1.50. Ministry of Health,Revised Training Module on the Five-Impact Programsfor

the Training of Bar an gay Health Workers (Manila: Ministry of Health, 1985).51.Ibid.

52. See Department of Health,Annual Report(Manila: Department of Health,

1988), p. 5.

53. R. Golembiewski,Humanizing Public Organizations (Maryland: Lomond

Publications, 1985), p. 5.

54. R. Denhardt, Theories of Public Organization (Pine Grove, California: Brooks/

Cole, 1984).Joaquin L. Gonzalez III is Fellow at the Department of Political Science, the National

University of Singapore. He is grateful to Edith R. Borbon, Elise B. Gonzalez, colleagues atthe National University of Singapore, the University of the Philippines, De La Salle

University, the University of Utah, the World Bank, and an anonymous referee for theirvaluable comments, suggestions, and encouragement.

200

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Asian Journal of Public Administration Vol