By Vanessa T. Siy Van (Health Sciences Program, Ateneo de Manila University) and Jhanna Uy (Research Department, Philippine Institute for Development Studies; Health Sciences Program, Ateneo de Manila University)
What is Multisectoral Governance?
Since the twentieth century, governments have recognized that health is as much a product of social, economic, and political conditions as it is of health system performance. Many of these determinants fall outside the purview of health programs, and thus improving health requires multisectoral action. In the case of reproductive health (RH), multisectoral action is instrumental to not only improving indicators such as maternal and child mortality, but also empowering individuals and the sustainable growth of populations, human capital, and economies. However, governing multisectoral action has historically been difficult, especially in low-and-middle-income countries (LMICs) because of weak public administration, chronic underfunding, and limited skilled human resources. While laws are usually deemed the most formal and binding form of policy, many LMICs struggle with obtaining the commitment of non-health sector leaders to commit and operationalize policy implementation in their spheres. Such has been the case for the Philippines, where we found that even with a policy-neutral, rights-based national law, the interest and buy-in of non-health state actors cannot be assumed. The case presents lessons for implementing multisectoral policies, as the presence of policy may not always translate into practice.
Philippines’ Reproductive Health Law
The Philippines is a unitary democratic LMIC where legislation and priority-setting are done at the national level, and social services are decentralized to regional offices and delivered by local government units (LGUs). The Responsible Parenthood and Reproductive Health (RPRH) Law of 2012 was passed in this context after decades of opposition and public debate. Immediately after passage, the RPRH Law’s enactment was delayed twice by the judiciary. Only after concerted efforts by national government agencies (NGAs), civil-society organizations (CSOs), and multilaterals, restrictions were lifted in 2017. Despite these challenges, the law remains one of few national RH policies in Southeast Asia and is celebrated for its explicit call for collaboration among health, education, economic, and social welfare sectors. However, nearly a decade later, the landmark legislation did not translate into significant improvements in RH outcomes: maternal mortality is twice that of the target set by the Sustainable Development Goals; Philippine HIV incidence is one of the fastest-growing in the region; and in 2020, a-third of Filipino children were stunted.
Challenges of Putting Policy into Practice
Through semi-structured interviews with national RPRH implementers, we examined national multisectoral governance practices and identified intersectoral coordination challenges. These were supported with document reviews and meeting transcripts of the RPRH National Implementation Team (NIT), composed of government agencies, CSOs, and multilaterals.
Our analysis found three main themes over seven years of RPRH operations:
1.National leaders, particularly the health sector, were unable to rally non-health sector actors around RPRH.
- Despite a lack of conflicts in sector objectives, there were no concrete strategies and operational plans for integrated RPRH service delivery across sectors.
- Most NGAs did not make formal changes to their organizational structures for RPRH activities, dedicate funds for RPRH, or develop intra-agency policies to institutionalize RPRH, causing delays in program implementation.
- The NIT’s Planning, Monitoring, and Evaluation Guide was developed in 2015 after implementation had already begun. The guide does not prescribe concrete targets and meeting mandates are left to the discretion of individual organizations.
- Multisectoral collaboration was hindered by pressure to preserve each agency’s image and NGAs’ frequent leadership and priority changes.
2.NGAs channel multiple paternalistic directives for RPRH down to smaller subnational units with larger burden for implementation but limited human resources.
- In the Philippines’ decentralized government, one LGU is expected to implement multiple parallel programs from over a dozen NGAs.
- Poorer LGUs must forgo some programs and responsibilities or be reliant on NGA resources for RPRH, which themselves are not stable.
- Due to their legal autonomy, LGUs have only weak accountability to national and regional offices; LGUs are also unrepresented in the NIT.
3.CSOs were important partners in implementation, but failure to manage their expectations and conflicts of interest decreased the effectiveness of the NIT as a platform for multisectoral governance.
- Given variability of LGU performance, CSOs were invaluable local implementation partners.
- However, CSOs had private, community-level interests that occasionally put them at odds with national priorities, making NIT unconducive for coordination.
Lessons for the Future
The absence of multi-agency plans, targets, and accountability systems fostered a culture of siloed opportunism. Local resource limitations associated with decentralization were exacerbated by paternalistic financing, coordination, and monitoring. Conflicts in interests and perspectives between state and civil-society actors went unmanaged. Future policy responses built on these system failures, as opposed to first addressing them, will contribute to inconsiderable gains in RH over the next decade. Formal legal policies alone are insufficient to institutionalize whole-of-government action. Advocacy and intersectoral discourse can bridge sectors’ understanding of the scope and depth of the problem, in line with WHO’s recommendations to make health equity a government-wide indicator for national development.
Image credit: Wayne S. Grazio