Ilocos Sur

How an Ilocos Sur town became a model for decentralized health services

Sherwin de Vera
How an Ilocos Sur town became a model for decentralized health services

SCENIC TOWN. The town hall of Santa, 4th class town in Ilocos Sur with 26 barangays bounded by the Abra River in the North, Mount Tetas de Santa in the East and the West Philippine Sea in the West.

The innovations of Santa's health program spare the poor from tedious rounds of begging for aid around the offices of local officials, and also slashes the risk of fraud and corruption

ILOCOS SUR, Philippines – The scene at the mayor’s office at the municipality of Santa in the morning of August 30 was typical of many rural towns across the country: several residents in need of medical financial assistance crowded the anteroom.

Manang Esmenia Claveria was caught in the crush of help seekers. Her grandchild, Grezelle, was in the hospital for an eye infection. Esmenia had a payment deadline.

“I am still P3,000 short after the hospital deducted the discount for 4Ps beneficiaries,” she said in Ilokano, handing over documents to the mayor’s secretary. 

Esmenia didn’t get cash. But after a short exchange about her grandchild, the person in charge handed over a piece of paper. With it, she could settle the hospital bill.

It was Esmenia’s first time accessing the local government’s hospitalization assistance.  

“My neighbors, who received assistance in the past, told me about it. They said processing is fast and easy,” she answered when asked how she learned about the program. 

The document Esmenia received was a guarantee letter covering the hospital bill balance. 

“It is very helpful for people like us who lack the finances to pay for our hospitalization expenses. I hope to avail [myself] of the other services in the future,” she said.

Santa – a scenic town bounded by the Abra River in the north, Mount Tetas de Santa in the east, and the West Philippine Sea in the west – is not the only local government unit (LGU) that offers constituents medical financial aid.

But its innovations spare the poor the tedious, sometimes humiliating, rounds of begging for aid around the offices of LGU officials. Even better, its system drastically slashes the risk of fraud and corruption.

A 4th income class municipality with an average annual budget of P118.67 million for the past five years, Santa holds several awards from national agencies and private institutions for its Hospitalization Assistance Voucher Program.

The Department of Health (DOH) Region I in 2016 acknowledged Santa Cares, the town’s health and social services program, among the “best practices” by LGUs.

RECOGNITION. Santa’s health care programs earned the town several coveted awards for LGUs, and Dr. Cardenas attributes part of their success to the insights she and Vice Mayor Bueno gained when they participated in the Municipal Leadership and Governance Program of the DOH in 2015. Sherwin de Vera/Rappler
Starting small

“Santa Cares was conceived because of the limited budget that we had. Its purpose is to provide the best medical service to our residents while maximizing our resources,” Vice Mayor Jeremy Jesus Bueno III explained during our August 26 interview. 

It started with the hospital voucher program, made possible through a partnership with the Ilocos Sur District Hospital and the Gabriela Silang General Hospital (GSGH), Ilocos Sur’s provincial health institution. It was one of Bueno’s flagship programs as the mayor from 2007 to 2016. 

Former Ilocos Sur provincial health officer Dr. Carmeliza Singson in a 2016 video lauded Santa for having its  “own version of the Point of Care Program of PhilHealth.”

“This good practice of Santa could be replicated in the different municipalities in the province. We have been telling other municipalities and mayors about this practice so that they will not be burdened with the hospital bills of their patients,” Singson said. 

Bueno said the program’s main objective was to “ensure that needed assistance is immediately available.” 

“We do not want our residents to worry about the tedious process of preparing and releasing the cash assistance. At the same time, it guaranteed a better utilization of funds,” the vice mayor noted.  

“Since adopting the no-cash-out policy, we saw substantial savings because of the reduction of fraudulent claims, so we were able to create succeeding components for the program,” he added. 

Yes, aid handled right can still lead to savings. It allowed the LGU to forge another agreement with GSGH for diagnostic services. 

“But since there are some diagnostic services that the province cannot provide, we looked for private hospitals that were willing to enter into a MOA with the LGU. That is why we have this partnership with the Northside Doctors Hospital,” Bueno added. 

The latest addition to Santa Cares is the town’s Community-based Mental Health Service, established through Ordinance No. 428-2022, which the municipal council passed last March 14. 

Aside from partnering with mental health care providers, the mayor is also authorized to enter agreements with groups and institutions that provide similar services and advocacy. The LGU also intends to look for a psychiatrist willing to provide quarterly checkups for the residents.  

Investing for health 

Based on the Commission on Audit (COA) record, Santa has a P68.19-million annual budget. It allocated 5.3% or P3.12 million for health services when it started the hospital voucher program in October 2013. 

When Santa Cares launched in 2015, health services received 11.1% of the town’s P61.92 million budget. 

Since 2017, the allocation for health has been above the national average and DOH target of 15% for municipalities and component cities.

The 2020 LGU Health Scoreboard Annual Reports (LGU-HSAR) shows a national average per capita LGU health spending of P1,441.85. In the same period, Santa alloted P2,473.42 per resident.

The municipal health officer (MHO), Dr. Marilou Cardenas, believes equitable investment should be the LGUs’ primary consideration to be able to provide quality health service.

However, “before investing in infrastructure and equipment,” LGUs must ensure proper compensation for health workers, she stressed.

“It was the first thing that I requested when I came in as MHO head in 2014. I believe that our health workers cannot properly do their roles and meet our targets if we do not provide them proper compensation,” the doctor said. 

When the national government devolved health services in 1992, small towns struggled with the cost of taking over DOH functions.  

For example, the Magna Carta for Health Workers (RA 7305) requires the provision of full hazard pay, subsistence, and laundry allowances for permanent health personnel, on top of salaries.

After 30 years of health services devolution, only 63.9% of LGUs provide these benefits, according to the DOH. 

“Of the three Magna Carta benefits, about nine of 10 LGUs were able to provide laundry and subsistence allowance and about seven of 10 were able to provide hazard pay to their public health workers,” the 2020 LGU-HSAR report stated. 

Santa encountered the same difficulty. 

SCOREBOARDS. Evangeline Corpuz, Santa’s municipal nurse for 21 years, reviews the local government’s health evaluation forms and health scoreboard, which have mapped progress in the past seven years since the town started Santa Cares. Sherwin de Vera/Rappler

Rural health unit (RHU) nurse Evangeline Corpuz recalled that they started receiving a P500 hazard pay in 2014. In 2016, the LGU adjusted the said benefit as mandated by law, which is 25% of the basic income. However, the LGU based the computation on their 2007 salary.  

“During that time, we received an average of P2,500 hazard pay on top of our monthly salary,” she said, adding that “it was comforting that our officials tried to give what we were asking.” 

Santa health workers also received their night shift differential at a time when only 53.2% of LGUs in the country were providing full benefits, according to a DOH report. 

It was in 2019 that Santa health staff started receiving the full benefits from the law, a green mark in “Equitable Health Financing” in the 2020 DOH LGU Scorecard on Health.

Among the DOH metrics are an LGU health budget not lower than 15% of a municipality’s budget, the presence of a health investment plan, and the provision of health workers’ benefits under RA 7305.

A green mark means LGU performance is equal to or greater than the national target. 

Cardenas has already requested for additional personnel since Santa’s expanded RHU services are now available 24/7.

From 10, the municipal health office personnel became 28 since the Santa Cares program started. While 18 have job-order status, Cardenas said these employees receive appropriate compensation for their work.

The town now has two RHU buildings for its 14,992 residents – way above the 1 RHU:20,000 population required by the DOH. The LGU also maintains 26 barangay health stations. 

Reaping the fruits

Section 17.b.iii of the Local Government Code directs municipalities to put in place primary health care and maternal and child care programs, communicable and non-communicable disease control services, access to secondary and tertiary health services, and efficient systems for the purchase of medicines, medical supplies, and equipment.

Santa’s residents enjoy most of these. Aside from a secondary laboratory, a birthing facility, and free ambulance service, the town also provides comprehensive maternal and child care and an expanded immunization program. There are also regular midwives on duty in the barangays, with assistance from the DOH.  

UPGRADE. With the Department of Health’s assistance, Santa town upgraded its regional health unit building, adding more rooms as it expands its health services for residents. Sherwin de Vera/Rappler

In 2016, a year after Santa Cares’ launch, DOH Region I recognized the LGU during its annual Pammadayaw ti DOH “for excellence in health governance” and programs in support of the Philippine Health Agenda.

Several LGUs, like  San Esteban and Narvacan in Ilocos Sur’s 2nd District, have also adopted the town’s program as a template for expanding health services. 

Zuellig Family Foundation (ZFF) gave Bueno the Health Leadership and Governance Excellence award in 2016, and acknowledged his public health initiative in 2018 with an award for Outstanding Bridging Leader in Public Health.

The foundation cited measures instituted during his term to expand the local health board and craft barangay health governance plans. 

“Barangay health governance bodies were formed and a system for barangay health worker recruitment was identified…. Rates for facility-based deliveries and births attended by skilled attendants are both 100% as of the second quarter of 2018. The municipality has also maintained zero maternal death from 2015 up to the second quarter of 2018,” ZFF noted. 

In 2018, the National Nutrition Council gave Santa its third consecutive award for being a Consistent Regional Outstanding Winner in Nutrition.

The Santa RHU is also among the top-performing Basic Emergency Obstetric and Neonatal Care Facility and a certified Mother and Child-Friendly Health Facility. It has bagged the DOH’s Adolescent-Friendly Health Facility Level III award. 

Lessons and challenges 

“When funds are limited, LGUs need to be creative and discover the system that would best suit the needs of our constituents,” Bueno stressed.

Ensuring the budget and efficient program spending also requires keeping tabs on state auditor recommendations. 

“We instituted the voucher system because of COA’s reminder during the early part of the program that we cannot deposit funds and only pay when services are rendered,” the vice mayor recalled. 

Bueno also emphasized the importance of continuity. 

There are cases, he said, where programs change with the administration. 

“So it is important to institutionalize these initiatives through legislation. While there will still be challenges during the transition, the programs will remain intact,” he added. 

Cardenas cites Santa Cares as a “dream program for health workers, a womb-to-tomb service.” 

However, she still sees room for improvement. 

“Our programs and infrastructures are now in place to respond to the health care needs of the residents, so what we need to do is put more effort on the preventive side,” she said. 

“We need to reach out and empower the barangays, increase their funding and systematize their monitoring and reporting mechanism,” she added. 

Santa was way ahead of the curb in implementing the Universal Health Care (UHC) Law. It has shown that clear priorities and prudent management of funds can make health services in small and lower-income class municipalities at par with cities and towns in the upper economic strata.  

Santa Cares’ reforms give it an edge in integrating the local health system with the rollout of the UHC at the provincial level. While it still faces substantial investment challenges, the years spent building Santa Cares puts Santa at the top of its class.

But “there is nothing earthshaking” about Santa Cares, Bueno emphasized.

“These programs are actually not original. What Santa did was merely to organize, make sure that the funding is sufficient, and the programs are accessible for the people,” he added. –

This story was made possible through a grant by the Philippine Press Institute under the auspices of the Hanns Seidel Foundation.

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