Chapter 1



Where do I belong? What price do I pay for where I choose to stand? - Diana Trilling




Just before the summer sun is up, hundreds of women spring from their beds and don their colorful clothes. Quietly, they leave their homes and walk into their respective barangay halls. Just then, the halls suddenly fills with lively chatter. It is the first Saturday of the month, time for the “Jogger’s Club” of Bustos, Bulacan to meet once again.

All over the town of Bustos, women from all the 12 barangays would meet up regulalry for this event. Mayor Arnel Mendoza drops by on his mountain bike to join the crowd. He rallies the women with a pep talk then regales them with a Bulacan love song. Dancing and singing ensues and won't wind down for a couple (do we really mean 2 hours or just an indefinite amount of time?) of hours. Dr. Joy Mendoza, the Mayor's mother, who is also the town’s Municipal Health Officer, makes some announcements on the latest health programs. Soon the crowd goes for a breakfast of lugaw, pancit and juice. What started out as a program for cardio-vascular health has evolved into a full-blown cultural phenomenon of dancing and merry-making.

When Health is in the Hands of the People

Public health took a significant turn in the Philippines when national government devolved healthcare to the local government units (LGUs). Unfettered by the directives from DOH and unconstrained by the specialist perspectives of the health economists, epidemiologists and hospital administrators, mayors and citizens began fashioning health programs on their own. With creative thinking, they figured out innovative ways for health to be woven into the multiple dimensions of community life.

This book is about such innovations and the type of leadership that makes such innovations possible. Devolution created the opportunity for the emergence of third generation public health managers. The various roles, skills and concepts of these third generation public health managers will be discussed in the following chapters.

Three Generations of Public Health Practitioners

Broadly speaking, three generations of public health leaders can be discerned from our history.

First were the pre-modern babailans who were healers, priestesses and community leaders rolled into one. Such healers were found all over the country and were called different names--mumbaki in the Cordilleras, muwa among the Badjaos and daniw among the Aetas (verify this with Yolly.) Their interventions were based on empirical rather than scientific knowledge. Taking a holistic perspective towards healing, the traditionalhealers dealt with diseases from more than one angle, from the physical to the psycho-emotional, from the spiritual to the societal. Their knowledge of traditional herbal medicines was used to cure the sick. To address the emotional and spiritual dimensions of illnesses, they prayed for their patients and provided emotional support. They read omens and cast away evil spirits that were said to have brought upon illness. As community leaders the Babailans also lead community rituals and assisted the elders in community governance. Today’s comadronas with their highly personal approach to the delivery of children, offer a glimpse of the traditional healers of old.

Making up the second generation of public health leaders are the scientifically trained physicians and medical professionals. Equipped with their knowledge of disease causation and prevention, they focus on disease control. Their intervention revolves around the application of the bio-medical sciences--epidemiology, biostatistics, pathophysiology, virology and pharmacology. Their tools included medicine, vaccines, and surgery, usually administered through clinics. The Philippine public health system, through the DOH, city and municipal health offices is still comprised mostly of second generation public health leaders.

The third generation of public health leaders is made up of mayors, governors and development workers. They specialize in the managerial and social sciences. They apply concepts such as social marketing, strategic management, health care financing, quality improvement, human resource development, knowledge management, community organization, operations research and policy analysis. Rather than seeing public health as a result of disease control, third generation public health managers see health as a result of various social, political, economic and spiritual factors.

Third generation public health managers are integrators. They rely on the second generation public health managers but do not confine themselves to the biomedical sciences. Instead, they also harness the skills of sociologists, community organizers, entrepreneurs, psychologists, engineers, agriculturists and other experts. With the help of these experts, they craft coherent and integrated plans that contribute to the overall wellness of communities and towns.

The Emergence of the Integrative Public Health Manager

“Cataclysmic” was the term used by one expert to describe this devolution of health services in the Philippines. In an act of law, the Philippine health system was broken up into over 1,600 autonomous town- and city-level sub-systems each controlled by the cities' respective mayors. Seventy-two provincial health systems were also created through this act, headed by governors who were given almost no power over the mayors in the problems. This was among the most radical acts of devolution in the health care system in the world. Devolution put management of the local health systems back into the hands of non-medical professionals. Caring for the health of communities was assigned to mayors and governors who often had little or no medical training. While this presents its own set of problems, having non-medical personnel at the helm changed the perspective of local health care. Unconstrained by the limiting disease-centered orientation of medical professionals, mayors and other local leaders can look at public health managers in a fresh perspective. Below is a sampling of LGU-driven health programs that reveals the integrative approach that local government units have taken in addressing public health problems:

• The people of Sulat, Surigao had limited access to healthcare due to the town’s poverty and remote location. This did not prevent the townsfolk from putting their own health programs in place. The Federated Mother’s Club, a local organization based in Sulat, monitored the health status of the residents and initiated the town’s first form of social health insurance.
• There was a lack of community infrastructure for potable water in Batanes and the absence of proper waste disposal infrastructure in Appari. The Ivatans worked with local leaders on a water system project and the Apparianos, who formerly dumped refuse along the shores, changed their waste disposal practices and rehabilitated their beaches.
• The town of Bustos in Bulacan and the highly urbanized city of Olongapo embarked on zero-waste management programs. Meanwhile, bustling Antipolo City in Manila’s outskirts refused to let the metro’s garbage into their community. Antipolo residents took to streets in opposition to the attempts to dump garbage in their backyard.
• Negrenses launched the Balik Ilahas program in Negros Oriental. This province-wide effort to protect the region's forests aimed to increase forest cover by 75%. It was prompted by the realization that denuded forests were the main cause of the infamous Ormoc flash flood that resulted in the death of over 5,000 people. Negrenses spearheaded a forest management program that reduced the risk of flash floods and resulting injury or death.
• To counter the increasing morbidity and mortality rates in Davao’s government hospitals due to inadequate blood supply, Governor P.S. Amatong issued an executive order for the “Provincial Voluntary Blood Sufficiency Program”. This was adopted by the Sangguniang Panlalawigan, League of Mayors, League of Provincial Councilors and the Association of Barangay Captains.

Public Health Management from a Mayor's Point-of-View

The examples above show that mayors do not see healthcare merely as the control of disease. (Hi, I doubt this statement has integrity as it applies to all LCEs, sounds like a PR thingy) There are more aspects to healthcare and there are various levels of intervention in the health system. The framework below shows a composite picture of the various health initiatives of the LGUs. Their departure from the disease-control orientation to a more integrated view of health systems is a breakthrough that is especially relevant in developing countries where resources are limited.

There are other aspects of human development that influence health such as socio-behavioral, economic, and bio-ecological aspects. Let's examine these different aspects and how they help shape the development of social healthcare structure.

Man as a Social Being.

Man is a social being. He assumes many roles as a member of his family, community, organization and society. When he takes on these different roles, he engages in activities that can affect his health and the health of other people around him.

As an individual, he may engage in activities that endanger his safety and well-being such as smoking, abusing drugs or playing with firecrackers on New Year’s Eve. On the other hand, he may engage in healthy activities such as exercising and eating a balanced diet. He has the right to choose between risky or health-enhancing behaviors and these choices would have a major impact on his health.

A person's health is not limited to his physical health. A person's socio-emotional health also comes into play. With this in mind, health might also be thought of as belonging to the realm of behavioral psychology and social marketing.

As a member of a group, be it a neighborhood or a purok, a person may choose to be active, passive or disruptive. He could become a barangay volunteer health worker. He could live like a hermit. He could dump his garbage in the creeks. As a hermit, he would likely have no impact on the health of others. As a volunteer he could improve the health of others in the community. By dumping waste in creeks, he would be negatively affecting the health of others. At this level of society, social psychology, volunteer management and community organization are some ways of understanding how to deal with healthcare situations.

As a member of society, a person's behavior may have far-flung effects on the health of a nation, region or province. A congressman can propose a bill to stop quarrying. However, another congressman can use his influence to secure environmental clearance certificates to allow quarrying operations to continue. At this level, it is important to look at social sciences such as political science, negotiation, advocacy and policy analysis when dealing with healthcare issues.

The Economic Man.

In satisfying most of his basic needs, man must engage other persons economically. Man’s economic activities take a toll on his health. The dynamics between man’s health and his economic activities are manifested in three levels.

As an Individual - Man is by nature an economic being as a consequence of his insatiable needs. Society’s wealth is circulated through the economic system and there seems to be an unwritten rule is that a person’s health is affected by how much or how little is his share of the society’s wealth.

As a Member of a Group - A person may be deprived of economic resources –he could be an impoverished child of tenant-farmer parents in some island. On the other hand, he could be born as a healthy child of a tobacco tycoon in the North. A person may contract hepatitis-B and it may progress without treatment because he cannot afford anti-hepatitis drugs. In contrast, the same person could have avoided the sickness in the first place if her parents could have afforded to have him vaccinated against the disease when he was still a baby. This seems to support "Man as an Individual" more than "Man as a Group", maybe we need an example for "Man as an Individual" to make the difference clearer

As a Member of a Society - Young women may turn to prostitution due to dire poverty and lack of jobs. In engaging with the said high-risk activity, these girls may contract sexually transmitted disease later on. In Indonesia, people trooped to the streets due to food shortages during the height of the Asian financial crisis. Which resulted in the injury and death of many people.

The Biological Man. Man is a biological being – an aspect of man’s health that is seemingly taken for granted. Man, though only a few people realize this, is a major component of the planetary ecosystem at large. Finally, the biological man is manifested at three levels:

As an individual - At the individual level, a person is merely composed of cells, tissues, and organs. As he goes about in his daily chores, he could get cancer, fractures, and infections. This is the usual bio-medical approach to health. This is the realm of vaccines, pharmaceuticals, surgery, and physical therapy. This approach primarily concerns itself with care for the human body.
As a member of a group - At a higher biological level, man is a member of the local ecosystem. In 1990, the forest denudation around the Ormoc City due to excessive logging resulted in flash floods that killed over 5,000 individuals. In coastal areas, fishermen who practice dynamite fishing destroy the coral reefs, which house the fish eggs and fingerlings. Fishes that were killed could have fed the fishermen’s children in the future. Olongapo City ventured in a solid-waste management program to prevent wastes from causing disease to the local population. This is the realm of environmental management, coastal resource management, forestry, and urban planning and environmental risk analysis.
As member of the human species - On the planetary level, the use of chlorofluorocarbons (CFCs) has damaged the ozone layer which resulted in increased exposure of humans to harmful rays from the sun. The population pressure for the human species (5 billion and counting) is taxing the resources of our planet. Jungles are torn down to make way for people, making still undiscovered species of plants and animals that could possibly have substances which could cure human diseases forever lost to the scientific world.
Man as a Conscious Being. Lastly, man is a conscious being. His actions are determined not merely by instinct or upbringing, but a result of an exercise of free will. Man experiences and creates the world, first in his mind and then in the temporal world.
As an Individual – As an individual,he has dreams and hopes and plans for herself. He has motivations and paradigms and values. He experiences hurts and frustration. This is the realm of developmental philosophy, psychology, psychiatry.
As a Member of the Group – He is a member of the small group such as the peer group, barkada, people’s organization or cooperative. He has concepts of membership, sense of belongingness and solidarity, and sense of equity and justice. When community spirit is strong, He sees himself as a part of a collective consciousness as the community’s collective story unfolds. This is the realm of social psychology, sociology, behavioral and organizational psychology.
As Member of Society - He is a cultural being seeing the world through the lenses of her culture and often transcending his ethnocentric paradigms.

Levels of Health Phenomena

By this point, it becomes clear that health phenomena can be experienced at different levels. For convenience, the said levels are categorized as we have seen above according to the scope of a person’s experience. It was classified as follows: the micro level or at the individual level; the meso level or at a group level or that of the family, firm, community, or even an entire municipality; and the macro level or at the level of the province, region, nation, and the planet. Notice that all of the following factors are inter-related: poverty, environmental degradation, urban congestion and sanitation, unemployment and crime. The health system is thus composed of inter-linked processes. The different dimensions of human health experience could therefore be observed at many different levels or scales. Putting all these concepts together, the health system looks something like this to the mayors and LGU public health manager.


Environmental Dynamics
Economic Dynamics











Levels of Health Phenomena











Micro Level (individual)
Meso Level (group, family, municipality)
Macro Level (region, nation, planet)






Socio-behavioral Dynamics
Concentric Circles Framework for Health

From the cases studied for this book, this framework is the composite picture of the implicit and explicit paradigms that serve as the conceptual foundations of the health programs. (Of all the cases studied, the town of Balilihan, Bohol had a written project framework that most closely resembles this framework, with the concentric circles denoting levels of intervention and 7 slices of the pie, rather than the 4 here, indicating the various sectoral “cuts” in the whole system. The Austin Model is also a similar framework, used for teaching environmental analysis in management school.) Such a representation reveals a systems approach, where there are systems of different scales, micro-systems, meso-systems, and macro-systems, and that these systems are related to one another. The systems perspective allows the public health manager to situate himself in the larger context and plan accordingly. The representation is also multi-perspectival, taking into consideration the paradigms of various scientific disciplines. Much of development work is divided sectorally, where there is a women’s sector, informal sector, coop sector, agricultural sector, environment sector, and health sector and so on. (Second generation public health managers are therefore sector managers. Because of their specialist orientation, they tend to further subdivide the health sector into disease clusters and disease control programs. Hence there are separate programs such as TB, malaria, maternal and child health, reproductive health.) Each sector has it’s sectoral problems and sectoral solutions. Sector-based planning makes it more manageable for sector managers to address sector-specific problems, but often fragments development and interventions. The target of a development program, on the other hand, may belong to multiple sectors. A woman vegetable grower, for example could be a member of the women’s sector, informal sector, coop sector, agricultural sector, environment sector, and health sector. By merging the systems approach with mutliperspectival vision, the third generation public health managers are therefore integrators who perform area management. All of the development problems occur in one geographic space. The economic, political, cultural, and biological-environmental events happen in an area, be it a barangay, a town, or a province. As area managers, public health managers orchestrate the initiatives of the numerous players within the area in order to effect sustainable and systemic improvement. In Negros Occidental, area management was implemented by reforesting the mountains to prevent human injury and destruction of property due to floods. In Bustos, it meant fostering a culture of dancing to improve cardio-vascular health among its citizens. The multi-perspectival vision was very clear in San Carlos City where the overcrowded city cemetery decongested by creating a memorial cemetery-forest in nearby newly reforested hills to improve both ecological, emotional and spiritual wellness.
The integrative approach at health management comes particularly handy in areas where resources are scarce. Particularly in LGUs, ther integrative approach will save them time and effort and will achieve more. To have a compartmentalized approach, on the other hand, is to have a more focused course of action. Yet, the trade-off will be that such an approach may be shortsighted. In adopting such an approach to health management programs, we may have solved the problem at hand for the time being but we have not addressed its root cause. Thus, it may result to waste not only of money but also of effort and time. To give us an idea of the trade-offs between the two approaches, it will help if we are to look at the table below:
A Comparison of Bio-medical approach and the Integrative approach

	Bio-medical approach	Integrative approach
Element	Protective	Promotive
Discipline	Biomedicine	Multidisciplinary –environment, socio-economics and biomedicine
Health	Health a result of host and agent factors (purely a bio-medical analysis)	Health as multi-factorial –as a result of economic, environmental, and biomedical aspects of life
Role of individual	Patient -acceptor of medical care	Co-creator and caretaker of a healthy ecology
Objective	Cure disease and prevent illness	Sustainable healthy environment
Locus of public health management	Health sector –composed of clinics, hospitals and health professionals	Business-state-civil society, economics-ecology-biomedicine, families-communities-institutions-society
Time horizon	One lifespan	Past, present, and future
Result of neglect	Illness	Illness, injuries and deaths due to environmental disasters (i.e. Ormoc flash floods), physiological deprivation, hunger, breakdown in food chain (economy - resource chain-value adding chain), sickness due to economic problems (malnutrition), injury due to socio-political breakdown (crime, war and riots), psychological unwellness due to environment and economic stressors (proliferation of street children, child prostitution, OCW orphans, victims of calamities)
Tools	Biomedical tools –medical procedures and medicines	Risk management, social marketing, community mobilization, education, policy, governance, and medical anthropology
End goal	Physically well patient	Optimal bio-psycho-ecologic equilibrium for an individual

Managing Parts of the Whole and Managing the Whole : Implications of the Third Generation Framework The framework reveals that the tasks of public health management fall not only on the mayor and municipal health officer but on all other municipal (and provincial) agencies. It involves the planners, the engineers, the teachers, the social welfare and development office, the information office and the agrarian reform office. Based on the four dimensions of health discussed above (economic, environmental, socio-behavioral, and cognitive), we could come up with four corresponding types of health problems as outlined below. To address the economic aspects of health, economic and health financing interventions are available to us. Among these are social health insurance, health maintenance organizations and other health financing schemes. To address the environmental aspects of health, engineering and environmental management interventions could be tapped. To address the socio-behavioral aspect of health, several teaching interventions –e.g. seminars and focused group discussions--could be used. For the cognitive issues, visions of what is and what is possible have to be reviewed, renewed or recast.

Effect of negative factors on the degradation of health at different levels illustrated

	Behavioral	Ecologic	Economic
Micro level Individuals	Unhealthy personal hygiene and practices (such as vices and drugs)	Unhealthy household environment	Unemployment
Meso level Family, community, and/ or institution	Unhealthy community health practices Rise of criminality and violence Racial hatred and bias	Lack of proper sanitation and garbage disposal system Floods due to improper garbage disposal Epidemics due to congestion and water shortages	Rise of unemployment Rise of depressed areas and number of urban poor over Population Food riots Proliferation of illegal drugs Rising cost of living
Macro level Society, Regional populations, and/or Nations	Crime, war and riots Racial hatred and bias	Lack of proper sanitation and garbage disposal system Flash floods due to environmental degradation Epidemics due to infestations or due to unsafe water	Rise of depressed areas and number of urban poor over Population Proliferation of illegal drugs Flash floods due to environmental degradation Rising cost of living

+++++

	Year 1 (post election)	Year 2	Year 3 (12 months before election)
With political opponents	Reconciliation and cooperation	Reconciliation and cooperation	competition
With bureaucracy	Introduce change, bunggo	Stabilizing change	Cashing in on positive outcomes, befriending bureaucracy
With polity	Introduce change, bunggo	Stabilizing change, improving political base	Cashing in on positive outcomes, consolidating and expanding political base

It is said that for as long as the local government units pursue its objective of improving the quality of life of the citizens, the concept of health and healing could very well be the ideas around which the vague term “quality of life” can be anchored on. With the concept of health pertaining to not just physical health but also social and economic health, then that quite neatly gives the local government a handle on quality of life.
Quote the public health manager from old iphm brochure.

	Bio-Medical, Ecosystem	Psycho-Social, Behavioral-Political	Economic
Individual	Medical/surgical care	Emotional education, psychotherapy, health education, social rehabilitation, stress management, hygiene, smoking cessation	food supplementation, health care subsidies/ financing
Household	Family health care, breastfeeding preparation	family counseling, responsible parenthood	income augmentation
Community	Primary health care, sanitation, waste management, vector-control	peace and order, sports activities	community health financing, HMI
Workplace/ Institution	Occupational safety and health, school-based health care	Gender sensitivity	_ HMI worker rights and welfare, employee health benefits
Town/ Society	Environmental health, pollution control, watershed management, forest management	health policy, anti-smoking campaigns	health economics, health policy