Broadening the Fiscal Design of Local Autonomy.pdf

7/28/2019 Broadening the Fiscal Design of Local Autonomy.pdf

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BROADENING THE FISCAL DESIGN

OF LOCAL AUTONOMY:PATCHING THE LOOPHOLES OF DEVOLUTION AND MAKING IT WORK

AN ACT CREATING THE SPECIAL HEALTH FUND

AND AMENDING SECTIONS 235, 236, 237, 273, 285, 287

OF THE LOCAL GOVERNMENT CODE OF 1991

Aonuevo, LesterCruz, Judy

Faller, Beatrice AstridKadatuan, Arif

Moran, Ralph EdwardRabanes, Eleazar

1A

San Beda College of Law

Mendiola, Manila


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INTRODUCTION

Local government units assumed a greater responsibility in local service delivery and in

the provision of health services since 1991. The decentralization of national government

function to local government units is an institutional reform that is expected to lead more

efficient and equitable delivery of public services. The expected gains from the devolution arebased from the assumptions that LGUs have better information about the preferences of their

constituencies, and also better incentives to act on their superior information because of their

direct accountability to the service clients.

As the declaration of principles and state policies expressly mention, Section 15 of

Article II expresses this states duty: The state shall protect and promote the right to health of

the people and instill health consciousness among them. In the fulfillment of this duty,

Sections 11 and 12 of Article XIII, specify what the state has to do, viz:

SEC 11. The State shall adopt an integrated and comprehensive approach tohealth development which shall endeavor to make essential goods, health and other social

services available to all the people at affordable cost. There shall be priority for the needs

of the underprivileged sick, elderly, disabled, women, and children. The state shall

endeavor to provide free medical care to paupers.

SEC 12. The State shall establish and maintain an effective food and drug

regulatory system and undertake appropriate health manpower development and

research, responsive to the countrys health needs and problems.

Public health services in the Philippines are delivered to communities by local

government units, with the Department of Health, through Centers for Health Development,providing technical assistance. Overall, access remains the fundamental objective of the delivery

of public health services. However, problems persist with quality and effectiveness of these

services.

The devolution of health services ended the concept of integrated care at the district

level. Public health and hospital services are now administered independently. The provincial

governments took over the management of secondary hospitals, while municipal governments

were put in charge of the delivery of primary level health care services and the corresponding

facilities such as the Rural Health Units and Barangay Health Centers. The national

government, meanwhile, has retained the management of tertiary level facilities. Fragmentation

is compounded by the management of the three levels of health care that is vested in three

different government levels.

While the post-devolution health care delivery system achieved gains, it is evident that it

weakened due to lack of resources and local capacity to manage devolved health facilities, the

unwillingness or inability of local authorities to maintain pre-devolution spending for health,


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and low morale and lack of opportunities for continuing education among devolved health

providers.

Background and Significance

The Local Government Code of 1991 clearly specified the tasks that should be devolvedto the local government units. As expressed in the following table, the following indicates the

distribution of tasks between LGUs.

UNIT FUNCTIONS

Barangay Section 17 (b) (1) (ii)

Health and Social Services which includes maintenance

of barangay health center and day care center

Municipality Section 17 (b) (2) (iii)

Subject to the Provisions of Title Five, Book I of the Local

Government Code, Health services which include theimplementation of programs and projects on primary

health care, maternal and child care, and communicable

and non-communicable disease control services, access to

secondary and tertiary health services, purchase of

medicines, medical supplies, and equipment to carry out

the services herein enumerated.

Province Section 17 (b) (3) (iv)

Subject to the Provisions of Title Five, Book I of the Local

Government Code, Health services which include the

hospitals and other tertiary health services

City Section 17 (b) (4)

All the services and facilities of the municipalities and

province

TABLE 1

Functions of Local Government Units in RA 7160

According to Pimentel (Philippine Congress Deliberations on LGS of 1991), access to

secondary health services means access to doctors for the treatment of disease and provisionof medicine for indigent patients. He further elaborated that tertiary health services means

access to hospitals. Provincial and district hospitals are funded out of the provincial

governments budget while municipal/city hospitals are financed by municipal/city budgets.

Management and financial parameters are determined primarily by the local chief executive

and, in varying level of influence and technical leadership.


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The DOHs Steering Role

Paralleling in the general decentralization trend in the past decades, health sector

decentralization policies have been implemented on a broad scale throughout developing

countries. In combination with health finance reform, decentralization has been touted as a key

means of improving health sector performance and promoting social and economicdevelopment (Brillantes, 1998).

The Local Government Code completely changed the terrain of the delivery of health

services as it gave local government units responsibility for and financial management of their

own health activities with the Department of Health providing guidance and advice through a

network of DOH representatives and Centers for Health Development.

With the devolution, the role of the Department of Health changed from the sole

provider of health services to provider of specific health services and technical assistance for

health for LGUs. It is designated as the national technical authority on health and is mandatedto define and formulate programs and strategies that will ensure the highest achievable

standards of quality health care, health promotion, and health protection, on which LGUs,

NGOs, other private organizations, and individual members of civil society will anchor their

own health programs and strategies.

The Department of Health was made servicer of servicers by developing health

policies, enhancing partners capacity through technical assistance, leveraging performance for

priority health programs among partners, developing and enforcing regulatory policies and

standards, providing specific programs that affect large segments of the population, and

providing specialized and tertiary health care. These functions brought radical changes in the

structure of the health service delivery system in the country.

The Department of Health is also mandated to maintain national health facilities and

hospitals with modern and advanced capabilities to support local services. The health facilities

and special hospitals should provide technical support to all rural health centers.

Interestingly enough, a unique feature of the Philippine health care system is the

existence of a non-devolved autonomous health care system in the Autonomous Region of

Muslim Mindanao which is provided mainly through a public sector health system managed by

a regional authority. This has retained the centralized character of the health system under

DOH-ARMM, which directly runs the provincial hospitals and municipal health centers underits jurisdiction instead of the component provinces and towns of ARMM.

The succeeding table provides the different facilities that are left to local government

units upon enactment of the Local Government Code.


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FUNCTIONS MUNICIPALITIES PROVINCES CITIES

Basic Primary

Health Care

2,299 Rural Health Units

10,683 Barangay Health

Stations

210 Peuriculture Centers

Municipal Maternity ClinicsMunicipal and Barangay Staff

Hospital Services 596 Provincial,

District and

Municipals and

Infirmaries

District and

Provincial Hospital

Staff

Administrative

Services

70 Integrated

Provincial Health

Offices

District Health

Officers

IPHO and DHO

Staff

60 City Health

Officers

Assistant City

Health

Officers

TABLE 2

Delineation of Functions in RA 7160

The LGUs, on the other hand, serve as stewards of the local health system and therefore

they are required to formulate and enforce local policies and ordinances related to health,nutrition, sanitation and other health-related matters in accordance with national policies and

standards. They are also in charge of creating an environment conducive for establishing

partnerships with all sectors at the local level.

Complementing the new functionality of the LGUs are the local health boards (LHBs).

These are special bodies that exist in all levels of LGUs expect in the barangays. An LHB is

composed of the local chief executive (i.e. governor for the provincial health board, city mayor

for the city, and municipal mayor for the municipality) as chair, local health officer (i.e.

provincial / city / municipal health officer) as vice-chairperson, the committee chair on health of

every local legislative body (sangguniang panlalawigan, sangguniang panlunsod, and

sangguniang bayan), a representative from private sector or nongovernment organizations

involved in health services, and DOH representative (provincial / city / municipality). The main

function of the LHB is to formulate policies on budget allocations and act as advisory committee

for the sanggunian.


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FIGURE 1Philippine Organizational Structure and Accountability in the Health Care System

(Romualdez et al, Asia Pacific Observatory on Health Systems and Policies, 2011)

The LGUs political and administrative terrain

Geography, politics, administrative and legal factors condition in a complex way the

emergence of consolidated local health systems in the Philippines being archipelago of around

7,100 islands, divided into 17 administrative regions. Each region, except for the National

Capital Region (NCR), is subdivided into provinces, and each province into municipalities and

cities, and each of which into barangays. In 2009, there were already more than 1600 provinces,cities and municipalities, and around 40,000 barangays.

The constraints to cooperation that the geographical barriers pose are supposed to be

offset by the political and administrative structures of local governments in the Philippines.

Each province in governed by a governor, each municipality or city by a mayor, and each


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barangay by a barangay captan. A local chief executive is elected every three years, for a

maximum of three consecutive terms, directly by his or her constituents.

Administratively, each barangay captain is under the municipal or city mayor, and each

mayor in turn is under the provincial governor. The provincial governor is administratively

under the national government. This administrative setup within each province provides a dejure venue for consolidating the local government programs and projects. Region-wide

consistency of provincial plans is attained during the regular meetings of the regional

development councils comprising the local chief executives and key officials from the local

branches of national government agencies.

Some LGUs however are outside the usual administrative setup. In the National Capital

Region (NCR), the 17 component cities and municipalities are each independent of one another

and there is no provincial government to supervise them. In some provinces, there are

independent cities that are outside the administrative control of the provincial government.

The constituents of these cities do not vote for the provincial governors, unlike the

residents of component cities in some provinces. In the Autonomous Region of Muslim

Mindanao (ARMM), a regional government is established and run by an elected regional

governor that supervises directly the component provinces.

However, all these LGUs NCR cities and municipalities, independent cities, and

ARMM regional government are administratively within the ambit of the national

government.

The question of whether devolution or decentralization is the better alternative to

achieve the desired health outcome cannot be answered directly since the experience in health is

not a perfect predictor since services lead to different outputs or impacts, which are both

important but not directly comparable contributions to human development indicators.

However, Capuno (2009) points, that in principle, broad trends in terms of welfare

impact can be established from data sets. Contributions to individual or household welfare or

well-being can be estimated and compared with the right data. While special surveys on users

access to and satisfaction with local public services or their awareness of decentralization were

conducted in the past, this provides limited sample socioeconomic information for firm

statistical evaluation.


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Review of Related Literature

Framing Decentralization

North (1990) provides that institutions are the rules of the game in a society or, more

formally, are the humanly devised constraints that shape human interaction. It may be askedthat when the government or public agency decentralizes, what sort of constraints or incentives

are changed that will align the objectives of government officials with that of the public that

they serve.

In a hierarchical organization such as a system of government in the Philippines, in light

of fiscal federalism, decentralization relaxes information constraints. Lower-level officials

interact more with service clients and because of their frequent contact, those who are informed

more would know more than superiors about the needs of the target beneficiaries and the local

social climate.

However, the information advantage is not sufficient to justify decentralization as

Bardhan (2002) suggested for it can be commissioned through surveys, client interviews and

focus group discussions. Thus, Bardhan posits that it is also necessary that the authorized

lower-level official should have the incentive to act upon superior information and proximity to

service clients.

A greater focus on accountability can be discerned from the recent literature on fiscal

decentralization (Bardhan and Mookherjee, 2006). In principle, decentralization could improve

accountability since:

At the local level, citizens can more easily learn of the activities and programs that their

local leaders have promoted and supported, discern how much effort they have devoted to

improving public services, and confirm whether they have delivered on campaign

promises. In other words, the information that citizens need to make judgments is more

readily accessible under decentralization. (Campos and Hellman 2005)

Under decentralization, the citizens can directly their feedback about their preferences to

local officials or service providers, instead of transmitting the same to policymakers. However,

they can still provide other information to policy makers to hold the local officials or civil

servants accountable for their performance.

In addition to incentives and accountability, three other aspects are important in the

design of decentralization policies. One important aspect is the determination the functions to

assign to each level in the organization or government. The guiding principle often used is that

a function should be assigned to that level whose jurisdiction covers all those who would be

affected by the discharge of that function. The idea is that the level should internalize all the

benefits and costs arising from the performance of its assigned function.


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Another important aspect is building the capacity of each level so that it can perform its

assigned responsibilities. The required capacity would include the powers or authority to

determine, raise and use the inputs and the processes needed to deliver the public service. The

inputs would include funds, human resources and organizational capital.

Where the lower-level official or unit unable to mobilize these inputs, then the higher-level official or unit should transfer the financial resources, provide the training and other

technical assistance. Finally, a system of monitoring activities and performance, and supervising

tasks and personnel should be in place. The responsibility to monitoring and supervise lower-

level units or personnel should be assigned to higher-level units or officials to avoid conflict of

interest.

Forms of Decentralization

Capuno (2009) provides three general forms of decentralization in government. The first

is devolution wherein the LGUs are given full autonomy and control over their assigned publicservices, subject only to oversight by the national government. In 1991, for example, most health

functions were devolved to LGUs in the country. In this case, the devolved health personnel

answer directly to local elected officials, who are responsible to their constituents.

The second form is deconcentration wherein the lower-level offices are bestowed

additional functions, powers or responsibility previously held by the higher-level offices within

the same government department or agency. Beginning in 2001, for example, more

responsibilities were delegated to sub-national education officials in the country. In this case,

the lower-level officials are still accountable to their superiors in the department.

Lastly, the third form of decentralization is the delegation of government functions to

parastatal units, private sector groups or non-government organizations who now act as agents

of the national government. The private sector group or NGO may be involved in service

production, delivery or financing, or in the monitoring and regulation of public services.

When the DOH, for example, commissions a medical association to train or certify local

health personnel or screen facilities for licensing, then it delegates some of its functions to a

private organization. The accountability of the private organization in this case is to the

contracting government agency.

Emerging Inter-LGU arrangements

One strand in the literature argues that in some circumstances smaller jurisdictions in

terms of geographic size and functional responsibilities can provide local officials with better

information about their citizens preferences and can thus make them more responsive and

directly accountable to the needs of their service clients. The larger number of competing local


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governments will give individuals more choices in publicly- provided services, and thereby will

better accommodate differences in preferences for these services.

Another strand favors larger jurisdictions that yield benefits from economies of scale

while promoting consistency in service quality. They are also in a better position to internalize

the costs and benefits of externalities generated by publicly-provided services. Moreover, theinformational advantages associated with smaller arrangements can also be achieved in a

consolidated set-up a national government agency, for example can assign some functions of

the central office to the local offices, which have direct and frequent contact with service clients

(Bardhan 2002).

Both factors - the economies of scale and customized local provision seem to underlie

the current arrangement of local health systems in the Philippines. The emergence of the inter-

LGU health arrangements is better appreciated within the context of the countrys nearly

twenty years of decentralization experience. Relative to the expected efficiency gains from a

devolved health setup, the realized gains are found modest, partly because of the weaknesses inthe design and implementation of the Local Government Code of 1991 (Lieberman, Capuno and

Van Minh, 2005).

One purported gain is the increasing share LGUs in total health expenditures, which

contributed to the rise in the share of health expenditures to GDP 2.9 percent in 1992 to about

3.3 percent in 2005 (Capuno and Kraft 2009). Per capita health spending has increased from PhP

334 in 1992 to about PhP 507 in 2005, representing a real 48 percent growth from 1992 levels.

Further evidence from a study by Racelis et al. (2005) on the Philippine National Health

Accounts suggest that total health expenditures exhibit an increasing trend in both real and per

capita terms after devolution, although minor setbacks were encountered in 1998, 2001 and

2002.

Under devolution, LGUs have also exhibited a capacity for innovation, particularly in

terms of establishing partnerships with the local communities, private sector, and non-

government organizations or in integrating health objectives into other programs of the local

government. Under the current setup, LGUs were also able to leverage existing systems (e.g.

health insurance) to solve health problems specific in their areas.

Some LGUs were able to hire more doctors and acquire more supplies that enabled them

to improve health outcomes. Infant mortality rate also continued to decline since 1991, implyingthat some desired trends in health were sustained despite the weaknesses in the Local

Government Code. Notwithstanding the proliferation of innovations in local public services, the

impact of devolution on health outcomes and outputs remains ambiguous at best.

The financing constraints, political realities, differences in organizational capacity, and

other institutional factors have led to insufficient services and deterioration in both the levels


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and quality of devolved health services. Differences in human resource capacities, as evidenced

by the inability of some LGUs to hire doctors, nurses and other critical health personnel, and,

more starkly, the unequal distribution of executive talents have led to widening variations in

performance across LGUs. Some LGUs are lucky to have innovative local chief executives.

Ostensibly, the devolution of the different levels of health functions followed theadministrative hierarchy of levels of governments in the country. On the one hand, the

Department of Health retained responsibility over the regional and specialty hospitals and

public health programs. On the other hand, the provincial governments took charge of the

devolved curative care services and most secondary and tertiary-level hospitals, while

municipal and city governments handle primary care and the operation of smaller facilities

such as the rural health units and barangay health stations.

Proposed Amendments

The landmark legislation, Republic Act No. 7160, otherwise known as the Local

Government Code of 1991 (LGC), introduced sweeping challenges in the Philippines political

process. The LGC dramatically shifted power from central government to local governments. Its

end goal is to unleash the potentials at the local level. It redirected the countrys strategies to be

locally driven as it transferred the responsibilities for the delivery of basic services to the LGUs,

including appropriate personnel, assets, equipment, programs and projects. The LGC altered

the mode, configuration and level of services that local government provides.

As Balisacan et al (2006) puts it, the code enlarges local bureaucracy, expressly grants

local governments the authority to implement organizational reforms in order to perform

effectively in a decentralized set-up, increases the financial capacity of LGUs, allows local

governments to seek alternative forms of service delivery, provides for popular participation in

decision-making and program implementation, and localizes accountability.

In the Philippines, one promise of decentralization is better local service delivery for an

improved quality of life (Magno, 2001; Manasan, 2007). However, for decentralization to realize

this, certain prerequisites which are mainly about policy, institutions, and finance - must be

met.

First, the design of decentralization needs to be based on rightsizing and proper phasing

of intergovernmental transfer of powers, functions, and responsibilities. The abrupt transfer ofpowers, functions, and responsibilities, especially on the decentralization of certain sectors such

as health, social services, and agriculture, has created a mismatch between LGUs powers and

their responsibilities and their institutional and financial capacities.

This has impacted on the delivery of services and public goods. In health for example,

the cost of devolution (PS and MOOE), has made the LGUs, particularly the provinces,


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incapable of delivering public goods and services; hence, the clamor to return health service

responsibilities to the national government.

Second, the institutional actors both local and national should be capacitated and be

imbued with a sense of urgency to own up the local service delivery agenda as a way to make

decentralization work for the people through their innovative ideas, capabilities, and politicalwill. With many LCEs not having the required capabilities and political will to own up the local

service delivery agenda, people suffer from poor quality of education and poor health and

sanitation.

Third, the functions, functionaries, and funds demand no less than commensurate

transfer and burden-sharing of the required capacity-building, institutional development, and

financial sustainability. The resultant resource constraints and institutional deficits experienced

by LGUs, mostly by 5th and 6th class municipalities and their barangays, as well as the low-

income provinces, greatly impact on the quality and quantity of services delivered.

Saddling these resource-starved LGUs with costly devolved functions in health,

education, and water for example, compounds their inability as institutional functionaries in

meeting the supply-side of governance and the basic needs of their people. The problems of

devolution described are very much apparent in the health sector particularly in the quality of

maternal and child health care services.

Capuno (2009) observes an overall decline in the means of both Infant Mortality Rate

and Maternal Mortality Ratio in the years 2000 to 2008, the standard deviation has been

increasing among provinces.In spite of the downward trend, the Philippines still has a high

MMR when compared with other countries. Some 230 women die in the Philippines for every

100,000 live births, compared with 110 in Thailand, 62 in Malaysia and 14 in Singapore.

To address this problem, the DOH and UNICEF now assiduously promote facility-based

delivery, in lieu of home-based delivery unless attended by skilled health professionals. This

strategy is adopted given the observation that countries with modest per capita incomes but

high proportions of facility-based deliveries have achieved relatively low mortality ratios.

Furthermore, the poor performance of the Philippines when it comes maternal and child

mortality rates can be partly attributed to the low percentage of facility-based deliveries. The

World Health Organization estimates that about 72 percent of deliveries in the Philippines

occur outside of health facilities, frequently without the assistance of a skilled birth attendant,

and many deliveries do not meet the minimal conditions for early essential newborn care.

Arguably, a greater reduction in IMR and MMR can be achieved with the concentrated

health interventions of local governments, namely the provinces and municipalities. There are

both administrative and political reasons why these local governments will consolidate their

devolved health services. Majority of the reasons expressed by the local government units is the


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narrow fund dedicated for health, especially investing on health facilities and program

interventions.

Creating the Special Health Fund

The proposed special fund shall be managed by the Local Health Board. Thus thefollowing provision in the Local Government Code shall be:

SECTION 235. Additional levy on real property for the Special Education Fund

and Special Health Fund Province or city, or a municipality may levy and

collect an annual tax of TWO PERCENT (2%) on the assessed value of real

property which shall be in addition to the basic real property tax. The proceeds

thereof shall exclusively accrue to Special Education Fund and Special Health

Fund, each amounting to the equivalent one percent (1%) of the aforecited real

property tax allocation and application of proceeds shall include the following:

a) The proceeds of the additional one percent real property tax accruingto special health fund shall be automatically released to the local

health boards

b) In case of provinces, the proceeds shall be divided equally betweenthe provincial and municipal health boards

c) Said proceeds shall be allocated as determined and approved by thelocal health boards concerned for the following purposes:

1. Operation and maintenance of public hospitals, rural healthcenters;

2. Construction and Repair of Health Centers, Health Facilitiesand Equipment;

3. Medical and Health Research;4. Purchase of Medicines, if warranted; and5. Training of Local Public Health Officers

Congruent to the increase of another percent (1%) in the additional levy on real

property, is the empowerment of the local health board in decision-making. The lack of

preparation of introducing the decentralization process resulted not only resulted to

decreased hospital occupancy and health center utilization rates, untimely or decreased

procurement of medicines and supplies, decreased but also the lack of capacity to

handle devolved health services.

Phased decentralization and good governance

The Philippine experience on decentralization is contrary to the Rwandan experience

which provides a more conclusive phased decentralization. According to the Ministry of Local

Government, Good Governance, Community Development and Social Affairs, the


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decentralization process is being implemented in three successive phases. The first phase (2000-

2005) established democratic and community development structures. To facilitate the

functioning of these structures, a number of legal, institutional and policy reforms were

undertaken. This prompted the creation of a matured local set-up to implement the devolved

health services.

The second phase was characterized by banking on progress and enhanced effectiveness

in service delivery to communities. This was achieved by increasing capacities at levels of

administration (Villages, Cells and Sectors) close to communities, promotion of integrated local

economic development and fostering community participation at Village level, in the planning

and management of local affairs.

The third phase of implementation (2011-2015) will improve and sustain the

achievements of the first two phases. The number of administrative entities will be further

reduced to diminish the distance between upper and lower levels of administration and make

the Government more effective, efficient and responsive to peoples needs and preferences. Inthis phase, multi-sectoral decentralization at local level will be reinforced and mechanisms for

partnerships between public sector and non-state organizations will be operational.

On 31 December 2005, Law No 29/2005 determining the administrative entities of the

Republic of Rwanda was published and represented the legal basis of the Local Administration

Reform Policy, adopted in 2005 with the following specific objectives: to promote and enhance

effectiveness in service delivery by making the Sector a truly service; delivery focal point with

adequate human, material and financial capacity, and to improve collection of data and

information at this level; to streamline and strengthen the coordination of public services and

local economic development at District Level by availing more technically competent personnel

as well as financial resources to the District to ensure sustainable decentralized fiscal regimes;

to strengthen the coordination of development activities; to establish and strengthen coherent

monitoring and evaluation systems as well as institutionalize accountability tools and systems .

The administrative organization of Rwanda is guided by the principle of subsidiarity.

The Central Government agencies roles and responsibilities are mainly in policy formulation,

regulation and support to Local Governments through capacity building, financing and

monitoring and evaluation throughout a steady pace.

Local Governments with the administrative entities are mainly in charge of

implementation of government policies and service delivery, and provide an avenue for citizenvoice and accountability. In this type of set-up, the decentralization implementation process

has been successful in reinforcing institutional capacity building in participatory (bottom-up)

planning, budgeting and monitoring and evaluation.

The first phase of the decentralization process widely promoted the creation of effective

partnerships between communities, local governments, central government, private sector, non-


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governmental organizations and international development partners, to engage in projects and

programs for improving local development and delivery of services through a joint fund. This

was evidenced by recent studies and surveys, which showed high rates of satisfaction among

citizens with the level of participation in decentralized governance and development program

through transparency and solidarity.

Citizens effectively participated in local governance and resources are managed in a

transparent and accountable manner. The phased decentralization policy has been specifically

designed to empower local governance structures with appropriate autonomy to bring public

administration closer to the people, and to make local governance accountable to the electorate.

Accountability embraces political, administrative and fiscal dimensions that need to be

reinforced along with mechanisms to improve transparency in public affairs of local

governments.

Imposing Mandatory Ad Valorem Tax for Idle Lands

Mixed Feedback on Quality

While the Department of Health has achieved a certain degree of devolution with

respect to functions, the quality of healthcare delivery after devolving the major tasks to LGUs

remains to be mixed. However, the challenges seem to be consistent. Experts expressed concern

over the deterioration of technical quality, while most of the people expressed more positive

views (de Mello et al, 2000). In the area of technical performance, there was no significant

change in the volume of in-patients treated or outpatient consultations in spite of quality of care

which deteriorated in terms of supplies, equipment and infrastructure because of decreased

funds for maintenance and other operating expenses (MOOE) and almost non-existent funds for

capital outlay.

The major setback of devolution is that it resulted in the significant deterioration of

employment conditions of devolved personnel, causing demoralization. In the health sector,

salaries of devolved workers decreased relative to central government employees (by one-fifth

to one-third on average), and civil-servant vertical career mobility was interrupted by the

fragmentation of the public health system (Miller 1998). Strong objections from healthcare

workers brought about the passing of the Magna Carta of Health Workers which resulted in

further disarray.

Some LGU officials became demoralized because some health workers received highersalaries than LGU executives. These gave local chief executives a reason to pressure the national

government to fund the implementation of the Magna Carta of Health Workers and provide for

the compensation of health personnel.

In People of the Philippines versus Florendo (2004), the Magna Carta Benefits were paid

100% by the National Government to the Municipal Health Workers of V. Sagun, Zamboanga


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del Sur. Salary increase as per Local Budget Circular No. 54 could not be implemented since the

salaries of organic personnel have not equaled after the necessary adjustment to that of the

devolved health workers of the municipality. For 1995, the Magna Carta Benefits were not

implemented due to insufficiency of funds. Instead devolved health workers were given

Productivity Incentive Benefits.

In 1996, only 50% of the Magna Carta Benefits were implemented again due to

insufficiency of funds and instead were provided Productivity Incentive Benefits. Under

Republic Act 7305, public health workers are entitled to a host of benefits. Mandating hospitals,

whether devolved or not, to provide Magna Carta Benefits without giving offices the

appropriate budget and restricting the implementation despite the enactment is an outcry.

Apparently, the budgets available to most of LGUs could not match all the requirements

concerning human resources.

Furthermore, the affected or devolved personnel have little or no chance of availing

themselves of any training or scholarships, both local and foreign, because national employeesare being prioritized. If ever there is a chance, the LGUs usually will not have the counterpart

funds required.

As far as technical quality is concerned, despite the extensive devolution that took place

in the health sector, there is a noticeable trend of re-nationalizing some hospitals. The DOH

continues to retain 48 hospitals, 35 of which are classified as tertiary: hospitals that are fully

departmentalized and equipped to treat most ailments. The number might have risen to 54

because the DOH regularly brings back to the fold other hospitals that have been re-

nationalized by Congress. The re-nationalization of these hospitals resulted in the DOH putting

52% of its budget into the maintenance of these hospitals. This explains the continuous increase

in the budget of the DOH, despite the devolution of almost 70 percent of its personnel.

As a consequence of the national subsidy for these hospitals which are usually in the

urban centers, a spatial bias has formed against rural and municipal health centersthe very

ones which should have received bigger budgets, since these are where the more numerous but

economically deprived members of society access health services.

Local government units were forced to stretch all possible ways to make the demand of

local service delivery and financial requirements meet (Solon, et al, 2009). The formal

administrative mechanisms for integrating the operations of the devolved health services is

expressed in the Local Government Code, it further stipulates that LGUs can form specialcooperative arrangements among themselves:

Section 33. Cooperative Undertakings Among Local Government Units. - Local

government units may, through appropriate ordinances, group themselves, consolidate,

or coordinate their efforts, services, and resources for purposes commonly beneficial to

them. In support of such undertakings, the local government units involved may, upon

approval by the Sanggunian concerned after a public hearing conducted for the purpose,


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contribute funds, real estate, equipment, and other kinds of property and appoint or

assign personnel under such terms and conditions as may be agreed upon by the

participating local units through Memoranda of Agreement.

Consistent with this provision, some LGUs have banded togther, presumably because oftheir common problems, shared goals or political alliances. For example, some LGUs have

formed collaborative arrangements to tackle more specific development concerns in industry

(e.g.Metro Iloilo-Guimaras Development Council), resource management (e.g. Northern Iloilo

Alliance for Coastal Development), urbanization (e.g. Metro Cebu Development Council) and

health (Inter-Local Health Zones).

These configurations ranges from simple coordination in the planning and delivery of

public services, to formal cooperation involving the joint use and financing of health services, to

consolidation of devolved health services under the administration or supervision of the

province or a single authority created for the purpose.

Apart from these voluntary arrangements, LGUs in many provinces have also

participated in the Province-wide Investment Plan for Health (PIPH), a strategy of the

Department of Health to forge LGU partnerships to coordinate local health plans, secure

resource commitments, and ensure the achievement of health goals in the province. Intended to

be an integral part of the LGU development process, the PIPH deviates from the usual LGU

planning practice wherein city or municipal development plans which include local health

plans are reviewed and put together perfunctorily into one provincial development plan, with

minimal regard for possible inconsistencies, duplications and potentials for possible economies

of scale or externalities.

To ensure LGU commitment, the plans under the PIPH are supposedly developed in a

participatory manner, implemented with support from the DOH and donor institutions, and

monitored and evaluated based on results.

Thus, as a means of support the little room of public expenditure, it is further

proposed to amend the following in the Local Government Code:

SECTION 236. Additional Ad Valorem Tax on Idle Lands. A city or a

municipality shall levy an annual ad valorem tax on idle lands at the rate of 20%

of the assessed value of the property tax which shall be in addition to the basic

real property tax.

SECTION 237. Idle lands, Coverage. For purposes of real property taxation, idle

lands shall include the following:

a. Agricultural lands, more than one hectare in area, suitable forcultivation, farming, dairying, inland, fishery, poultry and other

agricultural uses, one-half of which remain uncultivated or


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unimproved by the owner of the property or person having legal

interest therein. Agricultural lands planted with permanent trees of at

least fifty trees to a hectare, or a proportion thereof if less than one

hectare, shall not be considered idle lands. Lands actually used for

grazing purposes shall likewise not be considered idle lands.

b. Lands, other than agricultural, located in a city or municipality, morethan 1,000 square meters in area one-half of which remain unutilized

or unimproved by the owner of the property or person having legal

interest therein. The planting of permanent crops or trees of at least 50

trees to a hectare, or a proportion thereof if less than one hectare, shall

not be considered idle lands.

c. Regardless of land area, this section shall likewise apply to:i. Residential lots in subdivisions duly approved by proper

authorities, the ownership of which has been transferred to the

buyer-owners, who shall be liable for the additional tax:

Provided that individual lots, the ownership of which has notbeen transferred to the buyer shall be considered as part of the

subdivision, and shall be subject to the additional tax payable

by subdivision owner or developer; and

ii. Vacant lots intended for commercial, industrial, or residentialor condominium projects duly approved by proper authorities

shall be subject to the additional tax until full completion of

the construction or project as certified by engineer/building

officials of the local government concerned.

SECTION 273. Proceeds of Tax on Idle Lands. The proceeds of the additional ad

valorem real property tax on idle lands shall accrue to the special health fund.

The imposition of the idle tax under the present provisions of RA 7160 is optional

on the part of the local government units concerned. The proposed amendments is to

make it mandatory and increased from 5% to 20% of the assessed value of the real

property, in addition to the basic real property tax due.

The proliferation of idle and unproductive private lands should bear economic,

environmental and social functions. It addresses two-fold challenges for the government

as it would raise additional funds to address basic service delivery to the less-privileged

members of society.


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Expanding the basis of Internal Revenue Shares

Local Government Functions and Financing

Hospitals serve as the locus of health care delivery in the Philippines. Survey data shows

that most households go directly to hospitals for treatment of illnesses. With the breakdown ofreferral networks due to devolution, tertiary level hospitals which are designed to cater to more

serious diseases are also accommodating cases that can be handled to attend all its patients. In

the Philippines, a total of 1,578 hospitals were registered with the Department of Health in 2007.

Public hospitals account only for 39% of the total number of hospitals and are usually bigger

than private hospitals and relatively have higher number of beds as shown in the following

graph.

FIGURE 2

Number of Hospital Beds, Public and Private

(Philippine National Health Accounts, National Statistical Coordination Board)

Among the factors that affect the utilization of health facilities are geographical barriers,

cost of medical care and demography. Based on rough estimates on the 2003 National

Demographic and Health Survey, it shows that among those who utilized any health care

facility, 52% came from urban and 48% came from rural areas.

The type of health facility utilized also depends on the wealth level of households. The

poorest of the poor quintiles tend to utilize public facilities while the richer quintiles utilize

private clinics and hospitals.


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TABLE 3Utilization of Health Facilities by Wealth Quintile, 2003

(Lavados calculation based on 2003 National Demographic Household Survey, 2009)

With the breakdown of referral networks, tertiary hospitals which are designed to cater

to more serious diseases are also accommodating cases that can be handled by lower-level

facilities. This leads to tertiary hospitals requiring more financial resources to be able to attend

to all its patients. Aside from being expensive, the current arrangement leads to overcrowding

of tertiary facilities. The mismatch in the capability of tertiary facilities and the severity of cases

to cater to make costs of seeking health care higher not only for facilities but for patients as well.

The LGC provides for inter-governmental fiscal relations between National Government

and LGUs also known as vertical fiscal relation and between and among LGUs or horizontal

fiscal relations.

Vertical fiscal relation between NG and LGUs are in the areas of: (i) Shares in internal

revenue taxes (Sec. 284); (ii) Shares (40% other than the 40% internal revenue allotment) of

LGUs of the gross collection in the exploitation of national wealth within their respective areas

preceding the fiscal year (Sec. 290); (iii) Shares from the proceeds of government agencies or

government-owned or controlled corporations in utilizing and developing national wealth (Sec.

291); (iv) borrowings of LGUs either from private or public sources (Sec 297); and (v) local

budgets submission and review.

Section 284 provides for the forty percent (40%) shares in the national internal revenue

taxes of local government units. A differentiated allotment scheme is followed: (i) Provinces

Twenty-percent (23%); (ii) Cities - Twenty-percent (23%); (iii) Municipalities Thirty-four

percent (34%); and (iv) Barangays Twenty percent (20%). This revenue-sharing is based on an

FACILITY POOREST POORER MIDDLE RICHER RICHEST

Any health facility 18.4 21.1 20.6 20.2 19.7

Barangay Health

Station

28.2 27.6 21.4 14.9 7.9

Rural HealthUnit/Barangay

Health Center

20 24.4 23 21 11.7

Municipal Hospital 19.2 26.4 19.8 22.4 12.2

District Hospital 21.3 23.4 22.5 18.3 14.4

Provincial Hospital 16 26 20.7 21.5 15.8

Regional Hospital 19.8 20.5 20.6 30 19.1

Private Clinic 7.5 13 18.2 27.1 34.1

Private Hospital 4.5 8.9 16.6 24.7 45.3

Others 22.9 19.8 19.8 21.3 16.3


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allotment formula: (i) Population Fifty percent (50%), (ii) Land Area Twenty-five percent

(25%), and (iii) Equal Sharing Twentyfive percent (25%).

Each barangay shall receive a minimum of eighty thousand pesos per annum (P80,000)

depending on its population to be charged against the twenty percent (20%) share of the

barangay from IRA. Also, LGC grants LGUs credit financing powers to create indebtednessand to enter into credit and other financial transactions (Sec. 295) for human development and

other purposes.

These may be in the form of loans and credits with any government or domestic private

bank and other lending institutions (Sec. 297); issuance of bonds and other long-term securities

subject to the rules and regulations of the Central Bank and the Securities and Exchange

Commission (Sec. 299); inter-LGU loans, grants, and subsidies (Sec. 300); loans from foreign

sources through national government (Sec. 301); and contracts with the private sector (Sec. 302).

In Book II of 1991 LGC, LGUs are granted taxing and revenue-raising powers. Section129 states that Each local government unit shall exercise its power to create its own sources of

revenue and levy taxes, fees, and charges subject to the provisions herein, consistent with the

basic policy of local autonomy. Examples of local revenue generating sources are: (a) Province:

Real property tax, Tax on transfer of real property ownership, Tax on business of printing and

publication, Franchise tax, Sand and gravel tax, Professional tax, Amusement tax on admission,

and Annual fixed tax per delivery truck or van of manufacturers or producers of or dealers in

certain products; (b) Municipalities: Tax on business, Fees and charges, Fishery rental or fees

and charges, Fees for sealing and licensing of weights and measures, and Community tax; (c)

Cities: The cities either highly-urbanized or independent component cities - may levy and

collect among others any of the taxes, fees and other impositions which the province or

municipality may impose; and (d) Barangays: Taxes and fees, Service charges, and

Contributions.

However, there are still constraints that the IRA allocation formula leaves provinces and

municipalities at the losing end. Both levels of LGUs combined received 57% of the transfers but

shoulder 92.5% of the cost of devolved functions, including health, while cities and barangays

bear only 5.7% if the cost of devolution but receives 43% of IRA. Thus, provinces and

municipalities complain that budgets is inadequate to fulfill health and responsibility devolved

to them (Atienza, 2003).

There are LGUs, particularly municipalities, that are simply too poor to assume all itshealth responsibilities even if they wanted to. Second, even if an LGU has sufficient budget,

local chief executives and officials may not prioritize health. Finally, there may be a large

allocation for health but people in the locality may be too many for the budget to be adequate.

For example, a poor rural municipality like Irosin, Surigao noted for its successful

participatory health programs only spent roughly P90.31 per constituent based on its 2000


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health budget and population. Meanwhile, a high-income, heavily-populated municipality such

as Baliuag, with Sentrong Sigla-certified health facilities, roughly spent P83.93 per constituent

based on its 2000 budget and population (Atienza 2003).

As an offshoot of the financing, Diokno (2003) posits that rapid conversion from 72

municipalities to cities during the last 20 years, made a lot of sense since the IRA of cities couldincrease several times over by simply converting from municipalities to cities. This

phenomenon imposes no additional financial burden on the national government. Its a zero-

sum game. But there are losers and winners among LGUs: the big winners are the newly

converted cities; the big losers are the old cities that have to settle for a lower IRA.

Diokno continues to opine that the IRA allocation has created perverse results: the

higher, predictable, formula-based, and mandatory grant system has resulted in heavier

dependence of by local government units on the IRA. LGUs never had it so good. Instead of

being stimulative, the IRA has become a substitute for raising own taxes for most local

governments.

To put it frankly, local authorities have become lazy collecting own taxes. This is true for

most local communities, with the exception of some urban communities. The reliance on the

IRA is more pronounced for municipalities and provinces rather than cities. In 2010, IRA as

share of total revenues were 79 percent, 75%, and 50% for municipalities, provinces and cities,

respectively.

Cities happen to have broader tax bases than both municipalities and provinces. Local

health services, social welfare and local public infrastructure did not get top priority spending.

More were spent for general public services, that is salaries and wages for officials and

employees, and in running the office of the local chief executive and local councils.

However, Dioknos opinion is rebutted by a careful study of Hiroko Uchimura and

Yurika Suzuki in 2009 on fiscal decentralization of the 1991 Local Government Code, which

found that the heavy dependence of local governments is evident on intergovernmental fiscal

transfers and that the gap of total revenues by provincial governments in 2000 is wider than

that in 1990.

According to the study, the expenditure discretion of local governments is exceptionally

high in the country. However, qualitatively, the degree of local expenditure discretion lessens.

Along with the fiscal decentralization in the country, the local expenditure responsibilityincreased while the fiscal capacity was not strengthened.


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Lorenz Curve of Total Revenue Lorenz Curve of Tax Revenue including IRA

FIGURE 3

Fiscal Revenue Gap between Provinces in 1990 and 2000

(Measuring Fiscal Decentralization in the Philippines, 2009)

Figure 3 shows that the Lorenz curve of tax revenues excluding IRAs in 2000 is located

outside that in 1990. The Lorenz curve of tax revenues excluding IRAs in 2000 is located outside

that in 1990 which means that the gap of tax revenues including IRAs in 2000 also becomes

wider that that in 1990, although the width is less than for tax revenues excluding IRAs. This is

an indication, according to Uchimura, that IRAs become more important for alleviating the

disparity of local tax revenues between provinces in 2000 as it has expanded greatly after thedecentralization.

IRAs contribute to alleviating tax revenue gaps between provincial governments,

nonetheless, the local tax revenue gaps between provincial governments expanded greatly after

decentralization.

Prior to the LGC, the share of IRA to the different levels of LGUs was 27% to provinces,

22.5% to cities, 40.5% to municipalities and 10% to barangays. According to Manasan (2007),

barangays have been the biggest gainers in the reallocation of IRAs in the decentralization,

while provinces and municipalities are at the losing end. Thus, the aforementioned restrictionsmay be solved by increasing the weight given to equal sharing to equalize IRA in the following

amendment:

SECTION 285. Allocation to local government units, the share of the local

government units in the internal revenue allotment shall be allocated starting in

2004, after deducting therefrom the cost of devolved functions and capital

outlays, increased at the rate of 10% per annum shall be distributed and directly


24/27

remitted to the local government units concerned and the net or balance of the

internal revenue allotment shall be allocated in the following manner:

a) Provinces Twenty three percent (23%)b) Cities Twenty three percent (23%)c) Municipalities Twenty percent (20%)d) Municipalities Thirty percent (34%)

Provided, however, that the share of each province, city, and municipality shall

be determined on the basis on the following formula:

a) Population Fifty percent (23%)b) Land Area Twenty five percent (25%)c) Equal Sharing Twenty percent (25%)

Provided further that the share of each barangay with a population of not lessthan one hundred inhabitants (100) inhabitants shall not be less than Eighty

thousand (P80,000.00) per annum chargeable against the twenty percent (20%)

share of the barangay from the internal revenue allotment, and the balance to be

allocated on the basis of the following formula:

(a) On the first year of the effectivity of this Code:

(1) Population - Forty percent (40%); and

(2) Equal sharing - Sixty percent (60%)

(b) On the second year:

(1) Population - Fifty percent (50%); and

(2) Equal sharing - Fifty percent (50%)

(c) On the third year and thereafter:

(1) Population - Sixty percent (60%); and

(2) Equal sharing - Forty percent (40%).

Provided, finally, that the financial requirements of barangays created by local

government units after the effectivity of this Code shall be the responsibility of

the local government unit concerned.

Fixing at least 5% in the Local Development Projects for Health

The demonstrated lack of operational costs and a sufficient revenue base limits

the capacity of frontline managers and public health workers

SECTION 287. Local Development Projects Each local government unit shall

appropriate in its annual budget no less than twenty percent (20%) of its annual

internal revenue allotment for development projects, fixing 5% for health and


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health related programs and activities. Copies of the development plans of local

governments shall be furnished to the Department of Interior and Local

Government.

With the aforementioned premises, a strategic retreat from devolution is not only legally

problematic but also politically unpalatable. Devolution has even come to be associated withdemocratization as the transition from a centralized regime to one characterized by meaningful

local autonomy is never easy. While the negative effects of devolution on health care systems in

developing countries have been well documented, the innovative and effective programs LGUs

have implemented in their respective communities show that devolution can actually work.

Conclusion

A primary aim of decentralization is to increase the resource base for primary

care, by shifting as many resources as possible from central to peripheral locations. The

experience in the Philippines is that LGUs often lacked the financial commitment andcapacity to fund post-devolution services.

Secondly, the decentralization expanded the decision-making space of middle

and lower level managers, in order to increase the responsiveness of sub-national

authorities to local health needs and situations. Comparing to Asian neighbors, the

Philippines style of administrative decentralization is the most extensive.

Lastly, decentralization is there to enhance the efficiency and effectiveness of

health services management through prompt and appropriate middle level management

decision-making. The introduction of devolution has been associated with the

complication efforts to construct logical hierarchies of health services, mainly due to

existence of gray areas of responsibility between systems and the lack of preparation of

local managers to take on new roles.

The critical resolution of the decentralization challenge in the Philippines is to

widen the revenue base of local government units. With the proposed amendments of

creating a special health fund, imposing ad valorem tax for idle lands, increasing the

revenue base, and fixing at least 5% for health in the local development plans, the

primordial dilemma can be solved, mitigated the least.

Local service delivery, being triangulated by policy, institutions, and finance,and more specifically, by good policy environment and effectiveness, can be achieved by

inter-governmental fiscal and financial system, and accountable institutional actors. To

assume, generally, that devolution failed in the Philippines is to constrict

democratization.


26/27

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Documents

Broadening the Fiscal Design of Local Autonomy.pdf