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Chapter 5

restless_river — Fri, 15 Feb 2008 04:40:52 CST

Chapter 5 Leading Minds: Managing Myths, Memories, and Meanings

When the leader arrives, people are full of panic, uncertain what to do and defeatist about the future. When the authentic leader has spoken, they have been given back their courage. --William Rees-Mogg

From beginning to end, the rituals of our lives shape each hour, day, and year. Everyone leads a ritualized life. Rituals are repeated patterns of meaningful acts. If you are mindful of your actions, you will see the ritual patterns. If you see the patterns, you may understand them. If you understand them, you may enrich them. In this way, the habits of a lifetime become sacred. -- Robert Fulghum

In the play Miss Saigon, Leah Salonga in her character Kim, sings a song entitled “Movie in My Mind”. Through this song, Kim imagines and describes the life she hopes to live out. At the start, she sings out as an innocent village lass singing about the love she hopes to have. It starts out as a hopeful, innocent song. As the plot of the play moves forward, the “movie” unfolds in Kim’s mind and in Kim’s reality. Kim falls in love with an American soldier, marries him, gets separated from him by the war, and then bears his child whom she has to raise alone. Kim’s reality takes a tragic turn, but in the song, and in the movie in Kim’s mind, even sadness has meaning. Kim continues to sing Movie in My Mind plaintively into the darkness, as if trying to conquer tragedy with hope, imagination, and song.

Movies in Our Minds

Everybody sees life as a movie that unfolds right before his or her eyes. A young girl plays a princess or a pilot or a nurse; a young boy plays a conqueror of some island unbeknownst to the rest of the world. A farmer dreams of the day his children finish school and work in the big city. The market vendor envisions her daughter working abroad and sending over dollars, chocolates, and tuition for the younger siblings. We play this movie in our minds over and over again. We try to influence the outcome of this movie through our actions. These are our private movies, and we put private meanings to it.

The movies in our mind create our inner tensions and conflicts, our secret triumphs and tears, our personal values and dreams. If our actions are not enough, we go further by influencing the other actors in the movie, the script, the setting, and the relationships so that the movie unfolds the story as our hearts desire. In interacting with others, we too, become part of their our movies. Our movies become intertwined. People also share their dreams with others. And when they do, these movies break free from private seclusion of the minds and bear themselves out publicly. These become public movies – the stories, experiences, motivations, and meanings that guide a people.

Collective Consciousness: I Need We to be Fully I

The Zulus of Africa have a word for it—ubuntu (short for unmunta ngumuntu, nagabuntu)1 which means “I need we to be fully I.” The natives of Sagada, Mountain Province, manifest collective consciousness in a different way. Every ten years, they celebrate the Dangtey, a community ritual of prayer, gratitude, and offering done to ensure a bountiful harvest. The revolts in EDSA are a long-playing 3-part public movie—the first was a collective dream to oust a dictator, the second to impeach an erring president, and the third to try to redeem the impeached. In each of the three parts, Filipinos marched to the streets acting out the movies in their individual minds, as they pushed forward the public movie. As actors in this collective movie, they co-authored Philippine history.

Collective Consciousness and Channels of Governance

Governance is a key element in these "public movies". Among the social sciences, “public movies” fall within the realms of organizational psychology, behavioral psychology, social anthropology, cultural anthropology, community organizing, institutional economics, political science, and political sociology – the realms of the individual and collective consciousness. As discussed in the previous chapter, the public script is often written by the leaders in government. Citizens, knowingly or unknowingly, become spectators or actors in the movie. The interesting thing about the cases in governance studied here is that the movies are seldom simple stories to be interpreted literally. Instead, they are complex movies, rich with metaphors and symbolisms, paradoxes and dilemmas. They are stories with multiple meanings, filled with characters selflessly pursuing their noble longings.

Governance, in these cases can be thought of as occurring in the minds of the governors and the governed, in multiple channels. As on TV, the multiple channels are there for people to tune in to. Not all the viewers tune in to all the channels though. Some channels are more popular and some channels are seldom tuned into or understood. Waiting sheds, basketball courts, and free clinics can be viewed in the governance Channel 1. This is the most popular channel and seemingly most mayors and citizens are tuned into this channel. In this channel, the LGU interacts with citizens who are treated as passive clients, beneficiaries, or constituents. The LGU manages resources and outputs in order to deliver goods and services to the citizens. Performance is measured in kilometers of roads constructed, doctor-patient ratios, number of trees planted, and per capita incomes.

The logic in Channel 1 is that if the mayor installs a lot of highly tangible, high visibility projects, the citizens will remember him and vote for him come election time. Channel 2 focuses on the citizens as partners and co-creators of the municipality. Marikina’s Disiplina Sa Banketa, with it’s new ordinances, self-policing mechanisms, and painted sidewalks focus on getting citizen’s to give up the culture of chaotic sidewalks in exchange for order. Surigao’s Federated Women’s Club and its strong participation in LGU affairs through the implementation of self-help projects can also be viewed through this channel. Themes in this channel include consensus-building, multi-sectoral participation, political empowerment, policy-making, and establishing order in society. Fewer viewers watch this channel but this channel seems to be popular among NGOs, sociologists, and political scientists. Growth and maturation of the individual, community, and organization are key themes in Channel 3.

The quest for self-fulfillment (or self-actualization as described by Maslow) is a central theme in this channel. There is a recognition that each citizen is a traveler, going about each day trying to make meaning in his or her life. Each citizen yearns for fullness of life, and this fullness of life is not measured through per capita income; but by challenges faced, lessons learned, and meanings made. This is often thought of as the realm of development psychologists and psychoanalysts. When projects last for years, or when they take on multiple dimensions, or when the programs take on a life of their own (as described in Quadrant 4 in the previous chapter), then it is possible that the individuals behind these programs find and are motivated by deeper meanings they see in participating in the programs.

The Federated Women’s Club of Surigao, with its beginnings way back in 1976, and with it’s current membership of 7,200 members and multiple projects, is likely to have a few hundred to a few thousand members who are so deeply involved in it’s programs that it has become a way of life for them. Poetry and song, as shown in below written by a Barangay Health Worker of Bustos, can also be thought of as an indicator that the writer is deeply moved by their involvement in the LGU programs. Then there are tears which can also be thought of as an indicator of deep emotional involvement. Aling Deling of the Alay Paglingap Program of the Provincial Government of Bulacan, wept as she recalled how she used to wear her duster all day and comb her hair only once in the morning when she was but a socially isolated housewife in her barrio.

When she became a Barangay health Worker (BHW), she was liberated from her social isolation and took on more responsibilities in the community, eventually getting elected as barangay kagawad. One particularly touching episode came during a cataract surgery project at the provincial capitol. She referred a neighbor who had been blind due to cataract for years. With Aling Deling's assistance, her neighbor went thought the free surgery and came home with her sight restored. With teary eyes, Aling deling shared how that neighbor would embrace her out of gratitude whenever they would meet in the streets.

Spiritual growth and well-being of the individuals and community are central in Channel 4. This is usually the realm of priests, pastors, and babailans. El Shaddai, Couples for Christ, and other spiritual programs operate and communicate in this channel. The forest-cemetery program of San Carlos clearly operates at this level (among other levels), creating a forest sanctuary so that the citizens can commune with nature as they remember their dead. The BHW song of Bustos mentions Bathala, showing that somehow, a higher being is woven into their consciousness as BHWs and as individuals. Besides poetry, song, and tears that are indicators in Channel 3, other indicators include rituals, symbols, and prayers. Filipinos being a religious people, it is possible that Channel 4 has more viewers than Channel 3.

Socio-Emotional Health and the Inner Lives of Citizens

Why manage meanings? In developmental psychology, the concept of socio-emotional health pertains to the sense of inner wellness that individuals experience. The cases showed over and over again that LGU programs, when properly conducted by reasponsible and committed leadership, can enrich the lives of its citizens not just economically but also socially, emotionally, and spiritually through the different channels of governance. When funds are scarce and capacities limited, then this is an excellent way of improving the qualities of the inner lives of the citizens. As Professor Noel Tichy of the University of Michigan puts it: “it is a leader’s task to bring people on a journey into an uncertain and chaotic future—everyday. The best way to get people to venture into unknown terrain is to make it desirable by taking them there in their imagination.”

Hanapbuhay and Multi-Channel Leadership

The LCE or the public health leader can address social, emotional, and spiritual want by creating venues for growth. They merely have to participate in the weaving of dreams, provoke discernment and reflection, and engage the citizenry in the acting out of their individual and shared movies. This way, a training of BHWs is not just a transfer of knowledge and skills in health. The training is also a way of bringing the women out of their social isolation, getting them to take on new roles in the community, allowing them to meet new friends and ideas. It enriches their lives by providing them with new challenges, allowing them to relate with neighbors as care-givers. In the story of their lives, their role as BHWs phase could be the venue for them to achieve growth and self-fulfillment. LCE’s have only three years per term within which they are supposed to touch their lives of their constituents (enough to get elected in the following elections). During that period, few programs can radically improve the incomes of the citizens. Most will not, at least in three years. Through multi-channel leadership, the LGUs programs can touch the lives of the citizens in other ways though. After all, Filipinos refer to making a living as hanapbuhay, not hanappera. Multi-channel governance helps the citizens find that fullness of lives. Instruments for Managing Meanings

How can leaders evoke common meanings? Or how can leaders manage an existing meaning so that it becomes a rallying point for action? A review of the cases as well as other cases from history yield the following mechanisms. They range from the evocative to the prescriptive.
Evoking Memories and Emotions. Leaders can refer to memories of common pasts--e.g. Katipunan, Jose Rizal, Flor Contemplacion—to collectivize people’s thoughts and actions. EDSA 1,2, and 3 could be thought of as driven by memories and emotions. Former Philippine Ramos dubbed the Overseas Contract Workers as “Bagong Bayani”, reminding the public of the heroic effort the OCWs exert as they earn dollars to support their families back home.
Normative rhetoric/speeches. After the Americans left the bases, then Olongapo Mayor Dick Gordon rallied volunteers to maintain Subic. He got them to maintain the cleanliness and security of the Subic Base facilities without pay. Through rhetoric and speeches, he exhorted them to action.

Rituals. Public rituals help the citizens become mindful of certain themes in their inner lives that are woven into the collective consciousness. Acting out the rituals help renew their belief in certain values and relationships. The monthly dancing sessions in Bustos can be thought of as rituals celebrating health, life and togetherness. The building of kiosks using only volunteer labor in Balilihan is also a ritual, a rite-of-passage of sorts, that allowed the citizens to discover and unleash the latent power of solidarity and cooperation that they had among them.

Stories and drama. Marikina citizens would never forget the drama behind Mayor Bayani Fernando sledge hammering an airconditioner before city officials. The aircon unit was confiscated from the office of a wealthy businessman in Marikina when it was protruding from the building’s wall into the city’s sidewalk in violation of the some city ordinances.
To send the message across to the citizenry that the city meant to enforce its ordinances, the airconditioner was smashed during a Monday morning flag ceremony in front of the City Hall employees.

Down south, Mayor Jess Robredo of Naga City was seen early in the morning as among the first on the city streets sweeping debris after a powerful typhoon.
Stories like these travel far and wide and stay long in the memories of the citizens. When certain stories stay in the minds of citizens, they serve as reference for behavior. Structures and Symbols. Physical structures symbolize meaning in a stronger and more permanent way. The Purok Kiosks of Balilihan (case __ below) not only served as a venue for purok meetings. The Kiosks were symbols of the capacity of the community for collective action, serving to remind them that they could achieve significant gains through cooperation. Like symbols, structures communicate meanings. The red colored sidewalks of Marikina City reminded the citizens of the new order that the City hoped to create.

Rules and Relationships. Rules and ordinances communicate the values, relationships, and behaviors that the municipality or city upholds. Ordinances complemented the red sidewalks in Marikina in communicating the desired behavior on the streets. Policemen enforced these behaviors.

Information, education, and communication. Leaders can create and manage meanings through comprehensive education, training, and information campaigns. The advertising industry is one big industry that focuses on getting the public to behave in a certain way (that is to buy the advertised product), through messages delivered via the different mass media.

The Meanings Axis The management of meanings can therefore be thought of as the LGU’s contributing to the cognitive, emotional, and spiritual experiences of individuals and communities. LGU interventions can be located on the Meanings Axis, with the temporal, Channel 1, waiting shed-type interventions on the right side; and the transcendent, Channel 4, forest-cemetery-type interventions on the left side. Of course, since a project can be perceived in multiple channels, various project components may be located on multiple points in the Meanings Axis.

Channel 4 3 2 1 Cognitive (forest-cemetery) Temporal (waiting-shed)
In municipalities we cited where leaders managed the meanings, we see that citizens themselves “enforce” the new value-driven behaviors among each other. If all citizens appreciate the meaning of a clean and healthy environment, or of harmony in the community, we could imagine how much this reduces enforcement costs. We would need less money for garbage trucks, pay garbage collectors; or fewer policemen to enforce laws, settle local disputes and even avert crime. The cases showed that effective public health leaders do not merely provide health services. Public Health Leaders create inroads into the consciousness of their constituents, awakening their imagination, and encouraging them to write and collectively act out the shared movies in their minds. As in the movie, a fine script will not come alive in film unless the actors internalize it. Our actors are now ready for a take. It’s time to spring into… Lights, Camera, Action!

Case 6 Awakening the Sleeping Giant: Citizens Mobilization and the Balilihan Countryside Action Program

Aling Maria smiled as she related the various undertakings of Purok Talong, her purok in the town of Balilihan, Bohol. A retired teacher, Aling Maria emerged as one of the more active members of her “purok,” a small group of around a dozen households living adjacent to each other. Like other puroks in Balilihan, Aling Maria’s purok named their group after a vegetable (eggplant).

She showed the ledger of their finances, reflecting P15,000 worth in purok funds earned from income generating projects such as rice-reselling within the purok, ornamental plant-growing, and regular contributions from purok members. Taking out another well-kept notebook, Aling Maria showed minutes of Purok Talong meetings held over the years. Agenda, discussions, motions, and decisions were all well-documented.

The present Balilihan was a far cry from the rebel-infested town it was in the 1980’s. In the past, armed communist rebels even raided the municipal hall in broad daylight. Balilihan then had the highest rate of insurgency-related deaths in the entire province.

But in the 1990s, a strong partnership between the local government and the communities resulted in a flourishing civil society through the purok system, and a major improvement in the peace and order situation. The citizenry became active partners in development, and took more control over their own lives.

A rural purok initiative for community-based Primary Health Care (PHC) program began in Balilihan in 1983. Dr. Jude O. Doblas, the municipal health officer, ,tried setting up purok organizations from 1983 up to 1988. When Mayor Edgardo Chatto assumed office in 1988, he learned that the program has made little progress apart from the construction of purok kiosks and training of barangay health workers. Dr. Doblas got little support from other government agencies because of the compartmentalized view that health programs were the sole concern of the health sector, ,and that there was no need for cooperation and coordination with other development efforts.

Seeing the purok approach as a viable vehicle for community mobilization, Mayor Chatto and Dr. Doblas expanded the purok concept to involve other sectors serving the municipality. This brought about the collaboration of the local government, the rural health unit (RHU), and the agencies (private and public) tasked to deliver the basic services to the community. This initiative was named the Balilihan Countryside Action Program (CAP).

Community Organization Phase

Armed with new skills and attitudes, the municipal and barangay machinery was ready to engage the community as partners in development. CAP was launched with its purok system giving spirit to empowerment through community organizing, mobilization, and human resource development.

Once the puroks experienced initial successes such as the construction of their kiosks and the maintenance of a small vegetable/herbal garden, many of them took on a life of their own. out of their own initiative, they started all sorts of projects, often with little or no support from the municipal government. As a result, there emerged 186 puroks with 1,302 sectoral volunteers, acting as semi-autonomous extensions of government.

The purok system has become a way of life. Residents frequently spend their free time in the purok kiosks. Prayer groups are organized around the purok organizations. Household kitchens are somehow linked together as they drew their rice supplies from the same of rice collectively brought and stored in the kiosk kitchen. During elections, a candidate’s performance in his or her respective purok became an important criterion for voters. Many new barangay leaders emerged from the ranks of the purok volunteers.

Case 7BHW Theme Song (Composed by and for Volunteer Barangay Health Workers of Bustos Bulacan)

BHW pangalan mo’y dakila / Nasa yo ang biyaya ng lupa / Lupa, langit tumawag kay Bathala Di ka lilimuting hanggang sa mamayapa.
Kami ang babae (ang babaeng sexing-sexy) (mga health workers Kami’y naririto upang tumulong sa inyo./ Maging sa paggawa, sa pagtulong sama sama / Kung kaya’t nabansagang, nabansagang BHW.
Ay-ay-ay-ay zero waste ugaliin Upang paligid ay luminis din Basura ay dapat sinupin. /
Mga basyong bote at lata ipunin upang maging pera / Upang makatulong sa mga batang namimili ng garapa.
Kinikilo papel at dyaryo, pambalot sa kahit ano. Tipunin natin ito, huwag ikalat saan mang dako.
Maga dumi ilagay sa lata, pagbukud-bukurin sa tuwina. / Pampataba sa lupa, upang halaman lumago at gumanda.
BHW your name is great you hold the blessing of the earth the earth and the sky called to God /will not forget you till you die. ) / we are the women (sexy, sexy women) (we are the health workers) we are here to help you. in deed we help each other together / that’s why we are called Barangay Health Workers

ay-ay-ay-ay practice zero waste management / to clean the environment, too don’t trash too much
put together empty bottles and can to make money, /and to help the kids who collect and buy them

/ scrap papers and old newspapers reach kilos, they can be used to wrap anything / let’s save them, and don’t scatter them anywhere.

place the wastes in cans, and every time segregate them they are good fertilizers for the soil, so our plants can grow and be beautiful.

/

1 Translated by Carl G. Jung

 not her real name

Chapter 4

restless_river — Fri, 15 Feb 2008 03:54:40 CST

Chapter 5 Organizational Axis

Looking back and visualizing the whole slow accumulation of inventions that has made us human beings, and finally civilized human beings, we find, salient among them, man’s developing ability to include in the conception of his own group ever more people living at greater distance: his clan, his tribe, his nation, his religion, his part of the world

--Margaret Mead

Nothing is made without men; nothing lasts without institutions.

-- Jean Monnet

Social Organizations are an integrated system of interrelated psychological groups formed to accomplish a stated objective. An organization consists of people (members), capita (resources) and idea (stated objectives and goals). Groups can be loose or tight depending on the membership, the resources, and the idea, which drives people to a range of activity. Organizations can be loose (from cooperating individuals to associations) or tight (to enterprises) See Case 4.

Social Organization	Case citation	Indicator of function of group
Households putting out garbage at the same time	Olongapo	Garbage collection level, spillage, compliance rate
Individuals donating blood to increase reserve blood pool	Davao	Blood reserve levels
Individuals paying premium for health insurance	Guimaras	Premiums, positive cash flow of project
BHWs and friends getting together to dance once a month	Bustos	Uniforms, choreography
Filipinos abroad getting together to support a project in their home province	Sebaste	Funds generated
Care-givers attending class for caring for differently-abled	Alimudian	Attendance in classes
Purok committees planning purok development	Balilihan, Bohol	Purok kiosks, minutes of meetings, budget of purok
Confederation of health councilors	San Miguel, Bohol; Surigao	Minutes of meetings
Joint venture of municipality with private operator of X-ray machine	San Miguel, Bohol	Minutes of meetings, dividends from operations

Today, if you want to transfer to a new house, you will have to contract a Lipat Bahay (House Transfer) truck for a price. If you had made . (Note: It's not about the timeline, its also about the strength of materials, we had wooden houses back then...we call lipat bahay now to move out the household items...the house would most often be concrete..therefore I think wrong premise?) As immortalized in the arts of Botong Francisco, the concept of bayanihan can be traced back to communal traditions where community dwellers volunteer to help a family move to a new place. The moving out process involves literally carrying the structure to its new location. Bamboo poles are formed as frame to lift the stilts from the ground and carrying the whole house across the village with the men positioned to carry the wight at the ends of each pole. This is the spirit of Bayanihan to the Tagalogs, or Pintakasi to the Visayans. Filipino community life is characteristic of collectivism—people get their acts together towards one goal. Early Filipino barangays developed into a “closed, self contained political socio-economic ecolological systems.” Village priests, village elders, and tribal leaders engage the community in setting and enforcing rules, and mobilizing village resources.These rules and norms were gradually woven into the fabric of a village’s religion, economy, agriculture, and social structures; refined and distilled through time. It seems only one “law” guided, and stemmed from, this cultural evolution --live in harmony with each other and with nature. Each autonomous barangay had its own way of regulating village life, setting norms of behavior, and dispensing justice. In pre-Hispanic Bukidnon, for example, the lakan or village elder brought together opposing parties and have them settle their disputes. Up north particularly in the Cordilleras, village elders gathered and met in the dap-ay to decide on matters of consequence to the village. In Sulu Island group, the Badjaos had their babailan or chief priestess who brought people back to health and guided families and clans on ways of maintaining harmony with the each other and with the environment. Each healing session becomes a community event which everybody witnessed. The Organizational Axis tells us of collective action, of mobilizing social resources to achieve goals. Public health managers must harness the community’s collective spirit in implementing health programs. The Organizational Axis also shows how what could start initially as a health program becomes woven into the fabrics of community living either as a culture or imbibed practice(see Cases 1, 2 and 3 below). The logic of the organizational axis is primarily based on the social sciences, particularly anthropology, sociology, and political science. Subsets of these three disciplines indicate that these sciences are indeed disciplines along the same line. Under these disciplines are specialized fields such as: social anthropology, political anthropology, social psychology, behavioral psychology, cultural anthropology, social learning, political culture, policy analysis and advocacy. Also founded on these three disciplines is community development, which includes community organizing, awareness building, community building, and community mobilization. Case 1 The Sebaste Community Clinic Rural health professionals often deplore the lopsided concentration of health facilities, skilled manpower and advanced health technology in the urban areas. With little incentive for career improvement, physicians would rather practice in the urban center than in the rural areas. Even private practitioners, clinics, and hospitals don’t find it attractive to invest in modern and expensive medical facilities in the rural areas. Most local government units lack the logistics to adequately address these limitations. This pattern had isolated a large segment of the rural poor beyond the effective and efficient reach of these modern health facilities and expertise. As a consequence, health care had become more inaccessible and financially prohibitive to the rural poor. Such is the case of the coastal town of Sebaste, one of the poorest in the province of Antique in Western Visayas. A sixth class municipality, around 70% of Sebaste’s 12, 723 residents had income below the poverty level. Aside from two other municipalities, Sebaste is farthest from the capital town of San Jose, which is 109 kms away. Typically, it had the standard rural health center, with a total workforce of nine, composed of a government physician, a public health nurse, six midwives, and a sanitary inspector. Sebaste community people were confronted with these problems: inaccessible health services (the nearest secondary hospital was twenty kilometers away), limited availability of health personnel (the center was open from 8AM to 5PM, Monday to Friday and the only doctor was not available all the time), unaffordable health services (given that 70% of residents were below poverty line), and delayed medical attention (due to poverty, residents delayed seeking medical attention resulting to illnesses becoming worse, which in turn meant more expenses). Sebaste’s Local Chief Executive could not take the scenario sitting down. Worried that she was failing to provide her people access to tertiary healthcare (a mandate to the mayor stated in the Local Government Code), Juanita dela Cruz spearheaded the transformation of the rural health unit to the fully operational Sebaste Community Clinic (SCC). To finance the construction, the local government allocated an average P617,000 for the SCC yearly from 1994 to 1995. But this was not enough. Mayor dela Cruz brought her crusade for a healthy Sebaste community to Austria and Germany, where she organized many former Sebaste residents who were working there. The Eugene Daberto Memorial Foundation (EDABEM) in Austria and the Capiznon, Ilonggo, Aklanon, Antiquenhon Association (CIAA) in Germany were borne out of these visits, and since then, had consistently sent medicines and equipment to the SCC. Later, through these NGOs, other charitable foundations in Europe donated medicines, supplies, and equipment. These donations including an ambulance when quantified would easily run to hundreds of thousands of pesos. The Countywide Development Fund of an incumbent congressman was also tapped to construct another building for the children’s ward and dental clinic of the SCC. 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. Individual -family -purok –barangay-district -municipality-province Purok-communities-polity-society volunteer mobilization-community mobilization-rallies-advocacy-legislation If we are to follow Hollnsteiner’s “reading” of the social structures that saturate our local communities, then we will find out that this undermines or distorts development, which as Talcott Parsons identified is a function of the state to meet increasingly complex needs of its citizens. Development is a matter of getting people’s act together towards one goal. In most cases, that goal is prosperity, or increasing people’s capacity to meet their needs so they can have a better quality of life. Social change and development normally begins and happens at various stages. The Organizational Axis represents the various social phenomena at different levels of society, beginning with the individual level on the left (see the illustrations above), and reaching the societal level on the right. This closely approximates Zaltman’s representation of social change in a matrix. The Federated Women’s Club is an example of a tightly structured, operationally excellent organization that it becomes an enterprise. An enterprise sees end-to-end: the service delivery system has input processing unit (that involves peopleware, hardware, and software) and a measurable output. What started to be a women’s primary health care delivery unit became an enterprise of fathers and husbands, young adults, and even children. Women forged partnerships with the other members of the society and assigned areas of involvement to each, with specific activities, objectives and output. The structure and process in an enterprise sees from beginning to end of a program. Peopleware are those members engaged in the programs who make use of hardware (materials, equipment, funds, etc.) and software (trainings and seminars, awareness and capacity building activities, etc.) for a measurable output (improved nutrition rate). Hybrid structures (like the Federated Women’s Club) are effective instruments of health system development as it takes off where the state and the market fail. Hybrid organizations thrive in areas where there is state and market failure. People act together and make things happen when the state and the market can’t. This government-business-civil society configuration makes hybrid organizations effective—services are delivered to the people without much bureaucratic complexities, services are delivered to the people not to make money but to make the services affordable, and services are delivered to people by the people themselves thus becoming an act of goodwill. As their experience demonstrated, the Federated Women’s Club has cost-recovery mechanisms in place for it to propel its PHC service. Through the volunteer efforts of a pioneering midwife, the start up social capital (mothers and women volunteers, volunteer barangay health workers) sustained their initial activities. The FWC also made use of knowledge capital that is inexhaustible and can be multiplied tenfold through its awareness and capacity building seminars. Amongst themselves, the women learned and taught each other. With their increasing success the FWC was admired by local government leaders who then added to their resource—the political support given to the program, which eventually translated to financial support. As the organization progressed, the FWC leaders developed greater institutional and managerial capital through the various branch organizations managed by other members in the community. The next chapter discusses resource and recovery mechanisms fully. At this point we can say that money as the least, easily depleted resource should not be the only focus of the enterprise. Other capital harnessed through the people should greatly magnify the reach of meager funds. A leader’s role and contribution to an organization will always be recognized. But an organization solely dependent on the leader will not work effectively. When the leader ceases to act, the organization ceases to exist. The leader and the organization are not one. Even mother eagles who lead eaglets in the game called life, push their eaglets out of the nest when the right time comes. Then, thee aglets learn to fly by themselves and become involved in life’s acts—hunting for food, bringing in branches, courting. The quote that began this chapter reads: “People support what they help create.” Leaders must empower the people to lead amongst themselves so that people can sustain what programs because they have built it. Here are other ways hybrid enterprises help: Produce goods and services that private and government cannot produce due to market and state failure. Hybrid organizations deliver services which the government fails to deliver. And, as we observed in most cases, in the processes of initiating the service delivery, organizations elicit the support of government and eventually get it to act. Consciously or not, organizations become catalysts for this change as well. In the same way, hybrid organizations bring services to the people that people formerly cannot afford if sourced from the market. Hybrid organizations eventually also reel in support from the market for their activities. Reduce market/political information asymmetries (in short, the governor and the governed know about each other better). This in turn increases accountability and responsiveness of both the governor and the governed. It seems their cooperation make them each other’s keeper. Organizations become loci of power, whether political, economic, or knowledge power. This makes the power structure within the LGU more equitable. In fact, this brings greater power to the people because they are organized and make things happen for themselves. Increase absorptive capacity for new development initiatives. Whether LGU or organization-initiated, a social capital can propel development initiatives to fruition. Being highly organized, people can carry out development projects more effectively. Organizations become mini stake exchange ala stock exchange – meme jungle Contribute to discourse on area management. As active player in the community, hybrid organizations can more correctly represent the people’s genuine concerns and have these as benchmarks for the leader’s priorities. Serve as hubs in a network of responsibility and accountability. The hybrid organization holds together a network of constituents, government; private business enterprises that want to solve their own problems and make their lives better. Social Organizations Across Boundaries Localities have shared interests and so it is inevitable that social organizations at one municipality shares their hopes and fears with the social organizations at the next. For instance, it is common to two localities to work for a better health situation, and social organizations in these localities can pursue these shared interests jointly. We all belong to one larger ecosystem so what benefits one, benefits the other. What hurts one, hurts the other as well. This poses a strong reason for social organizations, municipal health offices, and even municipal governments to get together their own people internally get together. Inter-municipal relationships can draw from centrifugal forces, or the forces that pull municipalities together. Larger scale problems that hit across municipal boundaries bring municipal leaders together. Municipalities can agree with each other in sharing provincial resources for large-scale health programs, or they can collaborate to lobby for funding from the provincial board to augment to each municipal health office’s own budget. Another centrifugal force is regionalism. Collective consciousness in a region can get municipalities to act together. Party politics can also pull communities together. If two mayors happen to be under the same political banners, then it is more likely that they work together. Centripetal forces, on the other hand, pull the municipalities apart. These are also present in the municipality and can be stumbling blocks towards greater coordination. Municipal pull, or municipal leader’s tendency to deal only with smaller scale, internal interests; thwart efforts at greater collaboration. Municipal pull can be a trap especially for the poorer communities where leaders may not be as open to external coordination thinking they can’t worry about others when they are already swamped with their own problems. Partisan politics is another centripetal force. The community gets polarized in local elections such that one town’s mayor reaching out to the next town’s mayor for support will most likely be denied if they are under rival parties. Public health managers must apply the concept of mutually beneficial collective action through inter-municipality coordination. The leaders must know how to reel people across boundaries into a greater social organization. Increasing Pull Together We can generate greater centrifugal force and pull municipalities together through: Covenanting. Covenanting is entering into firm agreements. Municipalities can enter into agreements to launch health programs, share facilities, and mobilize resources. Widening Venues for Discussion. Municipalities can tap existing organizations that operate across municipalities as venue for discussion. If no such organization exists, then leaders can create one. Jaycees, Rotary Clubs, and other socio-civic groups can be platforms for bringing forward the health agenda. Resource Sharing. Municipalities can sometimes share various social, financial, and other types of resources. For instance, they can share MHOs so that if one MHO is absent, then a cooperating municipality’s MHO can fill in. It is also possible for municipalities to share ambulances, clinics, hospital facilities, and personnel so that at a larger scale, service delivery systems of primary healthcare are still functional. Municipalities can also share trainings so they can build awareness and capacity together. Smoothening Information Flow. If a dreaded diseases is detected in one town, then the town can communicate this to the next for precaution. Or if an expert visits one town to give a free lecture, then this town can invite other towns to attend. Municipalities keep smooth information flow because information is not lost when shared. Institution Building. Municipalities can also vote on or agree whom fiscal and political authority is given. As cooperating entities, they can gather together and forge an agreement on how to govern and spend money, on what projects will be launched to which town, and on how these will be funded. Summary: After the imagined future has been agreed upon, individuals –through social organizations -- become the embodiment of these new ideas. Based on the guiding ideas, these organizations produce the goods and services to address the health needs of the public. There is a technical/design dimension to the production of these goods and services, and these are discussed in next chapter.

Chapter 3

restless_river — Fri, 15 Feb 2008 03:04:28 CST

Chapter 3 Paradigm Pioneers
I have a dream... -Martin Luther King
All leadership takes place through the communication of ideas to the minds of others. –Charles Cooley

A forest-cemetery,that’s new.(actually not a novel idea but new for Philippines?) Mayor X of San Carlos City shared how pieces of the concept came together in his mind. First, he read about the 5-day war in Israel that resulted in some 5,000 casualties. In remembrance of those who died, a forest was planted. Second, he noted how Filipinos no longer cherished the forests and trees. Trees were cut and forests leveled because trees were merely objects to be converted into saleable lumber. That’s why there were denuded hills in San Carlos City. The third recognition was that Filipinos revered their departed family members, traveling from across the islands to visit their tombs on All Saint’s Day. Fourth, the city’s cemetery was getting congested. In the long run, the city could not be expanding acres for the dead as that that would deprive the living of the precious land. Thus, the concept of the first forest-cemetery in the Philippines was crystallized in his mind. A memorial forest would be planted and the remains of the dead would be transferred, after 5 years in the cemetery, to the foot of a specific tree. The family could then visit the tree to remember their loved ones. The forest has become sacred ground, as such no logger would dare cut down those trees. The city cemetery no longer needed to be expanded. Instead, the forest would become dense as the number of memorial trees increased when the departed citizens were moved to their final resting place of shady greens.

Leaders Make Things Happen Everybody has bright ideas about what government should be doing. Radio commentators, newspaper columnists, TV journalists, NGOs and even the beer-drinking bunch next door all have their bright ideas about how the town, city, or nation should be run. Unfortunately, not all of them have the opportunity to turn their ideas into reality. Unless they take things upon themselves and become entrepreneurs or decide to run for office, they remain fence-sitters, watching as others make things happen.
The Leader as Innovator or Early Adoptor Change happens first in the minds of the inventors and innovators. In the LGU, this may be the mayor or governor herself. Marikina City’s Mayor Bayani Fernando, asked what drives him to innovate, cites the “inventor’s high” as a major motivator. He gets a real kick by conceptualizing programs, implementing them, and seeing them succeed. (insert a summary of Marikina’s award winning program under Bayani Fernando.) Sometimes, the idea comes from somebody close to the mayor. The mayor’s role, in this case is to recognize the good idea s and move them forward into implementation. In many cases studied here, the innovations were conceived by the Municipal Health Officers and championed by the Mayors. There are describes five types of individuals within organizations according to the way they accept new ideas.1 These are:

Innovators – these are the dreamers who hatch new ideas.
Early adopters – these individuals recognize a good idea when they see one. Their ideas are respected within the organization. Though the ideas are not theirs, they try to convince others to accept it.
Middle adopters – accounting for the majority of the organization, they respond to the opinions of others. They are reasonable in their analysis of an idea but are inclined to maintain status quo.
Late adopters – these individuals are the last group to accept an idea and will often speak out against the proposed changes. They will usually adopt an idea only if the majority demonstrates support.
Laggards – these individuals are committed to the status quo and the past. They are always against change.

From Insight to Action Once the mayor decides that an idea is worth trying, she now works it through the bureaucratic structures so that it can be implemented. The following seven steps can be thought of as processes for injecting new ideas into the bureaucracy. Similar processes occur as the idea is presented to the citizenry.2

Step 1	Innovation. The innovator dreams up a new approach to current problems. He presents it to the Mayor.
Step 2	Information. The Mayor rounds up a technical working group to put together a program concept paper. The concept paper is then circulated. Initially, the new concept is not embraced. The new idea meets apathy, tradition, and prejudice. People resist change and point out the problems of the new concept. They try to prove how the status quo is better.
Step 3	Individual Change. The early adopters (often members of the initial technical working group) begin to see the strengths of the proposed concept and embrace the idea. Personal convictions replace complacency.
Step 4	Organizational Change. The early adopters are able to persuade more individuals (inside the bureaucracy and partners from the private sector or civil society) to support the program. Less defensiveness and more openness can be observed. Operational issues of the program are hammered out.
Step 5	Awkward Application. The program is implemented and early successes and failures are experienced. The learning process is rapid. Some assumptions are validated.
Step 6	Integration. Awkwardness begins to decrease. Efficiency and effectiveness increases. As new successes occur, more support from the middle adopters and late adopters is generated.
Step 7	Cultural Evolution. After repeated cycles of program implementation, the new scheme becomes the norm, the status quo, part of the culture – until the next wave of innovation.

Heading
Steps 1 to 6 are the common steps of in program implementation. This sequence works well in government programs where government provides the services and the citizens are passive spectators or clients. Such is the case in government-run a free clinic, day care center, or waiting shed construction. It’s different for programs where the citizens play an active role in implementation. In such cases, the citizens are not passive clients or beneficiaries of a program, they are themselves the actors. Marikina’s Pulitika Sa Bangketa (Case No.3), would have failed if the citizens refused to follow the rules. Of course, non-compliant citizens would have been fined or arrested, but widespread compliance made the program succeed. Widespread rejection of the ordinances would have resulted in the continuous chaos in the streets, as in many other areas in Metro Manila. In it’s traffic and parking management component Marikina’s Towards Hassle-Free Roadways mobilized the citizens not only to comply but also recruited them to enforce the ordinances through it’s self-policing mechanisms. LGUs as Supporting Actor In the entertainment industry, Sharon Cuneta, the Megastar and Vilma Santos, the Star for All Seasons have played a plethora of leading roles in their films. Through their powerful dramatic acting and sheer audience-drawing power that their movies became box office hits. Exemplary LGU programs, on the other hand, often do not intend for the LGU to be the Megastar. In programs where LGU resources are limited, when the problems addressed are complex and multi-dimensional, government has to recruit the citizenry for some audience participation. In such cases, the government is no longer the lead actor, or bida, but instead relegates itself to acting out supporting roles, allowing the private sector or citizenry to take the lead. Such an approach requires the government to take on a lot of new roles. Likening these roles to those in the entertainment industry, we can better understand what excellent LGUs do.

Example	Role	Tasks
Jess Abrera	social analyst/ critic	segmentize, understand publics, identify needs, wants, and motivations
Pete Lacaba	Scriptwriter	conceptualize plot, write script, strategize
German Moreno	talent scout and manager	identify and nurture talents, identify lead and supporting actors
Mother Lily	Producer	negotiate, contract actors, support crew, find investors
Marilou Diaz-Abaya	Director	Director, orchestrator, coach
Panchito	Supporting Actor/ Extra	Helps lead actor act out his role as extra, spices up the movie with antics and bit roles
Nestor Torre	Film Critic	evaluate, review, rate

adapted from Limlingan
In this scheme of things, an idea starts with a keen eye for the needs of the different sub-groups in society. It starts with a social analyst and critic studying, seeing and being disturbed by the realities around them. Like the social analyst and cartoonist Jess Abrera who comes up caricatures of Filipino life and culture in Pinoy Nga! published weekly in the Sunday Inquirer, the public health leader has to have a keen eye for details, and discern emerging realities and problems, and describe them to the rest of society so that they can be acted upon. Next, the public health leaders has to be a scriptwriter like Pete Lacaba. He understands and lays down the setting, conceptualizes a plot, and imagines the cast of characters and the roles they play in order for the story to unfold. The public health manager then has to be like German Moreno, the talent scout and manager. The talent scouts looks around for potential actors and recruits them for the movie. As a talent manager, he prepares a series of contracts so that the newfound talent hones his skills and grows into a powerful actor over time. A producer like “Mother” Lily Monteverde to assemble the production team to make the movie. She brings in investors, the technical staff (cameramen, lights men, and editors), director, and actors together. She orchestrates the ensemble of resources, manpower, and ideas together to turn the script into a movie With all the requirements in place, the public health leader then sets the stage, brings out the script and calls the people to action like director Marilou Diaz-Abaya. As director she ensures that the actors interpret their roles correctly and that the relationships between the characters develop as planned. The LGU or public health leader often also has to be an actor in the movie. Like Panchito (who was for decades Dolphy’s supporting actor), the supporting actor may play a significant role in bringing out the character of the lead actor and pushing the plot forward. If the actor plays a bit role, then he’s there to spice up the movie and provide a little support here and there. Finally, after the change happens or after the program is accomplished; the public health leader, like film critic Nestor Torre, evaluates the program for its strengths and weaknesses, its successes and failures. Public health leaders, therefore, have to be all these people rolled into one. There are some models in the entertainment industry who take on multiple roles. Jaime Fabregas not only tickles our bones with his comic and sometimes dramatic stints but also impresses us with his musical score. Cesar Montano has his hand on the script and musical score of his films, and even makes his tandem director, Marilou Diaz-Abaya, listen to how he thinks the act is to be staged. Action star Ronnie Rickets has produced (he owns a film production company) directed and wrote many of his films as well.
The Dancers Become the Dance The curious thing about treating the citizens as actors in the story is that sometimes, they take over the entire production. In the Bustos Jogger’s Club monthly dance get-togethers, it was the community’s event and Mayor Arnel Mendoza merely dropped by to say a few words and touch base with the participants. The various barangay “jogger’s clubs” financed the purchase of their own uniforms, and paid for their own merienda. At some point, the municipal bureaucracy had little or nothing to do with the perpetuation of the jogger’s club program. After some time in Marikina City, the citizens imbibed the behavior of discipline in the sidewalks. At some point, Disiplina sa Banketa was no longer a program to be implemented, but a sub-culture of the citizens of Marikina. Cultural evolution occurred. The dancers became the dance.
Transformative Leadership The roles of the public health leader, therefore, are multiple, and they shift over time as the health program unfolds. Table 4 below how the relationship between LGUs and it’s citizenry evolved in the course of the programs described in the cases. Table 4: The Empowerment Loop

	Partners passive	Partners active
LGU active	2 Early LGU-driven Well-defined program design Simple structures	3 participatory partner-strengthening LGU and partners as Co-equals
LGU passive	1 Stagnant, inaction	4 People-driven and LGU supported Diversification Differentiation Increased complexity LGU takes a back seat Evolution to a learning community

An LGU starts out in Quadrant 1 where the problem is not actively being addressed. Once a problem is recognized and a solution is to be tried out, the LGU moves to Quadrant 2. During the start-up of the program, the LGU is the main driver and the program moves along from Stages 1 to 5 (from innovation to awkward application) occurs in this quadrant. Leadership and decision-making is concentrated in the public health leader and the program goes more or less as designed. If the LGU and the public health leaders are willing to share power with the citizenry, the program moves to Quadrant 3 where the partners take a more active role in program in implementation. This quadrant roughly corresponds to Stages 2 to 6 (information to integration) as the partner organizations or the citizenry begin taking on the processes of the program. Some authority and responsibility, and therefore political power, is delegated to the partners. The partners become strengthened by the growing operational and political control over the program. The partners become increasingly autonomous, along with an increasing sense of ownership over the program. Takeover occurs in Quadrant 4, when the partners assume accountability for the program (stages 6-7, integration to cultural evolution). At this point, the LGU leaves the driver’s seat and allows the partners to drive the program. In a sense, the program takes on a life of its own and it become increasingly difficult to attribute the further outcomes of the program solely to the LGU. The program becomes woven into the partner organization’s operations or into the citizen’s culture. After 20 years of implementation, the Surigao Federated Women’s Club (Case 5), is clearly in Quadrant 4. By the time the case was written, the organization was already involved in a gamut of health programs, from family planning, to youth programs, to a health information program through local radio.
The Leadership Axis discusses various strategies for change management based on the management sciences. The Leadership Axis arranges managerial phenomena from micro-management on the left to strategic management on the right. It also orients the different change management strategies from evolutionary change on the left to programmed change on the right (see Case 4).
The Leadership Axis To help get a better handle on the concepts presented in this chapter, they are chunked up in the leadership axis (See Fig.1). In terms of management style, intuitive management is placed on the left and strategic/goal-oriented management is placed on the right. Leaders with formal management training or corporate experience are likely to be seen to the right. In terms of change management style, the goal-oriented. Leader-driven. programmed change is located to the right. Towards the left is the more process-oriented, participatory, and less controllable evolutionary and participatory change.
Figure 1: The Leadership Axis

intuitive mgt. - operations mgt. - organization mgt. - strategic mgt. disorder - evolutionary change - emergent change - programmed change people-driven/bottom up- participatory mgt. -leader-driven/top-down

Because of Marikina Mayor Bayani’s corporate background, his management style is highly goal-driven and based on strategic plans. The leadership style which is described as leader-driven, with programmed change based on strategic plan is plotted in the right side of the axis. His projects can be located mostly in Quadrants 2 and 3. (Marikina City is a Hall of Famer in the annual Galing Pook awards. Among the programs that bagged awards for Marikina City were Squatter-free Marikina; Barangay Talyer, Disiplina sa Bangketa and the Save the Marikina River.) Bustos, Bulacan Mayor Mendoza and his doctor-wife, are physicians by training but their highly innovative, process-oriented, people-oriented leadership style more than made up for that slack. At the start of Mayor Mendoza’s term in 1988, he had no strategic plans. His programs were driven primarily by good intentions. The husband-wife team’s leadership style could be located in the left side of the Axis because their efforts resulted in a highly participatory evolutionary change. We must note that the results here are no less effective than the right side type.
Conrado de Quiros describes this all succinctly. He wrote:
We need an ordinary mortal who rises to the extraordinariness by the heroic nature of her vision, by the epic nature of her quest, by the monumental scale of her dedication to it. We need someone who is humble enough to hear the voice of the people and is proud enough to bend the world to their will. We need someone who can push people to transcend themselves, and, doing thus, pull them to reach for things beyond their grasp. We need, in sum, a leader.

Case 4 Marikina City’s Politika sa Bangketa
Anarchy in the sidewalk of Marikina flourished through years of neglect and indifference. There was a call for change with the coming in of a new local chief executive. The battle cry was the need for discipline. " A man may be king in his domain, but once he sets foot on the sidewalk he has to bear in mind that he is bound by the rules of society and has to live by them." Appropriate ordinances, which prohibited the use of sidewalks for other purposes, were passed. Initially, the city disseminated to all households a pamphlet on "Disiplina sa Bangketa" (Discipline in the Sidewalk) outlining the rules and regulations to guide people's behavior in the sidewalk. The city paved around twelve kilometers of its sidewalk with red colored demarcation line to impress upon the public the value of conforming to the rules and mores of society to achieve physical and social order. Its operation was guided by the dictum of checking the smallest infringement in the law with the objective of eventful ease in reducing petty and bigger crimes on account of the citizen's obedience to simple rules and regulations.
The city government succeeded in liberating 90 percent of its sidewalk from any form of encroachment or obstructions. Trees were planted along the sidewalk and in other parts of the city in support of its program called " Puno Kahit Saan ( Trees Everywhere) to convert the whole city into a nursery of trees. Everyone was encouraged to plant trees everywhere with guarantee from the city government to remove and transfer the trees anytime for free. The city acquired a tree mover for balling out and transferring trees. In 1997, around 85,000 trees had been planted. The tree planting is consistently being pursued to attain its goal of having 1,000 to 1,500 trees planted per capita. Added to these accomplishments was the implementation of another program " Towards a Hassle Free Roadways" which strictly enforced the traffic and parking ordinances through self-policing policy. To support the program, a five-hectare parking area was built; street and traffic signs were upgraded; new access roads were opened to decongest main thoroughfares, among others. As a result, Marikina has some of the safest and most convenient sidewalks and roads in Metro Manila today.

Case 4 Federated Women’s Club in Surigao
Surigao City is known to award-giving national and international bodies through its primary health care program initiated and implemented through women's clubs. In 1976 Mrs. Zenaida Arana, a midwife of the City Health Office assigned to two barangays, began organizing mothers at the purok level and training them in nutrition, responsible parenthood, and sanitation so they could assist in the delivery of PHC services.
Barangay Health Workers (BHWs) assisted Mrs. Arana in her pioneering tasks. By the 1980's mothers clubs had become very visible in the city. Because of their success, local politicians took advantage of them and converted them into their private organization. This confused the members, and the organization died within one year. It took Mrs. Arana two years of hard work in 1985 and 1986 to form another set of ten mother's clubs.
LOCAL GOVERNMENT SUPPORT
In 1988 the new City Health Officer gave recognition to Mrs. Arana's efforts and assigned her as overall coordinator of the primary health care programme for all 54 barangays of the city. Because of that support Mrs. Arana was able to organize a functional PHC Women's Club in all the barangays. In 1991 the groups formed a federation. In 1992 it became the Surigao City Primary Health Care Federated Women's Club, Inc., and since then has been instrumental in propagating the PHC strategy.
FAMILY PARTICIPATION The women involved their husbands in primary health care activities. The men got into the program by organizing the BESIG (Barangay Environmental Sanitation and Implementing Group). The PHC Youth composed of 12-21 year-old family members and the Mini-Youth (from 7-12 years old) were subsequently organized by Mrs. Arana. By 1990 BESIG had become an indispensable partner of the PHC women's clubs. TRAINING AND AWARENESS
The PHC activities involve immunization, family planning, nutrition, implementation of the national tuberculosis programme, and control of the diarrheal projects. Believing in the capacity of mothers to implement PHC, the programme put emphasis on training women in leadership, community development, and management. PHC also runs a weekly radio programme to promote health awareness and serve as a communications facility among the members. ORGANIZATION
The federation is organized like a pyramid, with the 7,200 members of 180 chapters at the base. The chapters are grouped into seven districts composed of five to 12 contiguous barangays. Each level of organization has its own set of officers, including its representative to the next higher level. The PHC structure involves the City Mayor and Vice-Mayor as PHC Committee chair and co-chair, respectively. Mrs. Arana remains as PHC Coordinator and adviser.

FINANCING The PHC gets financial support from the development fund (20% of the City's IRA). The City budget also funds its health projects. However, the organization is essentially self-supporting. The annual membership fee is P10.00 (ten pesos). Each member also contributes P60.00 a year for funeral assistance to members. The organization also raises funds from special projects and accepts donations from external sources; cash awards from HAMIS (Health and Management Information System) in 1991 and 1994 went into the financing of PHC activities.
MEASURING SUCCESS
Infant mortality in Surigao City was a high 76.6% in 1981 and 69% in 1984. After PHC became active it was drastically reduced to 29.5%. By 1996 it was only 19.1%. Maternal mortality rate also went down from 1.9% in 1975 to .5% in 1996. In the years PHC was inactive, both infant and maternal mortality rates were high.
Nutrition rates for pre-school children have also improved. In 1980 there were only 38.1% of children who had normal weights. Although the figures fluctuated, the rates were lowest when PHC was inactive. In the last few years of PHC's re-emergence the rate of children with normal weights had been high--- 54.7% in 1992, 59.19% in 1993, 61.02% in 1995, and 62.54% in 1996. The establishment of BESIG in 1990 has increased household access to sanitary toilets (Table 8). Conversely, households without access to sanitary toilets decreased at a rate of 31% in 1990-96.
These figures show the impact of the PHC Women's Club in the lives of Surigao City residents.

1 Winifield Arn, Growth Report No.5., Ten Steps for Church Growth (New York: Harper & For, 1977). As summarized by John Maxwell, p.64.

2 Adopted from Maxwell, p.65, Developing the Leader Within You

Chapter 2

restless_river — Fri, 15 Feb 2008 02:51:06 CST

Chapter 2 Change and Development in a Municipality

I inherit from the past of my family, my city, my tribe, my nation, a variety of debts, inheritance, rightful expectations, and obligations. These constitute the given of my life, my moral starting point. --an Athenian Oath
A leader is a man who has the ability to get other people to do what they don’t want to do and like it. --Harry Truman

The Parable of the Boiled Frog

The parable of the boiled frog is told so well by MIT scientist and educator Peter Senge to illustrate maladaptation to gradually building threats. If you place a frog in a pot of boiling water, it will immediately try to scramble out to save itself. But if you place the frog in room temperature water, he'll stay put. If you just gradually turn up the temperature, something very interesting happens. As the temperature rises slowly, the frog will do nothing and may even show every sign of enjoying himself. As the temperature gradually increases, the frog will become too helpless to climb out. Though there is nothing restraining him, the frog will sit there, boil and die.

Challenging the Status Quo

Public health managers and local chief executives confront the same dilemma when they try to introduce change in the health behavior of a community. The community, like the frog, could be swimming in water that is heated slowly through time that it hardly notices the heat that could soon be fatal. Change starts with questioning what is “normal” by challenging currently accepted norms. The frog should have questioned why the water was becoming hot. Instead he just swam around the assumption that the water was just warm enough for swimming, not for getting boiled. This same mentality pervades many municipalities and cities. For example, air pollution increased gradually in Metro Manila until it reached toxic levels. Metro Manilans have learned to live with the gray, sticky air that stings the eyes and reeks with gasoline fumes. Tap water is no longer safe to drink, and drinking bottled water (from plastic bottles that pile up the landfills) is suddenly the norm. The mountain of garbage grew taller with each passing day in Payatas, until it was an avalanche just waiting to happen. In Appari, human waste was disposed of in the beaches for years. Not surprisingly the morbidity rate due to diarrhea has been high in these localities for decades. In Alimudian (as in many other places in the Philippines), differently-abled people have been constantly teased by their neighbors, children by other children. A common practice among Filipino families is to keep differently-abled family members in the confines of their home because of the stigma or sense of “hiya” that that family member brings to the family. The mentioned cases bear out the boiled frog phenomenon. It shows that a certain locality’s long-standing health behaviors may be harmful. Like the frog, the citizens may be ignoring harmful elements in their environment or in their culture, and go on inflicting harm upon themselves as they continue to accept and perpetuate these realities. But how does one change age-old practices? How does one press the alarm button to rouse a people out of their own stuporous complacency? How does the public health manager go against the tide of what is accepted as “normal” and change the status quo?

The Sky is Falling: Disturbing the Unwanted Peace

Challenging the norm is risky business. One risks being tagged an alarmist or doomsdayer. If a leader sounds the alarm too often for perils that the crowd cannot yet discern, he may be brushed off and ignored. His ego may be hurt and his credibility will because of his alarmist attitude—until the crisis that he warned about erupts. Then all he can say is “I told you so.”

External Critic-Induced Change. Fortunately, there are ways of inducing change that do not put one’s reputation at risk. In the case of Aparri in Cagayan, the LGU initiative to embark on a health project was triggered by the television feature of Channel 2’s Magandang Gabi Bayan. Appari was touted as having the “longest toilet in the world,” exposing the local’s practice of hurling their wastes to the long stretch of beaches in their town.

The news was not new to Aparrianos. The knew it all along. But the program segment touched the sensitivity of the Apparianos. The newly elected mayor --a doctor by profession who already knew of this situation long before the national broadcast was made—rallied the Apparianos to solve the unhealthy situation of their beaches and launched the “Marenu nga Bevay, Gauagagauyan ba Tatolay” (A Clean Sea, A Healthy Community) project. Because of an outsider’s criticism, the infamous “toilets” of Appari ultimately got the upkeep and attention of the indignant, and newly sensitized, citizenry. Alimodian has another story to tell. Outsiders, the staff of DOH’s Community-Based Rehabilitation Program, met with the citizenry and pointed out the plight of the differently–abled individuals in the community. In the same breath proposed an inexpensive solution which won the people’s support. With the people’s support, Alimudian’s Community-Based Rehabilitation Program pushed through, improving the lives of the differently-abled and winning recognition for the town in the process.

Crisis-Induced Change. Not all change is externally induced. Davao acted on a because of a blood shortage. With unusually high death rates primarily caused by failure to have blood transfusions, the provincial government was prompted to set up a blood self-sufficiency program.

Statistics showed that only one out of every five hundred Davaweños voluntarily donated blood. Of every ten persons needing blood, only three sourced blood from such donors. The rest relied on paid donors. Still, paid donors from blood banks in their locality could only supply less than twenty percent of the demand. Another five percent is supplied by the central blood banks of Davao City. The provincial government responded by setting up barangay blood pools to solve the problem.

Benchmarking. The Bulacan health program is interesting because it was triggered by a report from the Regional Health Office that the province lagged behind other provinces in the region as far as nutrition was concerned. A “kulelat complex” was triggered by performance comparison. The otherwise silent and undramatic problem of malnutrition suddenly became the focus of attention.

Only one out of the ten cases was triggered by an administrative report. Seemingly, when public health leaders are sensitive enough, they will respond to gaps in their system as shown when compared with other LGUs. High-performing LGUs, thus become the model and the standard for other LGUs to measure themselves against. For national government, this is one method that promises to help make improvements more widespread across the country.

Continuous Improvement or Programmed Change. The Olongapo Solid Waste Management Program is an example of a project that is triggered by a recognition of an emerging problem. Like the crisis-induced change, no external party is needed to point out the need for change. Unlike the crisis-induced change, the intervention happens before the crisis occurs. The project is therefore proactive, rather than reactive, anticipating and solving problems before they occur. Table 1 below is a summary of the triggers of change in the ten cases.
Table 1 – Triggers of Change in the Cases

Case	Trigger of Change
Aparri	External Critic, Negative News coverage on national TV
Olongapo	Recognition of emerging problem, failure of past attempts
Bustos	No information, called garbage town
Sebaste	Ongoing problem, poverty and distance of community to urban health centers
Guimaras	External critic identifies problems and proposes solution
Davao	Crisis, lack of blood supply
Pangasinan	Crisis, calamity triggers plan
Alimudian	External critic identifies problem and proposes solution
Bulacan	News that province lags within the region
Surigao	Recognition of emerging problems, ongoing expansion of health programs

Complaint-Induced Change. Citizen complaints can also trigger change. In his discussion of Total Quality Governance, Bolongaita shows how feedback from constituents-customers can benchmark what local government needs to act upon, what it will and what it will not act upon. Table 2: Priority Governance Matrix

	Perceived high severity problem	Perceived low severity problem
Government is not doing anything about the problem	Area of high priority (AHP)	Area of indifference (AOI)
Government is doing something about the problem	Area of lower priority (ALP)	Area of satisfaction (AOS)

Bolongaita (1996)1

Bolongaita’s survey of one business district’s service delivery system to constituents shows that while the local government was already doing something about the problem (mostly in city cleanliness, beautification, and maintenance), a lot of services are not yet delivered to other areas of high priority (curbing prostitution, pornography, vandalism, etc.) Not only did the constituents-customers show the local government where the demand is, they also show that they want change to happen, to make good things better.

Lengthen the discussion on this.
Governance Beyond the Boiled Frog Government “of the people, for the people, by the people” was assumed to naturally result in good governance. Devolution was designed to heighten the strengths of democratic government by putting power and resources for governance closer to the communities. (quote JP Perez paper from McNamara) In theory, people chose their mayors and governors in democratic elections and could easily remove low-performance mayors after three years. In theory, a Mayor would throughout his term attempt to satisfy the needs of his constituency or else he would not get reelected. Over time, only high-performance mayors would remain in power because the citizens were satisfied with the quality of his governance. Yet this does not happen. Excellent government programs are still the exception and not the rule. Many mayors continue with mediocre programs, building roads and waiting sheds and plod along only to win in the next elections.

The Politics of Angkan and Utang-na-loob

The electoral processes installed by the Americans did not work very as a feedback mechanism in the Filipino culture. The assumption in an electoral system is that the vote would be used as an objective, unbiased mechanism for allowing a citizenry to choose their leader freely. In the towns, people were not as free. Hollsteiner in her book, “The Dynamics of Power in a Philippine Municipality” points to four basic socio-structural relationships that exist in a typical locality. These relationships are as follows: angkan or clan relations, affinity, ritual kinship and friendship. The clan is the immediate social relationship one is literally born into. Affinity, on the other hand, is relationship acquired through marriages –one’s husband or wife is eventually integrated into her/his nuclear family. The third socio-structural relationship existing in local communities is the ritual kinship or the kumpare system. This is common among the Christian community. This kinship is established through the rituals of baptism and marriage. Lastly, Hollnsteiner identified friendship as the fourth basic structural relationship that binds communities. Utang na loob, or debt of gratitude in Philippine society is an important Filipino social construct. Utang na loob is the indebtedness of Person A to Person B for a favor received. In Philippine culture, the bigger the favor received, the bigger the utang na loob. Utang na loob is also familial, thus the indebtedness of Person A to Person B is also the indebtedness of Person A’s spouse and children, even Person A’s clan, to Person B. Utang na loob is a debt to be taken seriously, a debt that should not to be forgotten. Person A erases his utang na loob by returning the favor in another form at some later date to Person B. When the mechanisms of utang na loob are used constructively, it results in a healthy balanced exchange of favors and goodwill that flows between peers or neighbors as equals. Sadly, utang na loob is often harnessed as a basis for shady, counterproductive exchanges. When the Americans introduced the elections, however, the vote became a currency for individuals, families, and clans to pay their utang na loob to politicians. For example, tenants and their angkan who owed their landlords for the many favors granted to them “paid” their utang na loob by voting for their landlords into position. Local physicians, with the hundreds or thousands of patients they have seen over the years could also count the utang na loob of their patients as political capital that could thrust them into position if they wanted to. And when a politician won, they in turn paid back their utang na loob by awarding jobs and dispensing favors to their political supporters recirculating the utang na loob back into the relationships. This system is often referred to as patronage politics. Bolongaita points out that patron-politicians court people for their votes. Democracy assumes equality among citizens, thus they will vote based on quality of governance. Patronage politics, however, has citizens indebted to patrons, thus they vote for the patron regardless of political performance. Patronage politics doesn’t usually result in change for the better. Its not always that bad though. The cases of excellence in local governance show how it is possible to break out of this cycle or achieve excellence within this system. The point is that elections + utang na loob + clan systems + boiled frogs = a curious, complex, colorful, and spicy, socio-economic-political brew in the Philippines. (And then there’s vote-buying, partisan politics, the adversarial NGOs, the hypercritical media…) The effective public health leader has to understand all that.

Cultural Evolution

The public health leader should also learn to keep his hopes up though. The rest of this book discusses how things can go right and stay right. The situation can change for the better if only the public health manager knows how to trigger change and then how to sustain it. Zaltman defines social change as “the relearning of an individual or group in response to newly-perceived requirements of a given situation requiring action and which results in a change in the structure and/or function of social systems.” Table 3 below summarizes the different changes that occur until they become permanent. The Appari Case bears this out. First individuals are disturbed by the news story, so they change their daily waste disposal behaviors and improve their habits for a lifetime. Communities are mobilized to clean up the beaches. Organizational change is implemented by installing a caretaker system to keep the beach and the kiosks clean. In the end, the Appariano’s have cleaner beaches and a better image of themselves. Their children will grow up with clean beaches and better waste disposal habits than their parents. The culture has evolved.

Unit of Change	Short-term	Long-term
Individual	type 1 attitude change behavioral change	type2 life cycle change
Family community institution organization	type 3 normative change administrative change	type 4 organizational change
Society	type 5 invention-innovation revolution	type 6 socio-cultural evolution

Source: Zaltman, Management of Change readings (look for better citation)
The beauty of this approach to development is that it is learning-driven rather than resource-driven. The boiled frog does not need external funding support to get itself out of hot water. It just had to be nudged out of it’s stupor and it solved its problem pretty much on its own. With a learning-driven approach to public health (and development in general), financial constraints will seldom be an obstacle, and if they are obstacles they will be minor ones. As the cases later in this book will show, even poor municipalities can come up with sensational health programs. The only barriers to development would be the refusal to learn.
The Axes of Governance So what is governance? Generations of thinkers and political scientists - from Aristotle and Machiavelli to the likes of Osborne and Gablier--have pondered and produced voluminous texts on this matter. If we are to adopt a people-centered approach, governance is basically managing the area system so that it addresses the new needs and wants of the people that live in it. This definition is anchored on the premise that humans are evolving/growing in complexity as beings within a system, and it follows that a system has to evolve in complexity to address increasing human needs while maintaining long-term system viability. Governance could also mean managing the market of economic goods and services and managing the market of values and ideas, culture and social learning. It could also involve the regulation of the “consumption” of values and ideals. This book presents the dynamics of governance along five axes (lines). This will allow for a more systematic analysis of governance processes that hopes to be neither simplistic nor confounded by the complexity of the concepts.

Why an Axis?

The axis is a linear representation of a range or a series of phenomena. Being a linear representation, an axis provides directional or polar tendencies. It could be up or down, to the left or to the right. Lines parallel to each other can also show parallel phenomena. If horizontal, an axis presents the phenomena in a non-judgmental way—no point is higher than the other. The axis also represents even intersecting phenomena along one line. The line represents the phenomena in a simple way despite governance and its dynamics being complex concepts. The linear representation gives us a way of chunking together complex items so that we could better understand these phenomena. Phenomena in governance are clustered along five axes namely: leadership, meaning, organizational, technical and resource. From this point on, chapters in this book deal with the axes. Chapter 3: Leadership Axis discusses the leader as the initiator of change. It presents how the leader transforms his insights into action, and how he can get as many hands to work with him. Chapter 4: Managing Meanings Axis answers the question: How can a leader drive people to action? It discusses how leaders can manage meanings so that people can know what they are engaged in and why. In Chapter 5: Organizational Axis, we discuss how people -- driven by shared meanings -- can organize themselves to action. Chapter 6: Technical Axis shows how the technical processes have to be managed scientifically. Chapter 7: Resource Management Axis discusses a major component for starting and sustaining change—resources and how leaders can mobilize which resource for use and replenishment. Now that all components are in, we will also study in Chapter 8: LGU Dynamics, dynamics in local governments that affect our health programs—political relationships, etc. Finally, towards the conclusion, this book sees the healing in meaning; how from initially being involved in and benefiting from health projects community people “heal” and enrich their lives with meaning.

Case 1 Appari’s Clean Sea, Healthy Community
Because of its distance from urban centers, the northernmost Philippine island of Appari lacked sanitary facilities for its people. The shores covering five barangays at the eastern part of Appari were used as defecation area. Residents did not care about the serious damage dumping of refuse and human wastes posed to their health and the environment. These unsightly shores became favorite breeding ground for disease-carrying insects. Due to the deteriorating physical environment, Apparianos were exposed to health problems. Potable water source was left often susceptible to all kinds of impurities and bacteria. Makeshift houses also dotted the coastal areas, and residents had nowhere to dispose of all sorts of garbage but the waters below their homes.
In 1993, a wake up call for Apparianos came with a bang through a TV program. Magandang Gabi Bayan, anchored by Noli de Castro of ABS-CBN, featured Appari’s shores as the “longest toilet in the world.” This branding on national TV alarmed the Apparianos, especially the local chief executive.
This ill-reputation broadcast on television pushed Apparianos to unabated action. Mayor Tumaru dialogued with the members of Sangguniang Bayan and the Association of Barangay Councils to institutionalize “Clean Appari through KALINISAN SA BUDHI, SA SARILI, AT SA KAPALIGIRAN.” This then, started a collective decision to change.
Affected residents agreed to relocate their houses at identified sites through the “bayanihan” spirit of volunteerism. As stewards of the environment, they were tasked to level the ground and maintain cleanliness in their respective vicinity.
The municipal and barangay government constructed public toilets to answer the sanitation needs of barangay folks. Artesian wells were likewise installed. The users of the public toilets and water facilities were organized into groups and provided financial contributions for the daily upkeep of the facilities.
Clean up and rehabilitation of the shores were not done overnight. It became the community’s never ending commitment. Added to the beauty of the now rehabilitated Appari shores were picnic shades, which eventually became a source of auxiliary income for the town folks. In San Antonio beach, each resident acted as caretaker with permanent assigned picnicker’s shed to maintain. Incentive derived thru rentals of P50 per shed was divided equally between the Barangay Council and caretaker.
Training/seminars on entrepreneurship and livelihood generation were also provided to residents. An aggregate financial assistance amounting to Four Hundred Thirty Seven Thousand pesos was channeled to various livelihood projects and self-employment programs enjoyed by 172 beneficiaries of three coastal barangays.

1 Bolongaita, E., Total Quality Governance, Treating the Citizen as Customer, The Asian Manager, Asian Institute of Management, Makati, 1996

Chapter 1

restless_river — Fri, 15 Feb 2008 02:47:49 CST

Chapter 1

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

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

Home

elmer.soriano — Mon, 21 Jan 2008 07:29:06 CST

Next Generation Health Governance


1944		2015

Our health system has come a long way since the war. Help describe where it is now, and prescribe where it should go in the future by contributing to this bayanihan book. The community contribution approach to this book was inspired by www.bayanihanbooks.org.

Version 1 of this book was based on this paper entitled Making Devolution Work by E. Soriano, 2000 (click here to download copy). Another good book on the topic (and also more thorough and recent) is Making your Health System Work by Dorotan and Mogyorosi, 2004 (click here to download online copy).

You are warmly invited to contribute, edit, revise, update this book. Just login, open an account, and press "edit the content" tab on the left.

Table of Contents

Chapter 1 - Leading Minds

Chapter 2 - Change and Development in a Municipality

Chapter 3 - Paradigm Pioneers

Chapter 4 - All Together Now

Chapter 5 - Managing Meaning

Chapter 6 - It's All Chemistry

Chapter 7 - Finding Funding

Chapter 8 - Power Tango in a Municipality

Chapter 8

elmer.soriano — Mon, 21 Jan 2008 06:25:21 CST

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.

	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

--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.

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

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

	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

Alliance building
The Mayor
The “masses”
The fact that everybody Is concerned with health
Common alliances (bridge)
Creditors of power elite
External powers
Conservative bureaucracy

Threats

The Mayor
Alliances
Outbreak of diseases

Strengths

Professional stature
Health staff
Ability to generate utang ng loob
Personal alliances
Professional alliances

Be a partner of all alliances through group-specific health projects
Work with/through vote-rich alliances
Work through creditors
Get the mayor’s utang ng loob
Work through shared allies (bridge)
Help alliances have/own their own health programs
Get external powers interested in local health
Allow mayor to gain political mileage for all health programs
Projects should be organization-driven rather than MHO-driven

Use disease to form alliance (ex. A dengue council)
Use resources to counter-threat mayor

Weaknesses

Subordinate 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

Chapter 7

elmer.soriano — Mon, 21 Jan 2008 06:22:56 CST

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:

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.
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.
Educating the patient.
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.

Chapter 6

elmer.soriano — Mon, 21 Jan 2008 06:21:21 CST

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

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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

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.