The Practice of Power by Regional Managers in the Implementation of an Indigenous Peoples Health Policy in the Philippines

Document Type : Original Article

Authors

1 Department of Extension Education, College of Agriculture, Benguet State University, Benguet, Philippines

2 HPS Division, University of Cape Town, Cape Town, South Africa

3 London School of Tropical Medicine and Hygiene, London, UK

Abstract

Background
Indigenous peoples are among the most marginalized groups in society. In the Philippines, a new policy aimed at ensuring equity and culture-sensitivity of health services for this population was introduced. The study aimed to determine how subnational health managers exercised power and with what consequences for how implementation unfolded. Power is manifested in the perception, decision and action of health system actors. The study also delved into the sources of power that health managers drew on and their reasons for exercising power.
 
Methods
The study was a qualitative case study employing in-depth semi-structured interviews with 26 health managers from the case region and analysis of 15 relevant documents. Data from both sources were thematically analyzed following the framework method. In the analysis and interpretation of data on power, VeneKlasen and Miller’s categorization of the sources and expressions of power and Gilson, Schneider and Orgill’s categorization of the sources and reasons for exercising power were utilized.
 
Results
Key managers in the case region perceived the implementation of the new Indigenous health policy as limited and weakly integrated into health operations. The forms of power exercised by actors in key administrative interfaces were greatly influenced by organizational context and perceived weak leadership and their practices of power hindered policy implementation. However, some positive experiences showed that personal commitment and motivation rooted in one’s indigeneity enabled program managers to mobilize their discretionary power to support policy implementation.
 
Conclusion
The way power is exercised by policy actors at key interfaces influences the implementation and uptake of the Indigenous policy by the health system. Middle managers are strategic actors in translating central directions to operational action down to frontlines. Indigenous program managers are most likely to support an Indigenous health policy but personal and organizational factors can also override this inclination.

Keywords


  1. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374(9683):65-75. doi:10.1016/s0140-6736(09)60914-4
  2. UN Permanent Forum on Indigenous Issues (UNPFII). State of the World's Indigenous Peoples. 2nd ed. https://www.refworld.org/docid/55c89dac4.html.  Published 2015. Accessed October 23, 2019.
  3. Valeggia CR, Snodgrass JJ. Health of indigenous peoples. Annu Rev Anthropol. 2015;44:117-135. doi:10.1146/annurev-anthro-102214-013831
  4. Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study. Lancet. 2016;388(10040):131-157. doi:10.1016/s0140-6736(16)00345-7
  5. Department of the Interior and Local Government (DILG), Department of Health, National Commission on Indigenous Peoples (NCIP. Guidelines on the Delivery of Basic Health Services for Indigenous Cultural Communities/Indigenous Peoples (JMC2013-01). Published 2013.
  6. Belizario VY Jr, Totañes FI, de Leon WU, Lumampao YF, Ciro RN. Soil-transmitted helminth and other intestinal parasitic infections among school children in indigenous people communities in Davao del Norte, Philippines. Acta Trop. 2011;120 Suppl 1:S12-18. doi:10.1016/j.actatropica.2011.02.010
  7. Cariño JK. Country Technical Notes on Indigenous Peoples’ Issues: Republic of the Philippines. International Fund for Agricultural Development (IFAD); 2012. https://www.ifad.org/documents/38714170/40224860/philippines_ctn.pdf/ae0faa4a-2b65-4026-8d42-219db776c50d.  Accessed January 27, 2019. Published 2012.
  8. DOH (Department of Health). IP Health Strategic Plan. DOH; 2015.
  9. Reyes CM, Mina CD, Asis RD. Inequality of Opportunities Among Ethnic Groups in the Philippines. PIDS Discussion Paper Series No. 2017-42. https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps1742.pdf.  Accessed January 27, 2019. Published 2017.
  10. Marco JM. The Health and Nutrition Situation of Children and Women in Indigenous Communities: A Preliminary Review. DLSU-Social Development Research Center Technical Report; 1993.
  11. Millan DN, Go S. Indigenous health practices of the Bulacan Dumagat and the ideology of preservation/assimilation of modern health care system. The University of the Philippines Manila Journal. 2002;7(2):16-37.
  12. Palaganas EC. Transcultural caring among the indigenous people of the cordilleras. In: Ray MA, ed. Transcultural Caring Dynamics in Nursing and Health Care. 2nd ed. Philadelphia, PA: F.A. Davis Company; 2018.
  13. Makinde T. Problems of policy implementation in developing nations: the Nigerian experience. J Soc Sci. 2005;11(1):63-69. doi:10.1080/09718923.2005.11892495
  14. Erasmus E, Orgill M, Schneider H, Gilson L. Mapping the existing body of health policy implementation research in lower income settings: what is covered and what are the gaps? Health Policy Plan. 2014;29 Suppl 3:iii35-50. doi:10.1093/heapol/czu063
  15. Campos PA, Reich MR. Political analysis for health policy implementation. Health Syst Reform. 2019;5(3):224-235. doi:10.1080/23288604.2019.1625251
  16. Sriram V, Topp SM, Schaaf M, et al. 10 best resources on power in health policy and systems in low-and middle-income countries. Health Policy Plan. 2018;33(4):611-621. doi:10.1093/heapol/czy008
  17. Erasmus E, Gilson L. How to start thinking about investigating power in the organizational settings of policy implementation. Health Policy Plan. 2008;23(5):361-368. doi:10.1093/heapol/czn021
  18. Sheikh K, Porter JD. Disempowered doctors? a relational view of public health policy implementation in urban India. Health Policy Plan. 2011;26(1):83-92. doi:10.1093/heapol/czq023
  19. Hardy C, Leiba-O'Sullivan S. The power behind empowerment: implications for research and practice. Hum Relat. 1998;51(4):451-483. doi:10.1023/a:1016989830806
  20. VeneKlasen L, Miller V. Power and empowerment. PLA Notes. 2002;43:39-41.
  21. Orgill M, Gilson L. Policy implementation. In: Gilson L, Orgill M, Shroff ZC, eds. A Health Policy Analysis Reader: The Politics of Policy Change in Low- And Middle-Income Countries. World Health Organization; 2018.
  22. Lehmann U, Gilson L. Actor interfaces and practices of power in a community health worker programme: a South African study of unintended policy outcomes. Health Policy Plan. 2013;28(4):358-366. doi:10.1093/heapol/czs066
  23. Carrie H, Mackey TK, Laird SN. Integrating traditional indigenous medicine and western biomedicine into health systems: a review of Nicaraguan health policies and miskitu health services. Int J Equity Health. 2015;14:129. doi:10.1186/s12939-015-0260-1
  24. Llamas A, Mayhew S. "Five hundred years of medicine gone to waste"? negotiating the implementation of an intercultural health policy in the Ecuadorian Andes. BMC Public Health. 2018;18(1):686. doi:10.1186/s12889-018-5601-8
  25. Davy C, Harfield S, McArthur A, Munn Z, Brown A. Access to primary health care services for Indigenous peoples: a framework synthesis. Int J Equity Health. 2016;15(1):163. doi:10.1186/s12939-016-0450-5
  26. Gilson L, Schneider H, Orgill M. Practice and power: a review and interpretive synthesis focused on the exercise of discretionary power in policy implementation by front-line providers and managers. Health Policy Plan. 2014;29 Suppl 3:iii51-69. doi:10.1093/heapol/czu098
  27. Liwanag HJ, Wyss K. What conditions enable decentralization to improve the health system? qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines. PLoS One. 2018;13(11):e0206809. doi:10.1371/journal.pone.0206809
  28. Grundy J, Healy V, Gorgolon L, Sandig E. Overview of devolution of health services in the Philippines. Rural Remote Health. 2003;3(2):220.
  29. DOH (Department of Health). https://www.doh.gov.ph/.  Accessed October 26, 2019.
  30. Gilson L, Lehmann U, Schneider H. Practicing governance towards equity in health systems: LMIC perspectives and experience. Int J Equity Health. 2017;16:171.
  31. Yin R. Case Study Research and Applications: Design and Methods. 6th ed. London: SAGE Publications; 2018.
  32. Plant R. Indigenous Peoples/Ethnic Minorities and Poverty Reduction: Regional Report. Asian Development Bank; 2002.
  33. Gillham B. Case Study Research Methods. London: Continuum; 2000.
  34. Bowen GA. Document analysis as a qualitative research method. Qual Res J. 2009;9(2):27-40. doi:10.3316/qrj0902027
  35. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:10.1186/1471-2288-13-117
  36. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ. 2000;320(7227):114-116. doi:10.1136/bmj.320.7227.114
  37. Noble H, Smith J. Issues of validity and reliability in qualitative research. Evid Based Nurs. 2015;18(2):34-35. doi:10.1136/eb-2015-102054
  38. Cuenca JS. Health Devolution in the Philippines: Lessons and Insights. Philippine Institute for Development Studies; 2018. https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps1836.pdf.
  39. Dayrit MM, Lagrada LP, Picazo OF, Pons MC, Villaverde MC. The Philippines Health System Review. Vol. 8 No. 2. New Delhi: World Health Organization, Regional Office for South- East Asia; 2018.
  40. Barasa EW, Cleary S, English M, Molyneux S. The influence of power and actor relations on priority setting and resource allocation practices at the hospital level in Kenya: a case study. BMC Health Serv Res. 2016;16(1):536. doi:10.1186/s12913-016-1796-5
  41. Barrett SM. Implementation studies: time for a revival? personal reflections on 20 years of implementation studies. Public Administration. 2004;82(2):249-262. doi:10.1111/j.0033-3298.2004.00393.x
  42. Teo TC, Low KCP. The impact of goal setting on employee effectiveness to improve organisation effectiveness: empirical study of a high-tech company in Singapore. J Bus Econ Policy. 2016;3(1):1-16.
  43. Hill M, Hupe P. Implementing Public Policy: Governance in Theory and in Practice. London: SAGE Publications; 2002.
  44. Ham C. Governing the health sector: power and policy making in the English and Swedish health services. Milbank Q. 1988;66(2):389-414.
  45. Landsberg M. The Tools of Leadership: Vision, Inspiration, Momentum. London: Profile Books; 2002.
  46. Braynion P. Power and leadership. J Health Organ Manag. 2004;18(6):447-463. doi:10.1108/14777260410570009
  47. Rouleau L, Balogun J. Middle managers, strategic sensemaking, and discursive competence. J Manag Stud. 2011;48(5):953-983. doi:10.1111/j.1467-6486.2010.00941.x
  48. Gilson L. Everyday politics and the leadership of health policy implementation. Health Syst Reform. 2016;2(3):187-193. doi:10.1080/23288604.2016.1217367
  49. National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA . Cultural Safety Framework Summary. 2013.
  50. Fuller J. Intercultural health care as reflective negotiated practice. West J Nurs Res. 2003;25(7):781-797. doi:10.1177/0193945903256710
  51. McCalman J, Bainbridge R, Percival N, Tsey K. The effectiveness of implementation in Indigenous Australian healthcare: an overview of literature reviews. Int J Equity Health. 2016;15:47. doi:10.1186/s12939-016-0337-5
  52. Alves J, Meneses R. Silos Mentality in Healthcare Services. Valletta, Malta: 11th Annual Conference of the EuroMed Academy of Business; 2018. https://www.researchgate.net/publication/327838475.  Accessed June 2, 2019.
  53. Harfield SG, Davy C, McArthur A, Munn Z, Brown A, Brown N. Characteristics of Indigenous primary health care service delivery models: a systematic scoping review. Global Health. 2018;14(1):12. doi:10.1186/s12992-018-0332-2
  54. Gibson O, Lisy K, Davy C, et al. Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: a systematic review. Implement Sci. 2015;10:71. doi:10.1186/s13012-015-0261-x