Understanding health care decentralization as a community-specific process: The case of the Philippines

The Philippines provides an interesting case example of the impacts of health care decentralization to community levels. In decentralization, authority, responsibility, and accountability for the planning, financing and management of public services are transferred from the state to more local administrative or sometimes non-governmental levels. In the Philippines, health care has been decentralized to community levels. The goal of decentralization in the Philippines was to delegate powers, functions and responsibilities to the local authorities in light of better service delivery, allowing communities and municipalities to more or less govern themselves. However, in qualitative research conducted over 22 months in rural communities of the Philippines, inequitable distribution of knowledge and material resources in communities that were already receiving unequal government funding resulted in major challenges in local health care from decentralization processes. In the communities observed we found that health care decentralization did not foster greater physical and financial access to local health care. Nor was decentralization desired or sought by the communities examined; problematizing the community participation discourse that communities inherently welcome the responsibilities of decentralization. Furthermore, decentralization magnified existing inequities between communities and did not necessarily result in more horizontal control of health care due to the hierarchies of elites at local levels. We conclude that in order for health care decentralization to community levels to be more feasible, proper knowledge and material resources need to be distributed equitably amongst communities and communities require more input regarding their willingness and ability to be responsible for community health care.