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Chapter 8
Chapter 8 Special Topics: LGU Dynamics
Choose your battles.
--Sun Tzu
For Cinderella and the Man in the Iron Mask, beauty and royalty were an endowment with a bitter x-deal—demotion from heiress to kitchen maid, and incarceration to oblivion. Both have taken a rough road of power trip before reaching happily ever after. The Municipal Health Officer and his special mission to care for the constituent’s health also has to live with an x-deal: his entrance to the arena of municipal power play, where he could be actively engaged in a push or pull; or just tossed around. The work an MHO does makes him a powerful figure in the municipality. Unfortunately, given certain political flavors, this power most of the time works to his detriment and, farthest from his imaginations, can virtually be his self-detonating time bomb. But just how powerful is the MHO that he becomes enmeshed in a power struggle? The MHO is powerful because of his expertise as doctor (most of the time he is the only doctor in the municipality and possesses higher educational level than the mayor, and as such is highly regarded by constituents. The MHO’s membership to the local (professional-entrepreneurial) power elite due to his professional background1 can also make the mayor insecure. If they are of local ancestry, the MHO’s families are probably socially powerful, as landed or professional people oftentimes are), his strategic position in the municipality (where in the course of his work he mobilizes Barangay Health Workers, who can later on vote and campaign for him even in the remotest barangay in town if he indeed has political ambitions), and the support accorded him by municipal officials or his referent power. Often, the mayor who wants to secure his post could think of the MHO’s rising popularity among the people as rendering him lackluster, therefore flexes his muscle to suppress it at the expense of the MHO’s work. This is not baseless paranoia. In selected Galing Pook awardees, we saw that elected mayors were former MHOs. With the post-devolution set up that gave fiscal and political power to the local chief executives, health service delivery became vulnerable to political risks. The MHO can only implement projects the mayor stamps approved. The mayor, at least in theory, can therefore make or break the MHO and his office. The DOH intervenes only in times of epidemics of national magnitude. The Provincial Health Office (PHO) has little or no functional relationship with municipal health offices and of course neither with the local municipal mayors. Both national and provincial offices could influence the goings-on in the municipalities only through national legislations (lobbying for particular health agenda, which when passed into law, will have a national consequence), and through resource-driven health programs where the municipal health officer’s national counterpart provides for the resources –usually monetary or in form of medicines etc. Other than this, the relationship between the MHOs and PHO and much more with the MHOs and the DOH is almost only reportorial. Thus, the MHO is on his own in dealing with the mayor. The municipal health officers down to the barangay health workers therefore have to learn not only social but also and more importantly political skills that may come in handy as they interface with the municipal bureaucracy. For example, understanding how important it is to the Mayor to be popular among the people, the MHO would allow the mayor to take credits for successes of health programs, or would invite the mayor to every huge gathering where he could emphasize his presence to the people. It may sound uncomfortable, yes, but reserving centerstage appearance to the mayor does no harm to and even sustains the MHO’s work to uplift people’s health. And that’s what counts.
The MHO’s “Utang na Loob” Edge If the mayor would list down the possibilities for the MHO to unseat him, he would be counting stars. The exponential power of “utang na loob” alone is not to be undermined. The MHO reaps bountiful utang na loob without even the need to plant seeds. It’s an inevitable “reward” harvested through the daily doctor-patient interactions at the Rural Health Units (RHUs). Utang na loob then becomes the MHO’s invincible edge. Supposing the MHO treats a thousand or more patients in a year, he then almost automatically accumulates the same number of “utang na loob” points. And since according to Hollsteiner, the concept of “utang na loob” is familial, this means that all one thousand and more patients’ entire family feels indebted to the MHO altogether. “Utang na loob” is therefore multiplied not only to the nuclear but also to the expanded members of the family. If the MHO eventually decides to run for political post, this utang na loob virtually translates to votes agitated to get inside the ballot boxes. Although we know that people should not owe the MHO any utang na loob for taking care of their health. The MHO is paid (emphasis on “paid”) a fixed monthly salary by the municipal office for the job he does. At the earliest detection of such latent political threat, mayors give the MHO less latitude of decisions, limit the MHO’s inputs, and even go as far as clip the MHO’s wings. To a shortsighted local chief executive, any innovative health program successfully launched and implemented by the MHO will be seen as a move to oust him from office in the next municipal elections. Municipalities that enjoy flourishing health programs are those where the local government executives have high-trust relationship with a physician who can provide the critical technical inputs necessary in the design of a health program. Such is the flaw resulting from the devolution of services. Devolution exposed the incompatibility of the existing social and political systems with the innovative administrative systems. Political capital is inevitably accumulated by the MHO where the local chief executive does not want it, so there is a disincentive for the mayor to support innovations put forward by the MHO.
A Love-Hate Relationship: The Politics-Performance Loop for Municipal Health Officers The table below captures the dynamics of mayor-MHO relationship, though we must note that not all of the possible endings to this “love” story will be explored by the following discussion.
--Adapted from Hollander Quadrant 1-Introductions The newly appointed MHO will likely have low skill levels in public health management unless he/she has served as an MHO in another town before. Thus, being a novice to the field, the MHO may initially likely gain the mayor’s trust; more so if the MHO actively campaigned for the mayor in the previous elections. It is also possible even at this early stage for the mayor to eye the MHO with suspicion or contempt if the latter campaigned for the mayor’s rival. Still, there is no stopping the MHO from going about his/her job unless the mayor actively presses him against the wall –by disapproving his projects, withdrawing support, and the like. On the other hand, if the mayor lets the MHO go about his/her ways, the MHO will eventually learn the ropes of public health management. He/she will now organize or take over a previously existing BHW network and engage in low-profile projects. If these projects turn out to be successful, then the MHO will eventually earn the trust of the BHWs. Hopefully, the mayor will appreciate the initial successes of these projects and eventually recognize him as a partner in development. Thus, our MHO moves on to the second quadrant.
Quadrant 2 –Fascination At some point, the MHO will eventually be skilled and more properly equipped in public health management. The BHW network over time becomes more functional and ventures not only in one-shot curative health projects but also and more importantly in sustained preventive health programs. For example, the MHO goes through the yearly cycle of vaccinations for all children aged 0-6. The MHO earns at the very least the Mayor’s respect, perhaps even his trust (though this is doubtful if the MHO is strongly identified with the opposition). Recognizing the worth and impact of the MHO-initiated projects, a prudent mayor throws his support behind these health programs, improving further the MHO and the health programs’ effectiveness.
Quadrant 3 - Distrust As the MHO becomes even more popular not only for his innovative and cutting-edge programs but also for his personalized approach (contact with patients at the RHU, and the rest of the citizens through community-based health programs, vaccinations, etc.) to public health management, the mayor begins to recognize the political capital accumulated by the MHO and begins to treat him as a political threat –as though one of his political rivals. The mayor begins to flex his muscles to curb the MHO’s popularity. He may tap his legitimate power to limit the MHO’s movements and visibility. His rationality may be so clouded by envy that he disapproves even good projects as long as the MHO endorsed these. In a sense, the threatened mayor is just waiting for the right time to eventually pull the plug on the MHO.
Quadrant 4 – Falling out (of love?) Because of organizational inertia, the MHO still somehow manages to get the job done. The health service delivery systems still perform at close to optimal levels because the motivation and resources are still there. Continuing restrictions from the mayor, however, drops the MHO’s morale (eventually the material resources drop too). More energy is devoted to persuading the mayor to support municipal health projects. The performance of the health system is diminished, to the relief of the mayor who will bid for a reelection in a year’s time and to the detriment of the people whose health the mayor should be thinking of in the first place. But then again, one community’s lost is one man’s gain. It meant one less rival for the power-hungry mayor. For the MHO, if he doesn’t have the faculty to fight back –he has to settle for mediocrity or worse be swallowed into oblivion. Or he could always resign and thus end the bittersweet love story.
Situations for Previous MHOs and Newly Elected Mayors An MHO who has learned the ropes of and has become effective in health service delivery will find himself in quadrant 2 or 3, depending on how much the new mayor trusts him. If the MHO is somehow related to the Mayor, or if the mayor is somehow politically naive, then the MHO might enjoy the support and effectiveness in quadrant 2. If the MHO is somehow perceived by the new mayor to have been aligned with, or is too close to the opposition before and during the elections, then the new mayor may replace the MHO as what happens in quadrant 3 or 4.
Light at the End of the Tunnel: What can MHOs do for now? It’s not a hopeless case. The MHO can still rise above this political “persecution” by employing recourses that may require a lot of guts, if not prudence. Nothing-fishy here. Just plain conflict resolution strategies. Conflict Management Strategies
Source:Lontoc (1997) The MHO can “avoid” (lower right box) or “accede/accept” (lower left box) if he wants things to blow over and keep his job. Yet for those who would rather take things standing up and refuse to be beaten down, the MHO could either advocate or transform. It really depends where/how does the MHO perceive himself. His course of action all boils down to his self-evaluation (see the table above).
Election-Proofing your Health Programs Strategic MHO Positions2
The Emissary Indeed the politically savvy goal-driven MHO will leave to realize his visions, not wanting to invite political persecution from the mayor. Political savvy may come in the form of accommodating the local chief executive in terms of things as mundane as inviting the mayor to take the center stage and gain political mileage in the launching of various health programs –this is tall order specially for the MHOs who are new to this field (those who are yet to stomach the sad truths about municipal as well as city politics) but then again this is an MHO’s formula for political survival. In a Filipino sense, this strategy could be summarized “ibalandra ang politiko” or “let the politician take the limelight as long as the MHO and his BHWs get the job done.”
The municipal or city health officer’s socio-political tactics is summarized in the SWOT analysis table below:
Choose your battles.
--Sun Tzu
For Cinderella and the Man in the Iron Mask, beauty and royalty were an endowment with a bitter x-deal—demotion from heiress to kitchen maid, and incarceration to oblivion. Both have taken a rough road of power trip before reaching happily ever after. The Municipal Health Officer and his special mission to care for the constituent’s health also has to live with an x-deal: his entrance to the arena of municipal power play, where he could be actively engaged in a push or pull; or just tossed around. The work an MHO does makes him a powerful figure in the municipality. Unfortunately, given certain political flavors, this power most of the time works to his detriment and, farthest from his imaginations, can virtually be his self-detonating time bomb. But just how powerful is the MHO that he becomes enmeshed in a power struggle? The MHO is powerful because of his expertise as doctor (most of the time he is the only doctor in the municipality and possesses higher educational level than the mayor, and as such is highly regarded by constituents. The MHO’s membership to the local (professional-entrepreneurial) power elite due to his professional background1 can also make the mayor insecure. If they are of local ancestry, the MHO’s families are probably socially powerful, as landed or professional people oftentimes are), his strategic position in the municipality (where in the course of his work he mobilizes Barangay Health Workers, who can later on vote and campaign for him even in the remotest barangay in town if he indeed has political ambitions), and the support accorded him by municipal officials or his referent power. Often, the mayor who wants to secure his post could think of the MHO’s rising popularity among the people as rendering him lackluster, therefore flexes his muscle to suppress it at the expense of the MHO’s work. This is not baseless paranoia. In selected Galing Pook awardees, we saw that elected mayors were former MHOs. With the post-devolution set up that gave fiscal and political power to the local chief executives, health service delivery became vulnerable to political risks. The MHO can only implement projects the mayor stamps approved. The mayor, at least in theory, can therefore make or break the MHO and his office. The DOH intervenes only in times of epidemics of national magnitude. The Provincial Health Office (PHO) has little or no functional relationship with municipal health offices and of course neither with the local municipal mayors. Both national and provincial offices could influence the goings-on in the municipalities only through national legislations (lobbying for particular health agenda, which when passed into law, will have a national consequence), and through resource-driven health programs where the municipal health officer’s national counterpart provides for the resources –usually monetary or in form of medicines etc. Other than this, the relationship between the MHOs and PHO and much more with the MHOs and the DOH is almost only reportorial. Thus, the MHO is on his own in dealing with the mayor. The municipal health officers down to the barangay health workers therefore have to learn not only social but also and more importantly political skills that may come in handy as they interface with the municipal bureaucracy. For example, understanding how important it is to the Mayor to be popular among the people, the MHO would allow the mayor to take credits for successes of health programs, or would invite the mayor to every huge gathering where he could emphasize his presence to the people. It may sound uncomfortable, yes, but reserving centerstage appearance to the mayor does no harm to and even sustains the MHO’s work to uplift people’s health. And that’s what counts.
The MHO’s “Utang na Loob” Edge If the mayor would list down the possibilities for the MHO to unseat him, he would be counting stars. The exponential power of “utang na loob” alone is not to be undermined. The MHO reaps bountiful utang na loob without even the need to plant seeds. It’s an inevitable “reward” harvested through the daily doctor-patient interactions at the Rural Health Units (RHUs). Utang na loob then becomes the MHO’s invincible edge. Supposing the MHO treats a thousand or more patients in a year, he then almost automatically accumulates the same number of “utang na loob” points. And since according to Hollsteiner, the concept of “utang na loob” is familial, this means that all one thousand and more patients’ entire family feels indebted to the MHO altogether. “Utang na loob” is therefore multiplied not only to the nuclear but also to the expanded members of the family. If the MHO eventually decides to run for political post, this utang na loob virtually translates to votes agitated to get inside the ballot boxes. Although we know that people should not owe the MHO any utang na loob for taking care of their health. The MHO is paid (emphasis on “paid”) a fixed monthly salary by the municipal office for the job he does. At the earliest detection of such latent political threat, mayors give the MHO less latitude of decisions, limit the MHO’s inputs, and even go as far as clip the MHO’s wings. To a shortsighted local chief executive, any innovative health program successfully launched and implemented by the MHO will be seen as a move to oust him from office in the next municipal elections. Municipalities that enjoy flourishing health programs are those where the local government executives have high-trust relationship with a physician who can provide the critical technical inputs necessary in the design of a health program. Such is the flaw resulting from the devolution of services. Devolution exposed the incompatibility of the existing social and political systems with the innovative administrative systems. Political capital is inevitably accumulated by the MHO where the local chief executive does not want it, so there is a disincentive for the mayor to support innovations put forward by the MHO.
A Love-Hate Relationship: The Politics-Performance Loop for Municipal Health Officers The table below captures the dynamics of mayor-MHO relationship, though we must note that not all of the possible endings to this “love” story will be explored by the following discussion.
| | Politically neutral | Political threat |
| High performance | 2 High performance, high trust, high political support, low political capital | 3 High performance, low trust, falling out, low support, high motivation |
| Poor performance | 1 Low skills, low-high trust, low political capital | 4 Low trust, low performance, low motivation |
Quadrant 2 –Fascination At some point, the MHO will eventually be skilled and more properly equipped in public health management. The BHW network over time becomes more functional and ventures not only in one-shot curative health projects but also and more importantly in sustained preventive health programs. For example, the MHO goes through the yearly cycle of vaccinations for all children aged 0-6. The MHO earns at the very least the Mayor’s respect, perhaps even his trust (though this is doubtful if the MHO is strongly identified with the opposition). Recognizing the worth and impact of the MHO-initiated projects, a prudent mayor throws his support behind these health programs, improving further the MHO and the health programs’ effectiveness.
Quadrant 3 - Distrust As the MHO becomes even more popular not only for his innovative and cutting-edge programs but also for his personalized approach (contact with patients at the RHU, and the rest of the citizens through community-based health programs, vaccinations, etc.) to public health management, the mayor begins to recognize the political capital accumulated by the MHO and begins to treat him as a political threat –as though one of his political rivals. The mayor begins to flex his muscles to curb the MHO’s popularity. He may tap his legitimate power to limit the MHO’s movements and visibility. His rationality may be so clouded by envy that he disapproves even good projects as long as the MHO endorsed these. In a sense, the threatened mayor is just waiting for the right time to eventually pull the plug on the MHO.
Quadrant 4 – Falling out (of love?) Because of organizational inertia, the MHO still somehow manages to get the job done. The health service delivery systems still perform at close to optimal levels because the motivation and resources are still there. Continuing restrictions from the mayor, however, drops the MHO’s morale (eventually the material resources drop too). More energy is devoted to persuading the mayor to support municipal health projects. The performance of the health system is diminished, to the relief of the mayor who will bid for a reelection in a year’s time and to the detriment of the people whose health the mayor should be thinking of in the first place. But then again, one community’s lost is one man’s gain. It meant one less rival for the power-hungry mayor. For the MHO, if he doesn’t have the faculty to fight back –he has to settle for mediocrity or worse be swallowed into oblivion. Or he could always resign and thus end the bittersweet love story.
Situations for Previous MHOs and Newly Elected Mayors An MHO who has learned the ropes of and has become effective in health service delivery will find himself in quadrant 2 or 3, depending on how much the new mayor trusts him. If the MHO is somehow related to the Mayor, or if the mayor is somehow politically naive, then the MHO might enjoy the support and effectiveness in quadrant 2. If the MHO is somehow perceived by the new mayor to have been aligned with, or is too close to the opposition before and during the elections, then the new mayor may replace the MHO as what happens in quadrant 3 or 4.
Incompatibilities in the Political, Administrative, and Cultural Systems
This analysis bares out a chilling implication: politically inept MHOs might simply resign to the belief that he can only do as much, and therefore decides to stay in Quadrant 1.This is to ensure that he would never be perceived as a political threat by the mayor, and in so doing, secures himself a job. Again, this particular MHO succumbs to mediocrity. Sadly, this might be why a great fraction of Galing Pook awardees are those municipalities where the Mayor is a doctor or is married to a doctor. The case of Alimodian shows that the mayor’s wife, a doctor by profession, was chosen as coordinator for the particular health project which won Alimodian the award, rather than the incumbent MHO. Sure enough, the doctor-wife ran for Mayor in Alimodian in the 1998 local elections and won. Does the lack of applications of potential Galing Pook Awardees with none doctor-spouse-mayor tandems reflect that Quadrant 1 mentality dominates the MHOs? Does the scenario indicate that no mayor-MHO relationship could end up happily ever after except for those related by blood or affinity? We do not have the answers for now but we can surmise that the answer to these questions will in time, be revealed.Light at the End of the Tunnel: What can MHOs do for now? It’s not a hopeless case. The MHO can still rise above this political “persecution” by employing recourses that may require a lot of guts, if not prudence. Nothing-fishy here. Just plain conflict resolution strategies. Conflict Management Strategies
| | Low power | High power |
| High value | Advocate, Agitate | Alter/Transform |
| Low value | Avoid | Accede/Accept |
Election-Proofing your Health Programs Strategic MHO Positions2
| | Politically Naïve | Politically Savvy |
| Not goal driven | Rudderless | Machiavellian |
| Goal driven | Blindsided | Concordant, Sustainable |
The Emissary Indeed the politically savvy goal-driven MHO will leave to realize his visions, not wanting to invite political persecution from the mayor. Political savvy may come in the form of accommodating the local chief executive in terms of things as mundane as inviting the mayor to take the center stage and gain political mileage in the launching of various health programs –this is tall order specially for the MHOs who are new to this field (those who are yet to stomach the sad truths about municipal as well as city politics) but then again this is an MHO’s formula for political survival. In a Filipino sense, this strategy could be summarized “ibalandra ang politiko” or “let the politician take the limelight as long as the MHO and his BHWs get the job done.”
Lateral Entry
The MHO can also be a non-native unregistered voter who cannot run for any elected position in the said municipality; to remove the threat of direct political rivalry. This way, the MHO can be very popular and the Mayor would not care, since this growing political base cannot translate to votes. Yet, this particular MHO must be careful not to identify himself with any of the opposing political camps in the municipality. Otherwise, he will compromise the future of MHO-initiated projects in that municipality.Outflanking: Strengthening the Private Sector
Finally, a less conservative, more aggressive stance: the MHO can strengthen his alliance with the private sector, or be organized at a provincial if not national level to safeguard himself against such political persecution. In a way, the MHOs could find strength in numbers vis-à-vis facing powerful local politicians alone. A group could threaten to take a certain mayor to court for, let’s say, political harassment. The threat of a class action from an organization is enough dissuasion for the mayors. This outflanking effort will make local chief executives think twice before resorting to dirty tactics to pin the municipal health officer down.Confrontational
Similar to outflanking is the confrontational stance. The MHO could also take the local chief executive to court but this time -alone. This would be an MHO’s only course of action if there is no time to consolidate strength from the private sector and if the situation is already worse. Yet, we must throw caution to the air here –an MHO may choose this recourse if he deems that he has the resources (more particularly the finances) to carry on a legal battle. Once the MHO has opted for this action, there is no turning back. Borrowing a term from international politics, the situation would be a zero-sum game –the victor has everything to gain and the vanquished has everything to lose. Indeed, to resort to such an option is to run the risk of ending up with nothing and maybe even losing more.Public clamor: Improving Politically Irreversible Demands
Of all the options that will be available to the MHOs, this option is the most viable and most likely to guarantee that the MHO will come on top. After all and ideally, people are hoped to eventually take on the cudgels of an LGU-initiated project; thus, making health endeavors apolitical (assuming that such a situation in real life could actually exist) and establishing these endeavors as products of the community people’s sweat and toil, and not as a brainchild of one person (the MHO for instance). Though some will be quick to point that all collective action was brought about by the vision of a champion (brainchild), we must also note that a champion must know when to take back seat--that is when his work is done. The champion must know when to quit or it would be even better to quit while he is ahead. In the conduct of community- based health projects, the municipal health officer is no doubt the champion, but to avoid the initial efforts from going to naught, the MHO must recognize when to quit –that is more accurately when to loosen his grip on the project and on the community. There must be a transition from MHO-driven to a people-driven health service system so that the public themselves will clamor before the mayor for health services to be delivered.The MHO: Knowing when to take the backseat when the work is done
For health programs to sustain themselves, there is a need for institutionalization. The term institutionalization comes from the social sciences so this concept will be generally new to the Municipal Health Officers who are trained in the natural sciences. Put simply, an institution is a rule or set of rules followed by society. Other authors would say, that an institution is a value or set of values or common beliefs held by society. Both definitions are close enough to each other for the mean time. An example of an institution is money. Everybody understands and accepts the value represented by those pieces of paper that you keep so dear in your pocket. The “tindera” at your local sari-sari store accepts these pieces of paper in exchange for a bag of over-priced groceries; she in turn can use those pieces of paper to pay a part of her son’s tuition fee. Everybody knows and accepts the rules that guide the exchange of these items that represent monetary value. Come to think of it, the P1,000 bill is made of only a small piece paper and ink - materials which probably cost only a few pesos. But interestingly this same piece of paper represents a monetary value of P1,000 pesos, thus is generally accepted in exchange for an equivalent value of goods and services. In health care, one institution is the idea of sustainability of forces –in this case the demand or pull-forces. Sustainability of health care is guaranteed when a withdrawal of health services creates a clamor/uproar among the people. A good health care program is one that has a snowballing effect. As in all types of programs, once a good program provides for (a) sustained input side as demonstrated by a sustained availability of inputs through user fees, allocations of funds, sustained input of social capital and other intangible assets, and (b) sustained systems such as policy support, administrative and staff support. It also includes organizational structures, culture and knowledge maintenance. When these two factors are present in the community’s health program, the MHO can now take a backseat, relax and sleep snuggly at night knowing that his job is done… for now.The municipal or city health officer’s socio-political tactics is summarized in the SWOT analysis table below:
| | Opportunities
| Threats
|
Strengths
|
|
|
WeaknessesSubordinate of mayor Lesser authority than mayor | | |
1 Hollsteiner, power structure in small Filipino town
2 Hollander, Dory, The Doom Loop System, Penguin Books, England, 1991, p.344
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