Chapter 7 Resource Management Axis


Food from the food carts of the enemy are more valuable than from your own food carts.
--Sun Tzu
A plethora of health programs at the municipal health office faces risk of being shelved for lack of funds. The juggling act between enormous need and scanty resource can drive the Municipal Health Officer nuts. Resource management helps the MHO stretch the peso to the limits in three ways: 1) knowing how to work hard and work right to earn it, 2) knowing how to spend it right, and 3)knowing and using what other resources are present other than money. Resource management shows how the MHO can mobilize, utilize and replenish resources.
1. Increasing Circle of Influence
Resources in the community are controlled, influenced, or appreciated. Normally, communities are stuck with resources which they can control, or those which they own, while there are potential resources around which they only appreciate. There is a need to transform more of controlled and merely appreciated resources to influenced resources. This multiplies the community’s resource base tenfold.



















By moving more appreciated resources to influenced resources, the community’s resource base/sphere multiplies/widens despite controlled resources remaining the same.


Let us use the Health Balance Sheet as an example of how increasing the circle of influence can also increase our resource base. As in financial balance sheets, Health Balance Sheet lists down assets (resources available) liabilities (unmet health services) and equities (delivered health services).
Health Balance Sheet



1. Construction of 75-Bed P10 M Community Hospital
2. Procurement of Medical P5 M Equipment (X-ray machines, CT Scans, etc.)
3. Anti-Polio Vaccination P100T To 3 barangays
4. Family Planning Education P50T
5. Construction of Public Toilets P1M
6. Construction of Ambanguig P6M Water Station (to serve 7 barangays)
7. Rehabilitation of Lake Aikiki P3M
8. Construction of community P1M health clinics (for Malagutay, Pasonanca, and Ayala towns)
9. Hiring of 3 MHOs (for Malagutay, P60T Pasonanca, and Ayala community clinics)
10. Specialization Training for P100T current MHOs on preventive cure for tetanus neonatum TOTAL LIABILITIES P26,310,000.00


VALUE
VALUE
































Individual -family -purok -barangay-mun

Now, let’s take a look at what we have. We have total controlled assets amounting to P6, 900,000.00. Even if we added our appreciated assets to it (P6, 900,000.00. + P35,000.00), the total assets amounting to P6,935,000.00 is still too short for our P26,310,000.00 total liabilities. Now where do we get the extra?










From our Health Balance Sheet above, we need to raise P19, 375,000.00 more to be able to decrease our liabilities, or meet more health service needs. Notice that we have a plethora of untapped, latent assets that we appreciate but have not influenced yet. See what happens to our liabilities when these sleeping assets are already mobilized. ASSETS
LIABILITIES




INFLUENCED

1. Construction of 75-Bed P10 M Community Hospital
2. Procurement of Medical P5 M Equipment (X-ray machines, CT Scans, etc.)
3. Anti-Polio Vaccination P100T To 3 barangays
4. Family Planning Education P50T
5. Construction of Public Toilets P1M
6. Construction of Ambanguig P6M Water Station (to serve 7 barangays)
7. Rehabilitation of Lake Aikiki P3M
8. Construction of community P1M health clinics (for Malagutay, Pasonanca, and Ayala towns)
9. Hiring of 3 MHOs (for Malagutay, P60T Pasonanca, and Ayala community clinics)
10. Specialization Training for P100T current MHOs on preventive cure for tetanus neonatum TOTAL LIABILITIES P26,310,000.00


UNMET HEALTH SERVICE NEED


Financial
Organized Balikbayans, P1M Annual pledges
Dialogued with Governor, signs P1M Annual Foundation Anniversary Fund
Human Resource (Social Capital)
Mobilized Volunteer Health Workers P100T (manpower for constructions projects: Community Hospital, Public Toilets, Water Station, Community Clinics)
Private doctor volunteers to be MHO P20T will invite other doctor friends
Knowledge
Engaged Population POs for Family Planning Education for free P50T
Engaged Health NGO and Private P100T Doctors for free specialization Training on tetanus
Facilities Approached private drugstore to P25T Donate syringes for vaccination drive
Private hospital donates X-ray machine P2.5M


TOTAL INFLUENCED P4, 795, 000.00 ASSETS
With influenced assets now pouring in, we obviously see a major slash in the finances required for our unmet health service needs. This means we increase our implemented projects (or equities) and at the same increase our capacity to do more, despite our controlled budget remaining the same. We simply had to widen our circle of influence!

2. Increasing Leverage of Tangible vs. Intangible Resources

The bullet has small amounts of a highly combustible chemical called the primer which, once heated, ignites the gunpowder. The gunpowder then fires the bullet out of the gun. Health resources particularly monetary capital must be used like a bullet’s primer—funds must be used to generate more funds, to ignite greater explosion. Public health managers must not spend health funds for an end, but for means to an end. They must use this limited resource to trigger an avalanche of greater resource.
Leaders should use financial resources only when there is a cost-recovery mechanism. Members of health insurance systems pay their minimal annual premium to sustain the program. This way, the finances are cyclical: something flows in when something flows out. Cost-recovery works when minimal source funds are used to earn more sourced funds.
Social capital is a valuable intangible resource that in fact, increases with use. Goodwill, unlike money, returns voluminously when given away. Unlike money, goodwill never depletes when shared. People helping each other deepen their relationships through time. If at first, one shares room with the other, the other will be more than willing to share his entire house when one needs it someday. That is how goodwill works.
Leaders must also use the inexhaustible resource that is knowledge. Knowledge capital can become obsolete, yes, but can never be depleted. Knowledge can be multiplied infinitely, and can be highly transferable. Leaders must wisely use the knowledge resource available to them to save on financial resources.
Because complex knowledge requires complex peopleware and software to be absorbed, it is also a leader’s role to create municipal sophistication—to create sophisticated awareness and participation among its citizens and not to shy away from sophisticated processes.
Knowledge management is a critical tool in health development. It is particularly a major help when financial resources are scarce and when the community’s absorptive capacity for new knowledge is high. This ultimately leads to health-enhancing behaviors. Knowledge systems are usually composed of content, knowledge centers/repositories, behaviors arising from that knowledge and functional relationships. This knowledge system is often in a state of balance- naturally resisting new knowledge. We should identify where this so-called “knowledge” could be found. After all, there are interventions in health care that merely require knowledge transfer to the target learners.

Abundant Knowledge Resources

Abundant knowledge resources are technologies commonly taught at state and private universities and colleges such as medical technology, nursing and yes, even community development. Thus, this is synonymous to commonplace knowledge (at least among the faculty, students and other academicians).

Scarce Knowledge Resources

Scarce knowledge resources in a way can be found and are accessible only in highly urbanized areas such as Metro Manila or Metro Cebu. Some of this scarce knowledge would be in the form of health care financing or rehabilitative medicine technologies. Scarce knowledge resources are also those specialized body of knowledge and skills that are not readily available for development projects in the countryside. We cannot discount that the business sector may have these skills but are not interested in sharing the knowledge or they maybe willing to “share” for a handsome price.
Case 3 The Guimaras Health Insurance
Who would have thought that a national project piloted in a sleepy town would survive amidst administrative tensions?
In 1976, Medicare PII started as a pilot project in Guimaras, then the municipality of Nueva Valencia. Medicare PII was the national government’s second attempt at institutionalizing a health insurance system for the poor. The program survived through the years. In 1987, however, the Municipal Medicare Care Council (MMCC), the body that managed Medicare PII, was abolished by virtue of Presidential Decree 1519. Management of Medicare PII was removed from the municipality and restored to the revived Philippine Medical Care Commission (PMCC). Even without the council, Guimaras proceeded with the program. But without the usual support of the MMCC, the program weakened and was already near collapse.
In 1989, then Nueva Valencia Municipal Health Officer (MHO) Dr. Tronco formally approached PMCC for assistance. In February 1990, the Department of Health (DOH) and the municipality of Nueva Valencia entered into a Memorandum of Agreement to operate the resuscitated Medicare II as their joint undertaking. Shortly after, the PMCC assigned full-time personnel to extend technical assistance to Nueva Valencia. As early as then, Dr. Tronco was already lobbying with then Board Member Catalino Nava, himself a physician, to implement the program province-wide. Dr. Tronco believed that the only way to improve the coverage of Medicare II was to widen the membership base. While Dr. Nava was receptive to the proposal, he suggested that it would have a much better chance of being implemented should Nueva Valencia become a full-fledged province, at that time, the full provincehood of Guimaras was already being worked on.
After the 1992 plebiscite, Guimaras became a full-fledged province. Emily Lopez was appointed as the first governor of the newly created province. Gov. Lopez was so convinced of the program that it was one of the few she prioritized upon assuming office.
For the Medicare PII to work, there was a demand for greater membership base. To reach the target group, the community volunteers were utilized to advocate for the program and recruit membership. A house-to-house campaign was done. To further augment the activity, the provincial staff conducted continuous information dissemination in the barangays. But the best marketers of the program were those who actually availed of the program’s benefits. Their testimony about how the program actually helped them, and how it unburdened them of the prohibitive cost of hospitalization, had a powerful multiplier effect in the community.
Meanwhile, each participating municipality designated its own Medicare Program II coordinator and set up MP II desks at the municipal hall. The MP II coordinator in the municipal level took care of all program-related transactions.
Through these volunteer efforts, improvements in the main hospital (Guimaras Provincial Hospital located in the municipality of Jordan) poured in. The newly renovated 75-bed provincial hospital was strategically accessible to all the five municipalities. The province had improved its laboratory services and acquired medical equipment such as the 400 MA X-ray machine, a defibrillator machine (an emergency equipment) and additional medical beds. It increased its personnel and consultants to complement the increase in bed capacity.


























Knowledge-driven development uses what was discussed in the previous chapter as the Known-Problem, Known Solution quadrant. Leaders can make use of known solutions particularly the knowledge-intensive and not capital-intensive interventions for its health programs. For example:

• Health Insurance. As the case above shows, leaders can spend money to bring in experts and systems so that people can pay premiums for their own health insurance.
• Blood Bank. Davao’s provincial government spent money on advocating and generating support from blood donors rather than on buying blood.
• Home Toilets. In Surigao, local leaders spent money to purchase toilets for homes but enjoined the people to install the toilets at their cost
• Barangay Health Workers. In Bulacan, the local officials spent money training mothers to be Volunteer Barangay Health Workers. Over 300 BHWs have been volunteers for 10-15 years since the program started in 1989. Assuming each BHW puts in one person per day week amounting P140, this totals P2, 184, 000 in donated labor to LGU health programs.

Leaders must identify potential and energy and know how to convert this to actual energy. Guimaras Health Insurance Program actualized knowledge capital when it brought in a team of economic experts from the University of the Philippines to help them run their social health insurance. Knowledge capital is a valuable resource. But how can leaders create it?
Creating an effective knowledge architecture There are basically four key areas in building effective knowledge architecture. The key areas are as follows:

1. The establishment of a municipal-based knowledge center. A municipal-based knowledge center starts out by determining the learning roadmap for the community –a health learning roadmap is suggested below. A careful documentation of the learning of the community can serve to gauge the success of the project and as the basis for the future learning roadmaps.
2. The creation of a community or institution-based peripheral knowledge center. This is to complement the municipal-based knowledge center. Basically, it is the undertaking of community-based projects with community-based institutions above to ensure the longevity and fidelity of knowledge. It also guarantees that these learning may be used as a springboard for creation of knowledge.
3. Educating the patient.
4. Educating the public. As any medical practitioner will tell you, an ounce of prevention is worth a pound of cure. Thus, a well-informed public is vital for health efforts in a community.

By now – we should have recognized that medical efforts and knowledge management go hand in hand. For as we have pointed out over and over again, we cannot afford to engage in fund-intensive health projects and even manpower-intensive efforts (We must note that at times, the municipal health officer is the only doctor in the municipality –thus manpower-intensive efforts are out of the question), thus we must tap sources that are implicit yet infinite –that is knowledge.
3. Designing renewable resource flow
Enterprises are designed for sustained revenue/resource flows. Resources in an enterprise flow in a cycle of release and reclaim, so that resources are renewable and the cycle is undisturbed. Leaders can start with initial capital, produce the goods or services, and then recover production costs through user fees, product prices, or renewed social support or political support or a combination. The service delivery system as an enterprise begins with an input of hardware (equipment, facilities, building, space, etc.), software (procedures, work flows, work processes, systems, etc.) and peopleware (human resource). All these working together produces the output, which when utilized also becomes the input to connect the cycle and keep it continuous. The table below shows start-up resources and suggests how these can be renewed and sustained:

RESOURCE	HOW TO HARNESS/RENEW
Political Capital	Political prioritization and attention to projects
Financial Capital	Funds to start up project, collection fees, or patronage fees
Social Capital	Goodwill that is mobilized to power the operations through funds, manpower, and expertise. Goodwill also reduces transaction costs
Institutional Capital	Trust in a reputation of an institution that reduces transaction costs
Knowledge Capital	Enabling technologies that allow individuals and organizations to produce goods and services
Managerial Capital	Individuals and/or systems that enhance the effectiveness and efficiency of a system through intelligent management

The Philippines is a poor country, and many LGUs are beset with big problems and given limited financial resources. LGUs must learn how to manage their limited resources to achieve maximum impact. This is done through 1) influencing other resource systems in the area; 2) leveraging the limited tangible resources against the unlimited intangible resources; and 3) designing health interventions as “enterprises” so that resources are recovered or increased over time.