• I want my MDGs
• Whither the MDGs?
• Toilet trouble
• An island slakes its thirst
• Naga City’s class act
• A school board makeover
• Making sure Mama makes it
• No cure for costly medicines?
  Draft law affirms patient rights of drug firms
• Arroyo fails COA audit: Fairness of President’s books ‘doubtful’
• Gloria’s spending spree: Travel, ‘donations’ top Palace expenses
• First Person
  Still reeling from military junta, Burma a mess after cyclone
• Perspective
  An absolute privilege

VALLEHERMOSO, CARMEN, BOHOL — Had she been in the same situation eight years ago, Jesusa Panes would have probably just given birth at home, even without her husband in sight, and even if her neighbor the hilot (traditional birthing attendant) happened to be drunk. But things have not been the same for expectant mothers in this town since 2002, and so when the child in her belly starting demanding to be let out, Panes began trudging toward the birthing center that was several minutes away by foot from her home.

The drunken hilot did his duty by swaggering behind her, seeing to it that she got to the center safely. Carmen is in fact the only town in Bohol that has legislated that all mothers must give birth at designated birthing facilities in five barangays or at the town’s birthing center (rural health unit or RHU), a P2.5-million, sprawling facility that offers first-class service for very low fees. Carmen’s laws also say a hilot should bring laboring mothers to the nearest birthing clinic to ensure a comfortable and safe delivery. And even if a hilot is trained, he or she cannot aid in a delivery, unless a midwife sits nearby to oversee the process.

	THESE days, mothers like Lilia Angcog can give birth for only P500. [photo by Avie Olarte]

The result of such legislation has been practically no maternal death in Carmen’s 29 barangays in the last five years, save for one in 2006. According to Dr. Josephine Jabonillo, Carmen’s municipal health officer (MHO), that unfortunate mother-to-be tried to deliver at home, with her father-in-law as the hilot. The father-in-law turned out to be untrained; the woman hemorrhaged to death.

“Most maternal deaths can be prevented,” says Jabonillo, an obstetrician/gynecologist. “Mothers all over the world die due to the same major complications of pregnancy: hemorrhage, hypertension, sepsis, and unsafe abortion.”

Globally, women continue to die due to complications of pregnancy and childbirth at a rate of one per minute. The limited progress in making motherhood safer is more alarming in developing countries, where 99 percent of maternal deaths occur every year. Here in the Philippines, about 10 to 12 women die every day due to pregnancy-related causes. The government has even admitted that it may not meet its commitment to achieve Millennium Development Goal (MDG) Number 5 — to drastically reduce the number of maternal deaths — by 2015.

And yet here is this town of 41,519 people that has been demonstrating just how far better local governments can be at keeping mothers healthy. Aside from its innovative laws regarding maternal health, Carmen also has what it calls the Enhanced Safe Motherhood Program (E-SM), which not only pushes for a RHU-based delivery, but also includes a pre-natal assessment, monthly check-ups, access to medicines, and other maternal health services — all for a nominal fee.

Location map of Carmen, Bohol courtesy of Wikipedia

TO FULLY appreciate what Carmen has accomplished so far, consider this: as late as 2005, the proportion of births attended by skilled health workers nationwide stood at 63.7 percent. In 2006, meanwhile, the national maternal mortality rate — the number of deaths per 100,000 live births — was 162. To be considered as having met MDG No. 5, the Philippines has to have all births attended by skilled health workers by 2015, as well as have reduced the maternal mortality rate to 52.3.

This predominantly agricultural town with more than half of its people living under the poverty line has managed to best those numbers — and how.

Yet even up close, there seems to be nothing that can make Carmen stand out among other rural towns across the Philippines. There are the small town center that passes for its urban area and a collection of dusty barangays. There are some cars and jeepneys and a lot of motorcycles. And just like any other Philippine town, there are children — lots of them — scampering about in the streets.

Then again, there is that birthing center, a 10-bedroom facility that is complete with delivery tables and laboratory equipment and can top the services of any hospital in this province some 800 kms south of Manila. Completed in 2006, it won a Sentrong Sigla Award (Center for Vitality) the very next year. According to the Department of Health (DOH), it is one the best rural health units in the country.

Building a good facility was on top of Jabonillo’s list when she became the town’s health officer in 2002. But she says it was no easy task, recalling that she had to first lobby hard with the local government officials.

“Carmen at the time had a very high record of maternal death,” Jabonillo recounts, “So I told the mayor we had to address it.”

Although the E-SM was Jabonillo’s idea, the local health board (headed by the mayor, and with Jabonillo, a councilor, and a nongovernmental organization representative as members) helped craft the program.

For the past five years, Carmen has had no maternal deaths except for one in 2006. Credit that to its award-winning rural health unit, which is complete with bedrooms, delivery tables, and laboratory facilities. [photo by Avie Olarte]

Jabonillo says that the town records revealed that the maternal deaths in Carmen were often caused by unhygienic and improper birth delivery practices. She also noted that there were also few skilled birth attendants, while women barely had access to pre-assessed normal delivery from the provincial hospitals.

These days, aside from the main one in the town center, five of Carmen’s barangays have birthing facilities. There are no doctors in these centers, but a midwife is usually on call, along with an army of barangay health workers; should any complications arise, an ambulance (Carmen has six) can be dispatched to bring the pregnant woman to the RHU.

But convincing the women to try the services of these clinics proved difficult. For one, the women thought they would be charged high rates. For another, they were simply more used to the hilot, some of whom even discouraged the pregnant women from going to the RHU. (This is, after all, a country where half of births still occur at home, and a third assisted by hilots. In Bohol, 17 percent of all the births in 2006 were aided by trained and untrained hilots, most or 53 percent are assisted by midwives.)

On E-SM’s first year, the RHU had a total of only eight deliveries. But by 2006, which was also the year the council passed the ordinance banning trained hilot from delivering babies, about 400 women ended up giving birth in the town facility.

“Maternal and birth complications were reduced to 50 percent,” Jabonillo says, leading to Carmen’s near-zero maternal death record.

AT VALLEHERMOSO, one of the barangays with a birthing center, the barangay midwife keeps track of all the pregnancies in the area. The health unit has on its white wall a pregnancy watch board that lists the names of pregnant women, together with the estimated date of confinement, last menstrual period, place and (estimated) date of delivery. There are also free pre-natal check-ups and some medicines, like iron tablets (many of Carmen’s women are anemic), are free as well.

Lilia Ancog’s barangay has no birthing center yet, so when time came for her to deliver her third child, she went to the main birthing center in town. Even then, she says her total bill came to only P500, or about 25 percent of the cost of a hospital-based delivery. She says that with her two older children, she had paid double that amount, and those deliveries were even done at home through a midwife.

“(It’s) high quality obstetric services at very reasonable amount,” says Jabonillo, who does not charge a doctor’s fee for the deliveries she does.

The doctor says that all the birthing center’s proceeds go to buying medicine and supplies like gloves and cotton, on top of the P1-million worth of drugs that the local government allocates for the RHU every year.

A patient in Carmen can even end up not paying anything at all. Last September, Carmen came up with a program for indigents with the government-run Philippine Health Insurance Corp. Through the program, a patient can avail of the Maternity Care Package that covers the first three deliveries, newborn screening, laboratory works, accommodation, medicine, and the P500 user’s fee.

VALLEHERMOSO remains one of the most densely populated barangays in Carmen. More than half of its population live below the poverty line. [photo by Avie Olarte]

That’s not all: Carmen is also one of only three towns in Bohol that have adopted a Reproductive Health Care Code; Bohol province itself has yet to pass one.

Carmen’s code mandates, among others, that women must have access to safe and quality reproductive healthcare services and that there should be a continuous planning, implementation, and monitoring of effective reproductive-health programs.

The code also ensures a steady stream of funding for reproductive health services, on top of the P50,000 allocated for the reproductive health advocacy program. A look at the town’s spending pattern shows that it allots an average of nine percent every year for health services compared to an average of four percent for infrastructure. (In most towns in Bohol, as in many local governments, building roads and bridges is prioritized over health and social services.)

For sure, though, the code has its critics. Some church workers have called its proponents “devils” and even launched a radio program to discredit the local officials pushing for it. One official who suffered such a backlash is Nathaniel Binlod, a two-term town councilor and chairperson of the town’s health committee. He almost lost in the 2007 elections, he says, for openly advocating and raising awareness on reproductive health and population management.

“I’m not for abortion,” says Binlod, who was born and raised in Carmen. “What I’m campaigning for is responsible parenthood. Two to three children are enough.” (The average family size in Carmen at present is 5.3.)

ACCESS TO reproductive-health services in Carmen comes in the form of making contraceptives available to the public. Together with the United Nations Population Fund (UNFPA) — with which it has partnered for such things as the ambulances and setting up barangay birthing centers — the town has built a Pop Shop that sells condom and pills at lower prices than those at retail stores.

HEALTH workers keep track of the condition of pregnant women in Vallehermoso. [photo by Avie Olarte]

The RHU itself allots P50,000 to P75,000 a year for buying contraceptives alone. The award-winning facility even has a Family Planning Room where couples can consult with a doctor regarding which family planning method would be best for them.

More Pop Shops are already being put up in the barangays. But women like Beatriz Manda, a 44-year-old mother from Vallehermoso, are unlikely to step foot into one unless they visit a local health unit first.

Manda says the natural way doesn’t work for her and her husband, because she has irregular periods. They already have 11 children, with the youngest only five months old.

But it may take some doing before she and her husband consider artificial family planning methods. “I’m afraid of the IUD (intrauterine device),” says Manda. “My husband meanwhile doesn’t like the condom, he says it might slip off.”

Someone also told her that once she has had a ligation, she wouldn’t be able to help her husband in the farm anymore.

Manda confesses that she has not paid a visit to the barangay’s midwife, who could help clarify common misconceptions on artificial family planning methods. But she says she is planning to go one of these days.

CONDOMS and birth-control pills can be bought for a cheaper price at Popshops. [photo by Avie Olarte]

If she opts to go to the RHU, she may just bump into Lilia Ancog, the mother who just gave birth there. Ancog is planning to visit the town doctor again as soon as she has had a few days of rest. She says she and her husband need a family-planning method aside from the natural way, which doesn’t seem to work for them. Her husband wants a fourth child, but Ancog says they can afford only three.

As for Jesusa Panes — the pregnant woman who with her drunken hilot walked all the way from her home to the barangay health center — she reached the place in one piece, the baby still safe in her tummy. And while she was sweating profusely when she arrived and was visibly worried that she would give birth any minute, she seemed to calm down somewhat after she downed a glass of spring water. As people fanned her, Panes politely declined offers to bring her to the nearest hospital, saying the midwife would take good care of her.

She later gave birth to a baby girl, her fourth child. Mother and newborn daughter are doing fine.

TAKEN BETWEEN MAGSAYSAY AND DAVAO. Maybe there would be more smiling faces if it had been taken in Magsaysay. [photo by Red Batario]

Everything was different yet the same. The smell of early morning cooking — fish stew called tinowa simmering in an earthen pot — was a welcome greeting as we crested the last hill of the village. The same puny shrubs snagged our pants and the same emaciated dogs sniffed our legs. But where were the furtive glances, the scurrying away at the sight of strangers, the palpable presence of fear, or the guns openly wielded by almost everyone?

This was, after all, North Upi, a Maguindanao mountain town only 36 kilometers away from Cotabato City with a long history of war and conflict. We had been here in the late ’80s doing a story on internally displaced persons, victims of war. It was also here, in a small schoolroom with bullet-pocked walls, where we were held overnight by armed men incredulous at the tale of two journalists who walked for a day but wished only to do a story and nothing else.

We’ve always had this fascination with what’s going on in faraway communities, lured by the idea of living out of a suitcase. But we’d inevitably find ourselves repeatedly crossing the line between journalism and development work and, along the way, seeing little difference between the two.

As most journalists go, we had been trained to nose around, dig deep, unearth wrongdoing, write about problems, tell the public what’s wrong as truthfully as possible, especially about governance. But our journeys revealed that there was more to what we were reporting on, that some things were working in many small communities, that citizens and leaders were by themselves finding solutions to problems — that governance, at least in those places where our footloose nature took us, seemed to be working well. We were doing only part of the whole story.

Now we were retracing our footsteps, trying to bear witness to the transformation we had written about earlier. In many ways, our trip back was to validate in our heart of hearts that what we had seen years before had translated to self-sustaining, autonomous, and forward-looking communities. But the truth was, we weren’t really sure what we would find.

AND SO there we were, back at North Upi. We listened to the coughing of a truck engine, half-expecting a burst of gunfire to erupt at any moment. That was how we got stuck in that school up in the mountains years ago. But instead of gunfire, we now heard the gay chatter of children at play. We turned to look at them; behind the children, we noticed the newly painted office of DXUP FM, the station that Upi townsfolk proudly referred to as “our Peace Radio.”

Mayor Ramon Piang said the establishment of the radio station in North Upi was pivotal in addressing “our town’s most pressing concern…peace and order.” People need to know what’s happening the quickest way possible about local initiatives to bring peace to a seared land, he said. The programs do not focus on conflict like clan wars, but discuss the indigenous ways by which these can be resolved. “It is sort of facilitating,” explained the mayor.

The radio was only one result of Piang’s efforts in reshaping the governance landscape of North Upi, not through gunfire, but through dialogues and community consultations. After his election in 2001, he had asked the help of nongovernmental organizations (NGOs), church leaders, lumad elders, Muslim clerics, and businessmen to form the Mayor’s Advisory Council to arbitrate local conflict — but “not act as a court” — by integrating formal justice mechanisms and indigenous justice systems.

It didn’t take long for citizens to explore other avenues for participation, which Piang encouraged. They put up a Kapihan ng Sambayanan (community roundtable) to debate local issues and to examine and assess local government performance. What is not surprising is that discussions tended to focus on how to meld peace and development in the town. The Kapihan had limited impact, though, and larger implications of the issues discussed did not get wider public attention. So was born the Peace Radio through the formation of the Community Media Education Council composed of multi-sectoral representatives and chaired by the vice mayor.

The council sets the policy direction for the station and brings in multicultural voices into its programming. Many of its staff members are volunteers who were sent to training workshops around Mindanao.

It’s a good thing people in North Upi simply love to talk. By around 10 in the evening of our return visit, we were ready to call it a night — but people were still chatting around the town plaza bathed in light. A stiff breeze blew into the valley carrying the whispers of distant mountains. We spent the night in North Upi lulled to sleep by the stars we could see from our open window.

Magsaysay on our minds

“Can you see that curve in the road down the mountain?” she asked. “That’s where we’ll have to wait for the jeep that will take us to the junction.” Which was about an hour’s walk away. Sweet penalty for having started off late and for not eschewing breakfast.

We were headed for the town of Magsaysay in Davao del Sur, a place we could scarcely remember, having seen countless others wrought in the same small-town layout and architecture. What we could recall were the endless rice paddies and its old, quaint name, Kialeg, referring to a B’laan chieftain noted for his bravery.

The B’laan and other indigenous peoples like the Bagobo had long since retreated to the remote hinterlands from where they make contact with the rest of the townsfolk through tribal councils that they helped set up with Magsaysay’s local government.

Late afternoon found us in Barangay Kasuga where residents were rushing to have their teeth fixed, pay their residence tax, get their children’s birth certificates, request for seedlings, or have their animals vaccinated. Tomorrow the government was moving to another barangay, bringing with it essential basic services that people in remote areas find difficult to access. The mayor, Arthur Davin, called it Paglilingkod Abot Kamay (PAK, or Service Within Reach), a simple, no-frills approach to service delivery.

Town officials were obviously proud not only of PAK, but also of their other programs that they said were developed with the help of civil-society groups and other sectors that made up Magsaysay society. PAK and other programs like the Integrated Pest Management (IPM)-Diversified Organic Farming System (DOFS) were later incorporated by Mayor Davin in his Executive Agenda (EA). The EA spells out the local chief executive’s governance blueprint.

An elderly woman, lips red with betel chew, gave us a toothless smile when we asked her what she thought of the local government’s programs and services. She then pointed to a sari-sari store where a teenage boy was arranging on shelves newly milled upland rice in one-kilo plastic bags. We took a closer look and lifted one of the bags with “MagRice” printed on the stick-on label.

“Our very own Magsaysay rice,” said the woman, who was fondly called by neighbors Onor or Yonor — we couldn’t be sure, given the noisy exchanges going on among the women around the store.

What we did gather was that MagRice was not only developed to address poverty issues in the municipality by eliminating middlemen and providing farmers direct trading conduits, but also was an important result of the organic farming system introduced by the local government.

We also found out that despite initial difficulties like identifying markets outside the municipality, MagRice is now being exported to cities like Davao and Cebu with the help of the Magsaysay Self-Help Cooperative, which was put up by a local NGO and supported by the local government.

Over dinner that night, we couldn’t help talking about Magsaysay and its will to make things work without much external assistance. Its secret, we agreed, was getting people to understand that governance is all about sharing a common dream or vision for the community and of seeing that this is realized in the end with everyone’s participation.

“Are there others like Magsaysay?” We left the question hanging as we packed our bags for Bohol in the Central Visayas.

Charmed by Catigbian

UNUSUALLY HUGE waves slapped the hull of the fast watercraft from Cebu. We could feel their jarring impact down to our feet. It wasn’t always like this during our travels to Bohol, when calm waters swiftly carried us in less time than it takes to finish a VCD movie to the port of Tagbilaran.

We peeked through the fogged up windows, trying to make out the outlines of Tubigon where we were supposed to disembark. Rain began to lash the boat. But just as suddenly it stopped and we were mooring at the small pier lined with food stalls. We had never taken this route before and we felt a sense of adventure as we stepped off the gangplank.

We’d traipsed much of Bohol years ago and were proud to have, at one point in our peripatetic lives, participated in the province’s crafting of its environment code, the first in the country in the late 1990s. It was a time of much hope for what the Local Government Code, the decentralization law of 1991, could offer by way of opportunities for popular participation. Bohol was at the forefront of reinventing governance then. Now we hoped to see its impact on local communities.

A friend, journalist Diosa Labiste, had written an interesting piece about health and governance in Catigbian, a little-known place in Bohol. Here’s her introductory note: “While easily reached from Tagbilaran and Tubigon, the two major trade and transit points, Catigbian seems remote because of the sorry state of its roads, its poverty, and reputation as rebel-infested. It is said that only a Catigbianon loves the town that was bypassed by progress, if, among others it means potable water and the absence of malnutrition and other preventable diseases.”

True enough, we were soon replicating our bumpy boat ride on a van that had seen better days for the place we hoped we could love as well as one of its natives.

In Barangay Triple Union, we ran into Virgilia Sequina, a community leader who manages a Botika sa Barangay. A very busy woman, she also heads the Health Leaders Association and is active in the Department of Health-LGU’s Leaders for Health Program that brings together the mayor, town doctor, and community leaders to reinvent healthcare delivery. Through the program, the mayor and the community leaders attend a Certificate Course in Community Health Management at the Ateneo Graduate School of Business, while the doctor takes up a Masters in Community Health Management, also at the same school.

With many barangay folk suffering from preventable diseases and more than 850 children out of 3,331 in 2003-2004 weighing below normal, health was a governance priority in Catigbian. With the program’s introduction finally came a doctor who wanted to stay.

IT WASN’T easy at the start, and people like Sequina were skeptical that the newly elected mayor would be able to work with the doctor and community leaders almost like equals. The health center was a sorry mess and health workers were demoralized. But the mayor, said Sequina, was driven by a “mission and vision” just like the vice mayor, who understood quickly enough that waiting sheds could wait but health couldn’t.

One of the first things Roberto Salinas did as mayor of Catigbian was to ensure that the town’s two ambulances were used only for medical emergencies and not to ferry officials to fiestas and functions.

The program encourages the integration of health in the development agenda through needs identified in the barangay-development plans. It also ensures greater transparency, accountability, and efficiency by allowing spaces for participation by the volunteer doctor who is expected to stay for four years, the community leaders, and other governance stakeholders in developing the town’s health agenda.

During our visit, we found the Triple Union barangay health workers — all volunteers — preparing to conduct one of their regular village visits to give lectures on breastfeeding, sanitation, and the proper use of toilets. It was but another busy day, but we noticed a lightheartedness in the way they went about their tasks.

We asked one volunteer why they seemed so happy. Her reply: “Not only do we now have a new health center and renovated public market, we also have a doctor who even goes to the remote sitios and a mayor who believes that people’s health should be a governance priority.”

Soon the same decrepit van that brought us there heaved into view. But before we could board it, one of the health workers came up to us and said, “The changes you see here…the newly-painted office buildings and health center…are the physical ones but what had happened here in Catigbian is really all about changing our own mindsets and attitudes about how to govern a town.”

Suffice it to say that like any other Catigbianon, we’d fallen in love with the town.

As we headed for Cebu on the last leg of our journey, it dawned on us with amazing clarity that local governance is not about managing the affairs of the community, implementing programs, or crafting policies.

Sourcebooks and handbooks for local chief executives define governance as the act or process of governing through the exercise of governmental powers such as police, taxation, and eminent domain in the maintenance of the affairs of the state. It is also argued that governance is not the sole domain of government and that there should be a continuing interaction and cooperation of civil-society organizations and the private sector with government in crafting policy and implementing programs.

It is said as well that the context of governance arises from the understanding that sovereignty resides in the people and that public officials citizens elect and to whom they delegate power and responsibility are merely stewards of this power and are therefore accountable to them. It should also be understood that governance and participation are mutually reinforcing.

From our brief encounters with local folk in several small communities around the country, we’ve come to the conclusion that local governance is all about developing the capacities of people to fulfill their obligations and claim their rights while opening spaces for their meaningful participation. It is all about harnessing the potential of citizens to build community by sharing a dream. It is all about leaders who listen to the people they lead and who understand that steering well is better than rowing hard. The good thing about it is that it is happening in many parts of the Philippines.

Eternally optimistic, we are hoping the same thing could happen at the national level.

Victor & Adelle were the pseudonym used by Red Batario and Girlie Sevilla Alvarez when they were writing the column “On the Road with Victor & Adelle” for the Manila Chronicle. They currently head the Center for Community Journalism and Development (CCJD) as executive director and program director, respectively. They also consider themselves occasional journalists, since much of their time is now devoted to training other journalists.

Typical rural scene of the health department’s Ligtas-Tigdas campaign

ALLAN EVANGELISTA of Quezon City signed up with the Doctors to the Barrio program last year despite suffering from dilated cardiomyopathy, an incurable disease of the heart muscle that actor Aga Muhlach introduced to Filipinos through his 2004 movie “All My Life.”

This “walking time bomb” has had four attacks since being assigned in September to Catigbian, Bohol, an interior town 34 kilometers from Tagbilaran City. He has also experienced working under a mango tree for two months while his rundown health center was being repaired.

But the young doctor still counts himself lucky, and not only because he finds his work fulfilling. Last November, he asked and got a whopping 230 percent increase in the budget of his rural health unit.

The local government had been determined to impose austerity measures, and what ensued was the longest budget hearing the town ever had. Evangelista, however, was able to convince the town officials just how badly Catigbian needed health programs, including the appropriate medicines, for its people. His RHU was the only unit in the local government that was granted an increase.

Many of Evangelista’s colleagues in similar posts across the country have not been as fortunate. In fact, local governments often give low priority to health, and allot health services and programs sums so paltry that health centers practically have to beg for donations from patients, most of whom are indigent but still give anywhere from P1 to P10 each.

Combined with corruption and shameless politicking by local officials, the meager budgets for health have led to a frequent lack of medicines in health centers, among other things. Local health workers have also been denied many of the benefits they are entitled to under the law because of the lack of attention paid by local governments to health.

Mayors and governors have long given the more visible and more corruption-prone infrastructure projects top priority. To the dismay of public doctors and other health workers, the devolution of health services in 1993 hasn’t altered that mindset. Nine surveys of 80 towns and 301 barangays done in 2000 by the U.S.-based Center for Institutional Reform and the Informal Sector (IRIS), show local officials still emphasizing infrastructure over health, new jobs and aid to the poor.

First- and fifth-class municipalities alike complain about the lack of funds for health, according to a 1998 study done for the World Health Organization. Note the authors of the study: “There seems to be a lack of political will to allocate additional funds for health since it is commonly perceived that additional expenditures for health are not capable of turning in the votes. People normally consider the infrastructure record of candidates as basis for solid achievement.”

They further surmise, “Because of the old centralized setup where health is the responsibility of the Department of Health, people are not used to making health an issue during elections. Local political candidates who are re-electionists normally cite their public works record as measure of their performance. Even barangay officials use their local funds to construct waiting sheds, basketball courts instead of spending them for health.”

Doctors also complain of what they describe as the “narrow perspective” of local officials toward health. “It must be curative rather than preventive,” says a paper of the nonprofit Institute of Public Health Management, quoting doctors who have attended its health and governance conferences. “The notion that health is merely the absence of disease still prevails among the local chief executives and their constituents.”

Almost always, a town’s budget for the RHU is quickly eaten up by salaries of health personnel. In 2003, personal services accounted for nearly 80 percent of the towns’ combined P4.68 billion appropriations for health centers. Maintenance and other operating expenses or MOOE, which fund health programs and the purchase of medicines and supplies, made up only a fifth of the budget.

The budget of an RHU, especially those that have been doctorless for some time, could be as small as P50,000 a year, says Maritona Labajo, assistant director for field operations of the Leaders for Health Program, which allows barrio doctors like Evangelista to earn a master’s degree in community health management from the Ateneo de Manila University. Yet, points out Labajo, the same town may allot P500,000 to P1 million to buy medicines but put this not in the health budget but in the mayor’s discretionary fund, over which the local physician has no control.

This has resulted in municipal and urban health doctors being forced to innovate because of lack of medicine. A doctor in Laguna, for example, has resorted to giving tablets in place of suspension fluids as an antibiotic for toddlers. “I tell the mothers to cut the tablet into half,” says the doctor, “and mix it in glass of water with sugar.”

Other physicians recommend the use of herbal plants like oregano, a substitute for cough syrup, or lagundi for treating boils because their RHUs do not have the manufactured medical treatments.

Pork-barrel allocations of congressmen sometimes enable RHUs to have the medicines they need. The Department of Health (DOH) also distributes drugs in line with national health programs, aside from the usual anti-tuberculosis drugs, vaccines and micronutrients. But local health units rely mainly on their internal revenue allotment and locally generated funds to purchase medicines and supplies.

Yet since many doctors are hardly involved in the local budgeting process, it is difficult for them to lobby even for just the basic things needed by their RHUs. A Central Visayas-based municipal health officer remembers getting this instruction from his mayor when he was preparing the budget: “Just make sure na maswelduhan kayo (you all get your salaries). Don’t worry about the programs.” And, indeed, hardly any money went to the health programs of the fourth-class town.

An RHU in Rizal province, meanwhile, was given a budget so tiny it couldn’t even buy cotton. A Bicol RHU’s budget had no money allotted for soap, disinfectant, even writing paper.

The physical condition of RHUs is sometimes a good indicator of how much — or little — importance the mayor attaches to health. Richard Lariosa, who signed up with the Doctors to the Barrio program in 2001, was assigned to Tagapul-an, Samar, where he found himself seeing patients in a tiny room in a building that had windows that were falling off and a leaking roof.

The first thing Lariosa had done shortly after he arrived in Tagapul-an was to ask the mayor to repair the RHU while awaiting a P3-million new health center the Japanese government had pledged to build. When Lariosa was pulled out of remote Visayan town late last year, the mayor had yet to act on his request, and Japan had not released the promised funds. “We tried to patch the roof, but Vulcaseal didn’t work well,” Lariosa says.

But that was not all Lariosa had to put up with. The solar-powered vaccine refrigerator at his RHU kept breaking down, causing the vaccines to spoil. Exasperated, Lariosa stored them in a canteen operator’s fridge. “It wasn’t ideal because you shouldn’t be opening the ref as much as possible,” he says. “But I didn’t have a choice.”

Lariosa also found he was entitled to only P5,000 a year for travel and RHU’s midwives, P3,000 a year. As the RHU did not have its own boat, it had to rent one for P500 a day to visit the barangays. To stretch the budget, Lariosa and his staff pooled their travel allowances and conducted team visits so they could make regular rounds of Tagapul-an.

But it is the failure of many provinces, cities and towns to fully implement the Magna Carta for Public Health Workers that has convinced local doctors and health workers of the local governments’ neglect of the health sector.

Passed in 1992, Republic Act 7305 mandates a host of benefits not only for government doctors, nurses, midwives, dentists, barangay health workers, and sanitation inspectors at both the national and local levels. The benefits include hazard pay, laundry allowance, subsistence allowance, holiday pay, and even remote allowance or medico-legal allowance.

Health personnel in the national government’s payroll, including volunteers under the Doctors to the Barrio Program who are also known as rural health physicians, enjoy the full benefits provided by the Act. Majority of local health workers, however, do not.

For municipal health officers in poor towns, failure to fully implement the law has resulted in a bigger discrepancy between their pay and that of the DOH-hired rural health physicians. As things stand, many of them receive just more than half of the P20,824, basic monthly salary received by rural health physicians.

A number of barrio doctors fielded by the DOH have ended up fighting for the benefits of their RHU staff. Dorie Lynn Balanoba, who was in the first batch of 46 doctors sent to the countryside under the program in 1993 and now works at the DOH central office, led her staff in Jipapad, Eastern Samar in going on a two-week sick leave in 1996 to force the town treasurer to release the benefits due them.

In some towns, health personnel have filed administrative or court cases against their mayors. Alas, the courts have junked some of these cases, including the one initiated against the former mayor and treasurer of Catigbian by the municipal health officer who preceded Evangelista, the doctor with the heart disease. With the case under appeal, the new mayor has elected to observe the status quo. This leaves Evangelista in a bind whenever his RHU’s nurse and midwives pressure him to work for the release of their benefits.

Most, if not all, of the towns in Bohol have yet to fully implement the law, observes Evangelista. This appears to be the case for most parts of the country, he says.

Last September, the Association of Provincial Health Officers of the Philippines (APHOP) issued a manifesto addressed to President Gloria Macapagal-Arroyo, complaining that the Magna Carta has yet to be fully implemented.

Health workers complain that mayors and governors often mouth the famous line “subject to availability of funds” to justify the Act’s partial implementation. Yet they note that many local governments violate a Department of Budget and Management circular for mayors and governors to first appropriate the Magna Carta benefits in their budget before providing other nonmandatory salary items.

“The problem with devolution is that health personnel were not trained to deal with the (local governments),” says Nemecia Mejia, former provincial health officer of Pangasinan. Still, not everyone has had to just grin and bear the dire consequences of decentralization.

Municipal health workers in Pangasinan, for example, have had an easier time coping with the changes because some hospitals maintained an informal relationship with the rural health centers after devolution. Pangasinan was also among the pioneer provinces that enforced the DOH’s Health Sector Reform Agenda (HSRA). Implemented in 1999, the HSRA sought to improve the financing and delivery of health services.

The HSRA, among others, encourages the creation of “inter-local health zones,” or districts or catchment areas composed of neighboring municipalities with the aim of improving cooperation among themselves on health matters. In Pangasinan, a core hospital is in charge of one health zone. Mejia says the chief of hospital helps municipal doctors advocate for local programs and reforms to their mayors.

The HSRA, which has reforms in hospitals as one of its components, also allows for a systematic pooled procurement in provincial hospitals. Mejia says the bidded price in Pangasinan went down by more than half through bulk procurement.

The hospital and provincial therapeutics committees in the province oversee the procurement of drugs starting from the annual procurement plans of the 14 hospitals. This is to ensure quality of drugs and the procurement of drugs at lower costs. But Mejia explains they have yet to convince the municipalities to adopt a similar system. With money involved, she says, procurement has become a very sensitive issue.

The least the hospitals could do, says Mejia, is to refer the winning bidders to the municipalities and have them adopt the bidded price. “They don’t have to undergo another bidding because it was already bidded out in the provincial level,” she says. “We would like this to be implemented in the lower-class municipalities with very meager budgets.” — with Avigail M. Olarte