Chapter 6 Technical Axis
Everyday, calloused bare feet walked miles on dry earth from the village to the oasis. Like black ants in a neat queue, the African boys were just doing a chore: fetching gallons of water perched on their skeletal shoulders. Yuga, the youngest among the boys, one day put plastic scraps together and invented a huge round gallon, filled it up with water, and rolled it from the oasis to the village. For the first time in almost their entire existence, the African boys played. A simple, seemingly mundane but very elegant invention that was. Public health managers have long wanted to effect change in the community. Change introduced in forms of health programs, projects, and other innovations must have the right design architecture. They must be logical and technically sound. Technical Axis factors in the technical soundness of any health project. Projects can be technically efficient or inefficient. (see Case 5). Case 5 Olongapo Solid Waste Management Program
Urbanization brought a mix of opportunities and problems for Olongapo City. The economic prospects posed by the presence of a United States naval base in the area in the past attracted heavy urban migration from the neighboring municipalities as well as distant provinces. Other people came from nearby provinces like Bataan and Pampanga and from distant areas like the Bicol Region and the Visayas as well. It was not unusual, for instance, to see vendors from Bataan with jeepney-loads of food come to do business for the day. As urbanization ushered in, the problem of waste became even more pronounced. Even the Mt. Pinatubo eruption in 1991 and the pullout of the naval base in 1992 dampened economic activities only temporarily because the creation of the Subic Bay Free Port Area in 1992 eventually restored its zest to exploit economic opportunities. Asserting once more the need for an environmental sanitation program in the city.
Olongapo City’s Solid Waste Management Program stemmed from the recognition of a basic fact that when people settle in an area and discharge their usual activities, they are bound to generate or produce garbage. The program highlighted discipline in following the collection schedule, the use of plastic bags for garbage collection, and the payment of garbage fees. With strong political will and the active participation of the constituents, the system succeeded in addressing health and sanitation problems in the city. Private businessmen and individuals finally agreed to pay garbage fees provided collection was assured. The innovative program also created positive socio-economic benefits such as the imbuing of discipline and the generation of revenues to make the program self-supporting.
Solid Waste Management Program Features

1. Collection Schedule. Regular collection scheduled was followed strictly. Garbage was collected twice weekly from residential zones and daily from commercial zones and markets. The 17 barangays were divided into 3 zones. Proper scheduling of collection prevented accumulation of garbage in some areas and even prevented stray animals from scattering garbage and become disease carriers. Likewise, junk dealers, push cart boys, and refuse pickers had to observe the schedule. This made monitoring of compliance by the Sanitary Technicians easier. A household, for example, that took garbage out of schedule or a pushcart boy operating in the area during a collection period was easily noticeable.

2. Use of Plastic Bags. Only garbage that was properly contained in plastic bags or any kind of handy and closed container such as sacks and cardboard boxes, were collected. Although any kind of plastic bags were acceptable, those sold by the program were reusable. There were plans to replace the plastic bags with recyclable materials to make the program even more environment-friendly.

3. Garbage Truck with Public Address System. The program acquired five new garbage trucks which complemented the existing eight trucks to service all the 17 barangays of the city. Slogans posted on the sides of the trucks such as “Keep Olongapo Clean” and “Bawal ang tamad sa Olongapo” (Slothfulness Not Allowed in Olongapo) reminded the public of the values fostered by the program. The public address system installed in the trucks played the program’s jingle which served to announce its presence in an amusing and motivating way while educating the residents. The trucks were kept clean and well-maintained. These were washed after each hauling activity.

4. Garbage Jingle. The lyrics of the jingle was educational. It encouraged people to value health, cleanliness, and taught them proper garbage disposal.

5. Uniforms. Sanitary technicians (garbage collectors) and drivers wore uniforms and identification cards (IDs).

6. Garbage Fees. Garbage fees of P10-P20 were collected from the residential areas and P30 – P300 from commercial establishments. To facilitate billing and collection, the garbage fees were collected together with the electric bill. Not paying the garbage fee meant not paying the electric bill—something residents and establishment owners did not dare do.

7. Citation Tickets. Sanitary inspectors of the City Health Office regularly inspected their assigned areas and issued citation tickets to residents whose premises were found unclean. Those issued citation tickets for violations were directed to appear at the Office of the Mayor within three days for appropriate disposition of the citation. The case was forwarded to the Office of the City Fiscal within twenty four hours for filing of appropriate charges if the violator failed to appear within the period.

7. Organized Junk Dealers. Pushcart boys and junk dealers were organized. They had to observe collection schedules. Their carts were not allowed in the areas where garbage trucks were scheduled for collection. Their permits were revoked if they violated the rule. The carts were color-coded and assigned with body numbers to easily detect violators. Push cart boys were made to wear uniforms for identification purposes.

9. Thrash Barriers. To prevent garbage from flowing trash barriers made of net and floating wooden poles were set up along the main rivers. Six personnel riding in three bancas gathered the trapped garbage from the nets.

9. Dumpsite. The collected garbage was brought to the sanitary landfill located in a government-owned land in New Calaban, about seven kilometers away from the city. The 25-hectare dumpsite was reported to have been studied and approved as a dumping ground by technical experts through an assistance from the Economic Support Fund. Topographical, hydrological, ,and other tests were undertaken to ensure that the site would not destroy the environment in the surrounding areas. It was located in a relatively high area and an alternate road path which could be opened to allow rainwater to pass through to avoid flooding. There were no nearby bodies of water such as rivers or creeks which could be contaminated. Bodies of water were far enough from the area allowing the leachate to be filtered well before it reached the water streams. As garbage was loaded, sand deposits from the river were used to conceal the unsightly view. A bulldozer was always on hand for leveling garbage heaps in the dumpsite.

9. Recycling Program. Organized refuse pickers recycled the wastes at the landfill area. Approximately 100 sorters living near the dumpsite were organized. Every other day, half of them were allowed to gather recyclable materials from the dumpsite. They were divided into six groups each and were assigned to sort two trucks each. Plastic bags were rinsed and sold. A sorter earns approximately P150 per day. Though no combustion occurs, the sorters and collectors were required to wear dust mask to protect them from possible respiratory ailments due to lahar and dust. Children were prohibited from entering the area.

9. Organized Market Vendors. The approximately 1,000 sidewalk vendors were organized and trained to keep their place clean. Keeping their place of trade clean was made part of their duty in exchange of the privilege to sell without paying tax to the government. Each vendor was given an identification card and was required to wear a uniform at their own expense.

9. Clean-up Drive. Every Saturday morning, 500 to 700 out of 1,200 government employees were assigned to clean specific areas in the city.

9. Waste Reduction. The second phase of the program adopted a waste reduction program using the sorting at source system. The city residents and establishments were taught to segregate biodegradable, non-biodegradable, and recyclable garbage materials. Once again, everyone’s support was solicited during the massive information drive to minimize any resistance to the program. City officials consulted the people on their views about this new project after attending the seminar on waste reduction. The schools were tapped to educate children regarding the importance of waste reduction and solid waste management. Composting methods were also taught in the schools.

Managing the Program
The city mayor, in charge of the over-all operation, guided the program through weekly meetings with department heads and regular consultations with the program implementers. The city mayor exercised this function through the Environmental Sanitation and Management Office (ESMO), a new department created in 1989 for this program. ESMO had 99 personnel working in three sections, namely garbage collection, ,street cleaning, and motor pool. All were supervised by the Public Service Officer, the department head. The operations crew were called Sanitary Technicians. Although frequent absences were not a problem, the program provided contingencies by hiring two buffer employees. Street sweepers were also tapped for these purposes.
A Garbage Task Force responded to complaints and queries to complement its own studies and observations on the workings of the program. They were composed of nine personnel, seven posting and billing clerks, and one encoder and once supervisor.
The City Health Office complemented the work through their Sanitary Inspectors who issued citation tickets to violators of City Ordinances and Sanitation Laws.
Sanitary Inspectors had been provided with radio and motorcycles to shorten their response time.
Spotters were assigned in the dumpsite to ensure order and the strict compliance with regulations.






































inefficient/ineffective efficient/effective
The MHO must evaluate the health project according to the science behind the intervention. Below is a matrix of various approaches to known and unknown problems to guide public health managers:

Quadrant	Approach	Case	Whom to Approach	Hazards	Possible Breakthroughs/ Innovations	Comments
1 Known Problem, Known Solution	Benchmarking Copying the recipe	Marikina and Naga Quick Response, Guimaras Health Insurance	Solutions-provider who develop systems and capacity to solve the problem	Cookie-cutter approach; inability to customize and indigenize; use of obsolete solutions	Increased technical efficiency—the solution does it better New approach to an old problem—reengineering of solution	Effective innovations eventually end up in this quadrant, also a source of old solutions applied to new problems
2 Known Problem, Unknown Solution	Problem solving using common sense, action-research consultancy	Appari	Consultant problem solver	Expert/technical dependence Path determinism of expert Reinventing the wheel	Invention of a new solution—a tractor pulled ambulance in Palawan	Valuable solutions if proven effective, should be moved to quadrant 1
3 Unknown Problem, Known Solution	A solution looking for an application, an observation Process analysis, understanding why the solution works, then advocacy when applied	Binibining Cedula, Princess of Nutrition in Bustos Forest Cemetery in Negros Antiseptic Paint	Process engineering, Common sense	Tool fixation—if you have a hammer, you see each problem as a nail	Using old processes for new inputs and new outputs, cultural compatibility	Get solutions form quadrants 1 and 2 and see how it can be used in quadrant 3. Provocative thinking, Recombination
4 Unknown Problem, Unknown Solution	Blissful ignorance vs. anticipatory learning Trending and modeling to identify gaps	Bulacan, malnutrition Appari moved from quadrant 4 to 2	Data analyst to compare and identify gaps	Complacency, denial	Anticipatory learning, learning to accept reality, ,meaning—solutions, transcendence	Acceptance Transcendence Disturbance Satisfaction

Quadrant 1: Known Problems, Known Solutions
If a community encounters a known problem and finds a known solution for it (say, dengue outbreak therefore prevent aegis mosquitoes from breeding), it can benchmark; or act on the problem based on proven and set standards. Naga and Marikina cities, for example, put in place their Quick Response Program modeled after 911 quick-reaction for emergencies. To put in place their own health insurance, Guimaras emulated the Medicare II program initially launched by the government (it was a good thing the province was chosen as test bed for the Medicare II trial run). In both cases, problems were known therefore known solutions were used. Public health managers can outsource from solutions providers who would provide technical assistance in building the community’s capacity to act on the known problem given known solutions. Outsourcing, however, can be risky because solutions providers most of the time have canned off-the-shelf solutions that may not wholly apply to the community’s uniqueness. This pre-packaged approach is more often not customizable. For known solutions to known problems to become a breakthrough, leaders must be able to increase efficiency—doing the same thing better than it was done before. Leaders can reengineer and redesign solution to more carefully suit and address the community’s unique requirements which off-the-shelf solutions may not address. Tuberculosis, for example, is already a known disease having a known solution. In fact, anti-TB or TB prevention medications are already available to the community. A volunteer health organization embarked on anti-TB drive and gave medicines to people diagnosed with the disease. To the group’s dismay, reduction of TB was slow despite years of providing medicines. When they assessed the situation, they found out that patients did not take the medicines as prescribed. Some plainly neglected it. Worse, due to poverty, others sold it to the sari-sari store. To correct this, the volunteer group redesigned their approach of giving medicines to TB patients. This time, they required each person to drink the medicine in front of them. Through the years that this has been done, TB rate was reduced. All innovations should eventually fall under quadrant 1. If old known solutions are also applied to old known problems, then this becomes another innovation.
Quadrant 2: Known Problem, Unknown Solution
Public health leaders are normally confronted with many problems but few solutions. Obviously before research and development came to be known, our elders had to resort to God-sent common sense in dealing with pain, fractures, bites, etc. They made sense out of the situation. Of the more obvious causality of things. Today, however, public health leaders cannot solely rely on traditional trial and error in solving larger scale community health problems. For known problems and unknown solutions, the most logical course of action is to research for a solution elsewhere, to consult. Because Appari’s shores have long served as toilets for its residents, the local leaders had nary the idea where to start the decades worth of undoing. They had to research an outsider consultant to start the clean up and rehabilitation project. The hazard to this kind of approach is path determinism. Depending on his background, a consultant can approach a problem only through the knowledge he has and is comfortable with. People give varying directions to the same destination depending on their point of departure—or where they are coming from. Such that, if it were a marine biologist to solve Appari’s problem, then the focus might have been on salvaging the marine life. If it were an engineer, then the focus might have been on putting up the right infrastructures. We know that the situation on shores of Appari is more than just a marine and engineering issue—it is an issue of culture. It is important for public health managers therefore to reinvent the wheel—see beyond what consultants would offer so that the appropriate technology can be utilized.
For years, municipal health officers had difficulty reaching the uptowns of Palawan because of its ragged and unfriendly terrain. The steep, swirling rough roads were impassable to the ambulances, so that patients from these areas were hand carried by community fellows down to the nearest clinic. The doctor in the area experimented using the kuliglig, a motorized cart similar to a go cart used to help farmers plow the soil, to carry the patients from the uptown down to the town center. This was successful; in fact, the approach innovated the kuliglig-pulled ambulances in Palawan. This made health services more accessible to the uptown dwellers.
Quadrant 3: Unknown Problem, Known Solution
Meanwhile, there are also solutions which have not found practical applications. Through process analysis, observations, and experimentations; leaders formulate solutions but do not have problems to which these can apply. Out of his experimentations, a chemist discovered that antiseptic becomes a disinfectant when lit. He hunched that this discovery can be a solution to a problem somewhere. After much thought, he realized that this antiseptic can be used as paint for hospital walls, which when lit, develops into a disinfectant. This way, a known solution has found what used to be an unknown problem. Taking after the design of popularity contests, Bustos town in Bulacan holds the annual “Search for Princess of Nutrition” among pre-schoolers. Since 1989, this motivational activity has been successful in raising funds, awareness, and involvement for the community’s health and nutrition projects. The candidates competed in gathering the most number of seedlings of fruit-bearing trees. Candidates encouraged their supporters to bring as many seedlings as they can, which were planted on recycled cans and boxes and distributed to elementary schools for propagation. Another innovation of this sort is Lakambini ng Cedula, which curbed the town’s rising problem in resident tax collection. Local leaders patterned a beauty contest of sort but this time, the lady contestants competed for the most number of taxes collected from residents. In Negros, a mayor had to contend with two problems: rapid forest denudation and overcrowded cemetery. Deriving inspiration from Israel’s post-war experience (where leaders built living monuments by burying the dead in the foot of trees), the mayor came up with the concept of a “rented cemetery.” Relatives of the dead will rent a cemetery space for five years. Upon burying the dead, the relatives will also plant a tree in the forest and name it. After five years, the remains will be pulled out from the cemetery space. Relatives will then transfer the remains and bury these at the foot of the now five-year old tree. Amazing, isn’t it? With this, the mayor managed limited cemetery spaces and at the same time conserved and increased forest cover. Now a holy ground, people stopped cutting trees in the forest because every tree is a resting place for the dead. Eventually, innovations in Quadrants 1 and 2 must pass through quadrant 3 as well. This means that old solutions should reinvent themselves in new problems, and old problems must utilize knew solutions. The danger of discovering where to apply something brilliant, though, is that innovators can be fixed with this tool and fail to recognize other more appropriate ones. Leaders must always be on the lookout for fresh ways to do old things. Or how old methods can be revived in new fashion. This entails provocative thinking.
Quadrant 4: Unknown Problem, Unknown Solution
People can be wallowing in a problem that they don’t realize or refuse to acknowledge as one. Even leaders may fail to recognize problems and obviously the solutions as well. They are blissfully ignorant that something has to be done. If the problem is that there seems to be no problem at all, it helps for leaders to survey and compare the community with others. Trending and modeling identifies gaps, and can be a wake up call. Bustos town started to act on nutrition after a survey showed that the town’s constituents were way malnourished compared to the other towns in the province. Appari folks would not have considered undoing their lifestyle (of throwing refuse to the shores) had they not been cited on national TV as the longest toilet in the world. People can sometimes be oblivious to problems. To address this, public leaders can approach survey and analysis companies to study their situation and see how it can be better. The data analyst can compare and identify gaps which can benchmark next steps for improvement. The hazard to be dealt with here is complacency and denial. People defy change because they are lax and complacent, being content already with what they have right now and not seeing the need to change. But once they do (as in Appari folks) this change will sustain itself, as people learn to accept reality, learn from it, and do something about it. Good intentions alone don’t ensure success. These need some technical rigor to succeed. Technical Axis and the Health Dimensions
Relating this to our discussion of health practices and projects, we say that projects must be technically sound in all five dimensions of health. Below, we will see a matrix of technical flaws in various health dimensions, and the outcomes. This situation actually happened. Technically Flawed Provincial Health Financing Programs (Bukidnon Health Insurance Program)

	Flaw	Outcomes
Socio-political design	Physician-driven decision making, moral hazards facing MDs, Governor sponsored	Policies favored physicians, possibly more than patients
Bio-ecologic design	Sound/none	Clinical services delivered
Economic design	Provincial government subsidized, P10 M	New elected governor withdrew subsidy thereby killing the 9 year-old project
Noo-design	Stigmatized as “masa” project, poor social marketing	Dwindling participation

To further illustrate, project officers of Sulat town in Samar, were able to mobilize the local townspeople to construct a water reservoir that will serve as a collection base of water from a spring. Such a feat in mobilizing people is considered a breakthrough using the Social axis. However, water from the spring did not flow into the reservoir due to gravity -the reservoir was placed on a higher ground than that of the spring. Obviously, the engineering design was technically flawed. Thus, the reservoir turned to be useless. This same project will be deemed ineffective on the other hand if we are to use the Resource Management Axis in evaluation. Resource Management is anchored on the principles of allocative efficiency -to spend on the right projects based on cost-benefit analyses, and on technical efficiency conversion of inputs (money, man days etc.) to concrete ( livelihood projects, feeding programs etc.) outputs. The question of which to construct first – a municipal high school building or a municipal hospital, are issues of allocative efficiency. They fall along the technical Axis. Breakthrough Analysis It seems that most Galing Pook winners banked on perceived major breakthroughs in one or more axes. Hence, it is also conceivable that a waterworks projects can win a number of times because of breakthroughs in different axes. Loon Waterworks in the island of Bohol, may have won because of the people-power breakthrough (Organizational Axis). On one hand, the Batanes Waterworks project won primarily because of a technical breakthrough (Technical Axis) introduced in the said endeavor. Yet perhaps the Clarin Waterworks of Bohol can be seen as primarily a managerial breakthrough (Leadership Axis). Inter-Axial Intersection The elegance of certain projects often arises from inter-axial intersections. For example, the puroks in Balilihan were at first merely social groups. But purok members were given management training, making them a functional part of the managerial system. Later on, puroks were made an organic part of the Municipal structure by an act of legislation, further legitimizing the purok’s managerial role. The Community Primary Hospital Development Board of Negros Oriental and the Confederation of Health Councilors Association of San Miguel, Bohol were also an example of an intersection of Organizartonal and Resource Management Axes.