Democratic Survivability and the Parliamentary Critique of the ...

JULY- DECEMBER 2 oo s VOL VII NO 2

Democratic Survivability and the Parliamentary Critique of the Presidential Form of Government in the Philippines CRISLINE G TORRES

Multiple Constituencies, Bureaucratic Efficiency and Rational Choice in Public Sector Management NICETO S POBLADOR

Mix of Resources in Seven Devolved Antique Hospitals and their Corresponding Output/Outcome Indicators, 1998-2002:

Policy Implications FERNANDO M SISON

FEMAN RENE M AUTAJAY

Mainstreaming the Rights-Based Approach in HIV I AIDS Prevention: Learning Experiences from the Philippines NYMIA PIMENTEL SIMBULAN

P~BLIC t'OLICY

................................................................

EDITORIAL BOARD Francisco Nemenzo Jr, Chairman; Emil Q Javier; Jose Abueva;

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Editorial Assistance: SELENA J SALANG

Design: ARIEL G MANUEL

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PUBLIC POLICY

CONTENTS

Editor's Note

Democratic Survivability and the

Parliamentary Critique of the Presidential

Form of Government in the Philippines

CRISLINE G TORRES

1

Multiple Constituencies, Bureaucratic Efficiency

and Rational Choice in Public Sector Management

NICETO S POBLADOR

37

Mix of Resources in Seven Devolved Antique Hospitals and

their Corresponding Output/Outcome Indicators,

1998-2002: Policy Implications

FERNANDO M SISON FEMAN RENE M AUTAJAY

63

Mainstreaming the Rights-Based Approach in

HIV I AIDS Prevention: Learning Experiences

from the Philippines

NYMIA PIMENTEL SIMBULAN

83

EDITOR'S NOTE

As the country appears headed for uncertain times because of a looming fiscal

crisis, the ability of government to get its act together and weather this storm is in

question. Opposing movements between the executive and legislative branches trigger

once again debates on political reforms. One such debate is between advocates of

a parliamentary form of government and proponents of the presidential system. In

a recent public forum, parliamentarists claimed they had a more receptive audience.

But the arguments for a parliamentary form of government, while very cogent and

practical at the same time, need to be re-examined. The paper of Torres assesses

the empirical evidence used to support claims of superiority of the parliament over

the presidential form of government.

The threat of a fiscal crisis has led to some soul-searching in the area of public

sector management. As public clamor intensifies, public managers are coming under

increasing scrutiny and pressure. Hence, Poblador's examination of bureaucratic

efficiency and rational choice in public sector management could not have come at

a better time. The paper affords the reader a lens with which to examine the

performance of bureaucrats and bureaucracies and an explanation for inefficiencies

endemic in public institutions, e.g., government-owned and controlled corporations.

The performance and economic efficiency of devolved hospitals are examined

by Sison and Autajay in one of the two health sector-related articles in this issue.

Examining such proxy indicators as bed occupancy rate and average cost per patient

per day, the authors studied seven devolved hospitals in the province of Antique

and drew some policy implications specifically hospital reforms related to hospital

finance and governance. The article also offers a glimpse of r...l,.e effects of devolution

on hospitals.

In the last article of this volume, Simbulan draws some interesting lessons

from the Philippine experience in combating the spread ofHIV/AIDS. Deviating

from the narrow view of HIV/ AIDS as a medical problem, Simbulan' s article

connects the disease to a host of other issues linked to national development. Thus,

the paper provides an approach to prevention that transcends the medical frontier.

JULY- DECEMBER 2003

P~BLIC t'OLICY VOLUME 7 NUMBER 2

Democratic Survivability and the Parliamentary Critique

of the Presidential Form of Government in the Philippines

CRISLINE G TORRES*

This paper assesses the argument of the superior democratic

survival record of parliamentary over presidential forms of government

in the comparative constitutional design literature used by Filipino parliamentary advocates in calling for a shift to a parliamentary form

of government in the Philippines. The paper does this by tapping the other side of the comparative constitutional design literature that is critical of the pro-parliamentary position. The main argument of this

literature is that the impressive empirical evidence used to support the

claimed superiority of the parliamentary over the presidential systems in ensuring democratic survivability suffers from fatal methodological

flaws. The paper argues that if these Raws are considerect they would have serious conceptual and policy implications to the proparliamentary position in the Philippines.

* The author wishes to acknowledge the research grant provided by the Commission on Higher

Education (CHED) through the Department of Political Science, University of the Philippines, Diliman.

Torres

Introduction

The claim by pro-parliamentary scholars that parliamentary democracies have

be'tter survival rates than presidential democracies constitutes the most devastating I

critique against the performance of presidential democracies. Because democracies

with presidential forms of government are said to be more prone to regime

breakdowns than democracies with parliamentary forms, the parliamentary form

of government is prescribed by pro-parliamentary scholars as both superior to and

more desirable than the presidential form of government in the all-important goal 2

of ensuring that democracies endure in the countries where they are found.

While this argument that presidential democracies are especially prone to

democratic breakdowns has a long history in the discipline of political science and

the broader constitutional design and institutional analysis literature,3

the current

... the central concern of constitutional design

scholars has been in terms of recommending a form of

government that would help promote the stability,

survival, and consolidation of these new democracies.

This revival of interest in searching for the superior

form of government specific to the recent wave of

democratization found its way to the Philippines, one

of the countries that democratized in the 1980s.

2

revival of this concern has largely been

fueled by the recent dramatic wave of

democratization which started in Southern

Europe in the mid-1970s, sped to Latin

America and Asia in the 1980s, and swept

Eastern Europe, the former Soviet Union,

and sub-Saharan Africa by the late 1980s

and early 1990s. 4

With this proliferation

of new (or renewed) democracies, the

central concern of constitutional design

scholars has been in terms of

recommending a form of government

that would help promote the stability,

survival, and consolidation of these new

d . 5

emocraCJes.

This revival of interest in searching for

the superior form of government specific

to the recent wave of democratization

found its way to the Philippines, one of

the countries that democratized in the

PUBLIC POLICY

Democratic Survivability and the Parliamentary Critique of the Presidential Form of Government in the Philippines

1980s. In particular, this search for the superior form of government is a central

component in the debate to change the Philippines' 1987 Constitution as this debate

has continued in the three successive administrations that came after President

Corazon Aquino-the 1994-1997 Charter Change ( Cha -cha) campaign under the

Ramos administration, the 1999-2000 Constitutional Correction for Development

("Concord") campaign under the short-lived Estrada administration, and the 2001-

2003 re-launching of the Charter Change (Cha-cha 2) campaign under the present

Arroyo administration.

In this debate to change the 1987 Constitution, Filipino parliamentary advocates

have praised the claimed superior democratic survival record of the parliamentary

form of government as one of the most important justifications for shifting the

Philippines' existing presidential form of government to a parliamentary one. In

arguing for their case that the parliamentary form of government would be more

conducive to the goal of democratic consolidation in the Philippines, Filipino

parliamentary advocates employ comparative insights into the form of government.

These insights are drawn not only from distinguished democratization scholars like

Juan Linz but also from constitutional design scholars like Alfred Stepan and Cindy

Skach, who collaborated to provide quantitative support to the Linz argument about

the superiority of the parliamentary form of government in ensuring democratic

survivability.

This paper argues that the claim made by Filipino parliamentary advocates of

the superior democratic survival record of parliamentary over presidential systems

has remained unchallenged for two reasons. First is the one-sided appropriation of

the comparative insights to the local debate on the form of government. While

Filipino parliamentary advocates are able to employ comparative constitutional

design literature to argue for the superior democratic survival record of the

parliamentary system, they fail to employ works that are critical of the pro

parliamentary position. For example, the important and influential works of scholars

like Mark Gasiorowski, Stephan Haggard, Robert Kaufman, Scott Mainwaring,

Timothy Power, and Matthew Shugart, have been ignored in the local forms-of

government debate.

VOLUME VII NUMBER 2 (July- December 2003) 3

Torres

Second is the failure both of the local opposition against the shift in form of

government and of the local skeptics of parliamentary democracy to confront head

on the theoretical validity of the democratic survival record of the parliamentary

democracies as advanced in the Philippines. Instead, the opponents and skeptics

of the parliamentary position have confined themselves to the argument that

constitutional change for the Philippines is not appropriate at this time since it will

be too divisive and disruptive to the nation's political life.

Given the one-sidedness of the constitutional change debate in the Philippines,

this paper undertakes the first step towards presenting the other side of the

comparative output on this issue of democratic survivability. This is done by

employing the comparative constitutional design literature critical of the pro

parliamentary argument on democratic survivability.

Employing this other side of the comparative literature to the presidential

parliamentary debate in the Philippines is crucial. Not...only would it inject a healthy

dose of skepticism to the claimed superior democratic survival record of the

parliamentary system but, more importantly, it will also offer a fuller appreciation

of the vast array of positions on constitutional reform issues. In short, it would

guarantee that the debate will not only be familiar with just one side of the

comparative argument.

Thus, by employing the comparative literature critical of the pro-parliamentary

position, this paper tries to answer two central questions: ( 1) how robust

methodologically is the scholarship of the comparative literature that argues for the

superior democratic survival record of parliamentary over presidential ones and

which forms the basis of one of the most important arguments of the pro

parliamentary position in the Philippines in advocating the shift from the presidential

form of government to a parliamentary one?; and (2) what would be the conceptual

and policy implications to this particular pro-parliamentary position in the Philippines

if the methodological critiques of other constitutional design scholars on the claims

of the superior democratic survival record of parliamentary over presidential

democracies are considered or accepted?

In answering these questions, this paper is organized as follows. First, it presents

the conceptual explanations raised by Filipino parliamentary advocates on the

4 PUBLIC POLICY


superior democratic survival record of the parliamentary form of government. Second,

it presents the empirical evidence they raised from the pro-parliamentary comparative

literature on constitutional design to give support to their conceptual arguments.

Third, it assesses the empirical evidence of the claimed superior democratic survival

record of the parliamentary system by employing works from the comparative

literature on constitutional design that are critical of the pro-parliamentary position.

Finally, it offers some implications to the local pro-parliamentary position if the

criticisms raised against the claimed superiority of the parliamentary system in

ensuring democratic survivability are considered.

conceptual Explanations on Parliamentarism's Democratic survival Record: A Local Perspective

The fact that since the 1986 restoration of presidential democracy, the Philippines

has faced numerous threats to democratic stability and survival helps explain why

the claimed superior performance of the parliamentary form of government in

ensuring democratic survivability attracted at least three Filipino parliamentary

advocates, namely Florencio Abad, Jose Abueva (in his later works), and Pablo

Tangco. Among the reasons they gave for proposing to shift the country's existing

presidential form of government to a parliamentary one is because the parliamentary

form is better in promoting the consolidation and deepening of Philippine democracy

than the presidential form of government embedded in the current constitution.

Of these three Filipino parliamentary advocates, Abad represents by far the

most significant position. There are three reasons for this. First, it is the central

concern of Abad to recommend an institutional framework that would ensure the 6

survival of Philippine democracy. Second, Abad is one of the few-if not the only

one-among Filipino parliamentary advocates who systematically draws and

discusses at length comparative insights on the form of government.7

Third, the

work of Abad has been used as the reference material by other Filipino parliamentary

advocates like Abueva to argue their pro-parliamentary position.8

Because Abad' s work represents the most sophisticated version of this position

in the Philippines, it is therefore useful to center on the conceptual arguments he


Torres

raises regarding the superiority of the parliamentary over the presidential form of

government in ensuring democratic survivability.

In answering why the parliamentary system is a more appropriate framework

of government compared to a presidential system in facilitating the consolidation

of democracy in the Philippines, Abad argues along the ideal-typical institutional

distinctions between presidential and parliamentary democracies. From here, he

demonstrates how each of the institutional features affects the performance of the

presidential and parliamentary forms of government in promoting democratic

survivability in the Philippines.

Drawing conceptual support from Linz, Abad believes that the parliamentary

system is a more appropriate framework of government compared to a presidential

system in improving government capacity to function more effectively and in

facilitating democratic consolidation in the Philippines. This is because the

parliamentary system is less prone to suffer from institutional problems such as

executive-legislative gridlock and prolonged political crisis that are said to be inherent

in a presidential system. These institutional problems are inherent in a presidential

system because of its two main institutional features. These are the "separate but

co-existing democratic legitimacy" enjoyed by the president and members of the

legislature since both are direcdy but separately elected by the people and the fixed

terms enjoyed by the executive and legislative branches which guarantee that their

tenure is independent of each other.9

The institutional features of separate elections and fixed terms work hand-in

hand to hinder the presidential system's capacity to ensure democratic survivability

in the Philippines. Abad identifies at least two problems directly brought about by

these two basic institutional features of presidential democracies that make them

more prone to democratic breakdown than parliamentary types.

The problem of executive-legislative gridlock

One problem that presidential democracies face is executive-legislative gridlock.

According to Abad, this problem is brought about by the presidential system's

institutional features of separate elections and fixed terms of the executive and

6 PUBLIC POLICY


legislative branches. The separate elections of the

executive and legislative branches in a presidential

system provide weak incentives for cooperation

between the two branches since direct election gives

each of them a direct mandate to represent the people.

On the one hand, the executive has the feeling of

superior democratic legitimacy over the legislative.

One problem that presidential democracies face is executivelegislative gridlock.

This feeling of superiority springs from the fact that the president does not only

hold the highest office of the land but also represents the nation as a whole. As a

result, the president is said to be unwilling to compromise with the legislature on

crucial policy issues.10

On the other hand, the legislative branch also feels that it

cannot be dictated upon by the executive since it too enjoys a direct mandate from

the electorate and, in its collective capacity, also represents the whole nation. This

"dual democratic legitimacy" may make it difficult for the executive to achieve the

necessary cooperation needed to push its policy agenda in the legislature, even in

situations when the executive has majority control of it.

This problem becomes more acute in cases wherein the president does not

have majority control in the legislature. Since they are elected separately,

presidentialism is prone to situations where the executive and majority of the

members of the legislature come from different, even opposing, parties. As Abaci

points out: "This problem is aggravated by the inability of presidential democracies

to obtain strong congressional cooperation through majority control of the legislature.

As a result, the legislature rests in the control of politicians who represent a

constituency with a different political choice from that of the constituency that

supports the president." (1997, 60) Where outright conflicts between the two

branches happen, these conflicts then degenerate into a prolonged and unproductive

gridlock or impasse since, and this is the crucial part, there is said to be no clear

democratic mechanism to resolve the conflicts.

In such cases, presidential democracies will most likely fail to respond in an

efficient and timely manner to the many challenges and opportunities that they

face. When the deadlock reaches crisis proportion, Abaci warns that it is probable

that the executive may resort to extra-constitutional measures which may lead to a

VOLUME VII NUMBER 2 Guly- December 2003) 7

Torres

reversal to an authoritarian regime as can be seen in the experiences of a number of

d I . II

eve oping countnes.

Being a presidential system, the Philippines has been plagued by the same

problem of executive-legislative gridlock. Abad offers as his evidence the "endless

political squabbling among legislators and between government and Congress on

almost any major policy issue that comes for deliberation." (1997, 59-60) This

"problem of wasteful and time consuming stalemates" serves as one of Abad' s

justifications for calling for a change in the country's form of government.

The executive's failure to secure majority legislative control prompted Philippine

presidents to adopt measures that ranged from "anti-party" practices to secure

approval of their policies bv the legislature to extra-constitutional actions to coerce

the legislature. Abad notes the enduring practice in the Philippines whereby

presidents dangle "pork barrel" to legislators in order to secure the latter's approval

of the former's policies and the party-raiding and party-switching that follow the

start of every presidential term.12

Far more brazen is the extra -constitutional measure

used by Marcos when he decided in 1972 to close down Congress and to impose

"constitutional authoritarianism" in the Philippines, using Congress' intransigence

l"b" 13 as an a 1 1.

According to Abad, this problem of executive-legislative gridlock inherent in

presidential democracies does not affect parliamentary systems. Where the

legislature is the only directly elected institution and from which the executive

the prime minister and cabinet-emanates, there is said to be no dual democratic

legitimacy conflict. Moreover, the flexibility of the tenure of both the executive and

the legislature where each has the power to dismiss each other, the prime minister

abolishing parliament and calling for new elections and the legislature securing a

vote of no confidence on the prime minister and/or cabinet, provides a built-in

powerful incentive for cooperation between the branches absent in a presidential

system.

Following Linz' s argument, Abad believes that this mutual dependency between

the executive and the legislative branches found among parliamentary systems allows

these systems not only to avoid deadlocks between the two branches but more

importantly, it allows the executive to muster majority support from the legislative.

8 PUBLIC POLICY


Because of this, he urges that a parliamentary system must be preferred over a

presidential system.

The problem of rigidity of presidentialism in responding to crisis

Another problem that presidential democracies face is their rigidity in responding

to changing and unexpected events or circumstances. This problem is said to be

largely brought about by the institutional feature of the fixed term of office of the

president. Abad echoes Linz's point that because presidents are elected for a fixed

term, their term of office cannot be modified under normal circumstances. This

means that the term can neither be shortened nor, in countries that ban reelection,

be prolonged.

The inability to shorten or prolong the chief executive's term of office would

have at least two implications to presidential democracies. On the one hand, because

the president's term cannot be shortened, this means that even if a president has

been tainted by scandals or deemed incompetent, presidential democracies will

have to wait until the president's term of office expires before he or she could be

replaced by a new president. This happens because the institutional mechanisms

for the removal of a president in presidentialism such as voluntary resignation and

impeachment are impracticable to ensure an early termination of the president's

term.14

On the other hand, because the president's term cannot be prolonged due

to the reelection ban in most presidential democracies, then this means that

presidential democracies will be denied the chance to extend an incumbent president

who is deemed to be performing well in office.

But while prolonging a competent president's term of office may not be as

urgent, the same cannot be said when faced with a situation that requires cutting

short the term of office of an erring and

incompetent chief executive who has lost much

of his or her mandate to govern. Without the

necessary institutional mechanisms to address

this impasse, presidential democracies tend to

suffer a "crisis of government," which, when

VOLUME VII NUMBER 2 Quly. December 2003)

Without the necessary institutional mechanisms, presidential democracies tend to suffer a "crisis of

t" governmen ...

9

Torres

prolonged, may escalate into a "crisis of regime." Faced with this situation, the

president either bypasses the legislature or rules by decree. In other instances, the

military might exploit the situation and take over from the civilian authorities:

The absence of these self-correcting devices in the presidential regime

leads to a paralyzing stalemate that ensures that nothing substantial gets

done until a new government is elected to replace the previous one-that is,

if the people are patient enough to wait until the next election cycle. In

many instances, most notably in Latin America, either the president bypasses

the legislature and rules by decree or a military coup overthrows the

government. In both situations, the institutional framework collapses and

those who take power rule extra-constitutionally. (Abad 1997, 65-66)

Abad argues that because parliamentary systemssio not guarantee a fixed term

of office to the executive, crisis of government escalating into crisis of regime that

may bring an end to democratic rule is a more remote possibility among parliamentary

democracies.15

A sitting prime minister who has become unpopular and discredited

may be removed in-between elections through the vote of no confidence in

parliament. Alternatively, a prime minister at loggerheads with parliament can dissolve

parliament and call for elections for a new parliament. In both cases, the executive

and the legislative need not wait to finish each other's term to resolve serious inter

branch deadlocks. The presence of such an institutional mechanism therefore

prevents a crisis-of-government situation in parliamentary systems from escalating

into a crisis-of-regime situation that gives the executive or the opposition the incentive

to pursue drastic extra-constitutional measures.

Based on the above discussion, it is clear for Abad that the problems of executive

legislative gridlock and the rigidity of presidentialism in responding to political

crisis make the presidential system more prone to suffer from democratic breakdown.

Worse, these problems could not be addressed in a presidential system because

they are claimed to be inherent to the presidential system itself, that is, they are

brought about by the system's basic institutional features of separate elections and

fixed terms. In contrast, parliamentary systems are not as prone to democratic

breakdown because their institutional features of the election of the executive by

10 PUBLIC POLICY


parliament and of the flexibility of tenure are able to mitigate the problems associated

with presidentialism.

Empirical support to Parliamentarism's Superior Democratic Survival Record

The claimed superior democratic survival record of parliamentary systems has

been backed up by impressive empirical support. One of the most systematic attempts

to provide quantitative support to this claim is the collaborative work of Stepan

and Skach, "Constitutional Frameworks and Democratic Consolidation:

Parliamentarism versus Presidentialism" published in the journal WOrld Politics in

199 3. Using various sources of data, they identified a number of empirical evidence

that reveal a strong correlation "between democratic consolidation and pure

parliamentarism than between democratic consolidation and pure presidentialism."

(Stepan and Skach 1993, 4-5) These empirical results are used by Abad to support

the conceptual arguments he raises (or adopts from Linz) regarding the claimed

superiority of the parliamentary over presidential form of government in fostering

democratic survivability.

The first empirical evidence directly related to democratic survivability that

Abad draws from Stepan and Skach to support his argument is based on the data

set of countries that were categorized as democracies in the Gastil Political llights

scale16

for at least one year between 1973 and 1989. Democracies that belonged to

the Organization of Economic Cooperation and Development ( OECD) were

excluded to ensure that the variable of economic development would not interfere

with the validity of the correlation. They were able to come up with 53 non-OECD

members that were democratic for at least one year between 1973 and 1989. Of

the 53 countries in their data set, 28 were "pure parliamentary," 25 were "pure

presidential" and no semipresidential or mixed types. In order to measure the

correlation between constitutional frameworks and their capacity to be democratic

survivors, they then set out to count which of these countries managed to survive as

democratic for ten consecutive years within this period. They found out that"( o )nly

five of the twenty-five presidential democracies (20 percent) were democratic for

any ten consecutive years in the 1973-89 period; but seventeen of the twenty-eight

VOLUME VII NUMBER 2 Ouly- December 2003) 11

Torres

pure parliamentary regimes (61 percent) were democratic for a consecutive ten

year span in the same period." (1993, 10) These data prompted Stepan and Skach

to conclude that "parliamentary democracies had a rate of survival more than three

times higher than that of presidential democracies." (1993, 10)

The second empirical evidence directly related to democratic survivability that

Abad draws from Stepan and Skach' s work is the correlation between forms of

government and vulnerability to military coups. Using the same data set of 53 non

OECD countries that were democratic for at least a year in the period 1973 to

1989, Stepan and Skach found out that of the 28 pure parliamentary democracies,

only 5 experienced a military coup while under a democratic rule. By contrast, 10

out of the 25 pure presidential democracies suffered a military coup while under

democratic rule. This translates to a "military coup susceptibility rate" of 18 percent

for parliamentary democracies and 40 percent for presidential ones. Hence, Stepan

and Skach declared that "presidential democracies were also more than twice as

likely as pure parliamentary democracies to experience a military coup." (1993, 10)

The third empirical evidence directly related to democratic survivability that

Abad employs from the Stepan and Skach study is their alternative data set to

investigate the correlation between constitutional frameworks and their capacity to

be democratic survivors. Data for this correlation are drawn from all the 93

countries-regardless of regime type-that became independent between 1945 and

1979. This time they wanted to know the correlation between the regime form

these countries chose at the time of their independence and the chances of surviving

(or evolving into--since some were not even democratic during their independence)

as continuously democratic over a ten-year period from 1980 to 1989. Examining

the regime form that these 93 countries chose at independence, 41 countries were

parliamentary, 36 were presidential systems, 3 were semipresidential, and 13 were

ruling monarchies. The main finding of Stepan and Skach is damning for

presidentialism:

12

At this stage of our research, we are impressed by the fact that no

matter what their initial constitutional form, not one of the fifty-two countries

in the nonparliamentary categories evolved into a continuous democracy

for the 1980-89 sample period, whereas fifteen of the forty-one systems (36

PUBLIC POLICY


percent) that actually functioned as parliamentary systems in their first year

of independence not only evolved into continuous democracies but were

the only countries in the entire set to do so.17

(1993, 11) ... not one of the fiftytwo countries in the

Stepan and Skach believed that the empirical

evidence, far from being statistical flukes, is the

logical and predictable result of the choice of the

basic constitutional framework involving the form

of government.18

Armed with both the conceptual

non parliamentary categories evolved into continuous democracies ...

arguments and the impressive empirical evidence to back them up, Stepan and

Skach confidently asserted that parliamentarism is a more robust and enduring

constitutional framework than presidentialism.

Assessing the Empirical Evidence

Indeed, the quantitative evidence marshaled by Stepan and Skach is impressive

enough to lend an empirically grounded justification to the Linz argument that

parliamentary systems fare better than presidential systems in sustaining democracy.

Employed by Abad, and repeated by other Filipino parliamentary advocates, the

evidence from Stepan and Skach's article has served as the reference scholarship

backing up the Filipino pro-parliamentary position's claim of the superior survival

record of parliamentary over presidential democracies.19

Compelling as they may seem, the empirical evidence offered by Stepan and

Skach has not remained unchallenged in the comparative literature. As mentioned

earlier, the challenges raised against the empirical evidence offered by Stepan and

Skach, unfortunately, have not figured at all in the Philippine debate on the two

forms of government. While the findings of the work of Stepan and Skach on the

superior democratic survival record of parliamentary democracies have been picked

up by the pro-parliamentary position in the Philippines, the methodological critiques

of these findings have been disregarded not only by the parliamentary advocates

but also by the latter's critics.


Torres

In this light, this section presents the other side of the debate, that is, the

criticisms raised against the empirical evidence offered by Stepan and Skach. Key

to the task of presenting the other side of the debate is to be able to employ works

of the comparative constitutional design literature that are critical of the pro

parliamentary position. This task is crucial in addressing the one-sidedness of the

presidential-parliamentary debate in the Philippines.

Critics accused the works of Stepan and Skach as methodologically flawed

because the empirical evidence they generated to support the argument about the

parliamentary system's superior democratic performance was in fact a product of

selection bias and spurious correlation.20

Most critics of Stepan and Skach's work center on the most impressive finding

of the two scholars on how not even a single presidential regime that became

independent from 1945 to 1979 managed to survive as a democracy for ten

consecutive years from 1980 to 1989 while 15 of the 41 parliamentary systems did.

Critics have identified at least five serious methodological flaws.

First, the selection of successful parliamentary democracies is biased towards

microstates.21

Shugart in his 1995 review of the Stepan and Skach arguments points

out that of the 15 continuous parliamentary democracies, 10 are in fact microstates

(or island-nations) having a population ofless than 1 million, with 4 actually having

a population of less than 100,000 (1995, 170). The smallness of the population

size of these 4 microstates even prompts two other critics, Power and Gasiorowski,

to exclaim that the office of the Brazilian national legislature which employs more

than 10,000 employees has more people than the inhabitants of either Nauru or

Tuvalu, both of which are included in the success stories of parliamentary

democracies in the Stepan and Skach study (1997, 129). Haggard and Kaufman in

pointing out that many of Stepan and Skach's survivors are microstates dismiss

these states as "ofhighlydubious comparative significance." (1995, 349)

Choosing from among the microstates to argue for the parliamentary system's

more successful democratic survival rate leaves presidential democracies out of the

picture since there are no presidential systems among microstates. Many presidential

democracies are in large countries such as Argentina and Brazil. If this is the case,

then the correlation that Stepan and Skach made for the success of the parliamentary

system in ensuring democratic survivability may not lie in parliamentarism per se

14 PUBLIC POLICY


but in the countries' population size. Mainwaring and Shugart argue that countries

with a very small population have the advantage of enduring democracy since their

populations tend to be relatively homogenous in terms of ethnic, linguistic, and

religious considerations, thereby helping reduce potential sources of conflict ( 1997,

21 and 23). On the basis of this, they argue that if population size is conducive to

democratic stability, then parliamentary

democracies have the built-in

advantage of being found in a number

of small states.

Power and Gasiorowski similarly

argue that "the inclusion of microstates

inflates the success rates of

parliamentary systems with respect to

ensuring democratic survivability."

(1997, 130) This methodology is

unacceptable to them since they insist

Choosing from among the microstates to argue for the parliamentary system's more successful democratic survival rate leaves presidential democracies out of the picture since there are no presidential systems among microstates.

that the problems of governance profoundly differ between the microstates and the

far more populous Third World states. They argue that while tiny island republics

with small population size can facilitate democratic stability because of its smaller,

more homogenous population, it may not be the case for Third World states, which

are not only populous but also suffer from "multiple cross-cutting cleavages such as

ethnic, linguistic, religious, and urban divisions." (Power and Gasiorowski 1997,

129)

Second, the selection of the successful parliamentary democracies is biased

towards the former British colonies. Shugart identifies 14 of the 15 countries (with

the exception of Israel) as former colonies of the British empire (1995, 169).22

Shugart, this time in collaboration with Mainwaring, criticizes Stepan and Skach

for underestimating the impact of British colonial rule as an important factor for

promoting democracy:

The strong correlation between British colonial heritage and democracy

has been widely recognized. Reasons for this association need not concern

us here, but possibilities mentioned in the literature include the tendency to


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train civil servants, the governmental practices and institutions (which include

but cannot be reduced to parliamentarism) created by the British, and the

lack of control of local landed elites over the colonial state. (Mainwaring

and Shugart 1997, 23)

Third, the selection of the successful parliamentary democracies is biased

towards those that adopted a two-party system. Haggard and Kaufman are relevant

in this respect. They observe that an overwhelming majority of these surviving

parliamentary democracies approximated a two-party system with only Israel and

Papua New Guinea having more than 2.5 effective parties (Haggard and Kaufman

1995, 349-350).23

This observation leads the two scholars to raise the possibility

that it may be the party system rather than the parliamentary form of government

that helped ensure democratic stability in these countries.

Fourth, the selection of the successful parliamentary democracies is biased

towards a specific time frame. By focusing on the 1980-1989 period, Stepan and

Skach were able to highlight the superior performance record of parliamentary

systems in enduring democracy. However, serious doubts are cast on this claim if a

different set of time frame is employed. For instance, Mainwaring and Shugart

argue that a different, contrary picture emerges if the wave of democratic breakdown

among the parliamentary systems during the 1920s and 1930s periods was taken

into consideration. Among the democracies that broke down during these periods

were Germany, Italy, Portugal, Spain, and the three Baltic states. With the exception

of Germany,24

each of these regimes had a parliamentary system.

They also show that if the 1980-1989 period is expanded to the 1977-1995

range, there were in fact more parliamentary democracies replaced by authoritarian

regimes than presidential democracies in the Third World (Mainwaring and Shugart

1997, 27-29). They identify eight instances of democratic breakdown in seven

countries between 1977 and 1995. Except for Turkey which experienced two

instances of democratic breakdown, all these countries suffered at least one instance

of democratic breakdown during the said period: Fiji, Grenada, Malaysia, Gambia,

Peru, and Sri Lanka. From this sample, parliamentary systems experienced five

instances of democratic breakdown (since Turkey had two), while presidential

16 PUBLIC POLICY


democracy suffered only one (two countries, Peru and Sri Lanka were classified as

hybrid). Table 1 shows this breakdown.

Total No.

Table 1

COUNTRIES THAT SUFFERED DEMOCRATIC BREAKDOWN/$ BETWEEN 1977-1995

Parliamentary

Turkey ( 1980)

Turkey ( 1994)

Fiji (1987)

Grenada ( 1979)

Malaysia (1984)

5

Presidential

Gambia (1994)

Others

Peru (1992)

Sri Lanka (1989)

2

Source: Based on Mainwaring and Shugart's Table 1.5 "Democracies that broke down between 1977 and 1995." See "Presidential ism

and Democracy in Latin America," p. 28.

Moreover, if the base years used were extended earlier to include the period

between the 1960s and 1980s, it could be shown that longstanding parliamentary

systems broke down as well. These were Greece in 1967 and Turkey in 1980, both

of which broke down after a series of open competitive elections. In addition,

democratic breakdowns were also found during the same period in short-lived

parliamentary regimes like those in Burma, Kenya, and Somalia (1997, 20).25

The same point is raised by Power and Gasiorowski when they expand the

time frame from 1930 to 1995. They identify a total of 56 democratic transitions

(some countries have two or more transitions) in the Third World from this expanded

period.26

In assessing the democratic survival record of parliamentarism and

presidentialism, Power and Gasiorowski arrive at three measures of democratic

consolidation, namely, ( 1) post-founding election; (2) alternation in power; and the

(3) twelve year duration.

The post-founding election looks at "whether a new regime survives through

the holding of a second election for the national executive (subsequent to the

'founding election' that inaugurated polyarchy)." (Power and Gasiorowski 1997,

132, emphasis in the original) The alternation in power looks at whether regimes


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that survived democracy are able to effect an alternation in executive power. The

twelve year duration looks at democracies that survived after twelve years of

democratic experience (1997, 13 3).

Applying these three measures in their sample consisting of 56 transitions to

democracy enable Power and Gasiorowski to test the Linz thesis (and empirically

supported by the Stepan and Skach work) that the presidential system of government

is more prone to democratic breakdown than a parliamentary system. In all these

three measures, they observe that the difference between the survival record of a

presidential and a parliamentary form of government is statistically insignificant.

They declare that:

On the basis of samples ranging from 48 to 56 countries depending on

the test involved, we can find no evidence that constitutional type has had

any significant bearing on the success of Thitd World experiments in

democracy between 1930 and 1995. (144)

In terms of the post-election founding measure of democratic consolidation,

they find that:

Some 31.3% of the presidential democracies broke down before reaching

this milestone, compared with 25% of the parliamentary democracies.

Results of a Pearson's chi-square test show no statistically significant

relationship between these breakdown rates (p=.608). (137)

In terms of the alternation of power measure of democratic consolidation,

they show that:

18

Since 1930 approximately half of all Third World democracies have

broken down before effecting one alternation in executive power. Here again,

the results do not confirm the Linz thesis. The breakdown rates of presidential

and parliamentary democracies are nearly identical, 46.7% and 45.8%,

respectively; and again, there is no statistically significant difference between

them (p=.951). (137)

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In terms of the twelve year duration measure of democratic consolidation,

they reveal that:

The Twelve Year Duration measure turns up virtually identical

breakdown rates for presidential democracies (61.5%) and parliamentary

democracies (63.6%), with no statistically significant difference between

them (p=.881). (137 and 144)

Fifth, the selection of the successful parliamentary democracies is biased against

a specific regional grouping. Shugart argues that by focusing on the rise of independent

states during the 1945-197 5 period while ignoring those that became independent

prior to 1945, Stepan and Skach have automatically excluded the Latin American

region where many countries won their independence prior to Stepan and Skach' s

time frame.27

Since an overwhelming majority of Latin American countries have

presidential systems, the exclusion of the Latin American cases left Stepan and

Skach with mostly the economically poor and deeply politically divided African

states that were then used to illustrate the failure of presidential systems to continue

to be democratic. These African states, Shugart argues, would be extremely

challenged to evolve into or survive as democracies under any constitution.

Mainwaring and Shugart point out that presidentialism is more likely to be

adopted in Latin America and Africa where obstacles to democracy are formidable

while parliamentarism is likely to be adopted in Europe and in former British colonies

where conditions for democracy are generally more favorable. Thus they warn about

the need to be cautious in readily accepting the correlation, no matter how impressive

at first glance, between constitutional form and democratic success.28

Taken together, the criticisms raised against the Stepan and Skach work put to

question the robustness of the claimed superior performance of parliamentary

systems in ensuring democratic survival. At the same time, these criticisms warrant

the need to exercise caution in making sweeping conclusions that a country's success

or failure in ensuring democracy is brought about by the form of government. As

shown, the serious problems accompanying the quantitative evidence offered by

Stepan and Skach reveal that the claimed success of parliamentarism in enduring

VOLUME VII NUMBER 2 Quly- December 2003) 19

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democracy may not be brought about by the parliamentary form per se but by non

institutional (e.g., size of the population and British colonial heritage) and other

institutional (e.g., party system) factors.

Implications to the Filipino Pro-Parliamentary Position

Understanding the criticisms raised against the claimed superiority of the

parliamentary over the presidential system in ensuring democratic survivability is

crucial in the forms-of-government debate in the Philippines. This is so because the

same empirical evidence criticized for its methodological problems is the same

evidence used by the local parliamentary advocates led by Abad to launch their

campaign to change the country's form of government from the current presidential

system to a parliamentary one, thus justifying an over4auling of the 1987 Philippine

Constitution. For if the methodological critiques of other constitutional design

scholars of the empirical evidence that supports the claims of the superior democratic

survival record of parliamentary over presidential democracies are considered or

accepted, then this would pose some serious implications to the local pro

parliamentary position. These implications can be found at the conceptual and policy

levels.

conceptual implications

At the conceptual level, the appropriation of these criticisms seriously imperils

the argument of the Filipino pro-parliamentary position on the superior democratic

survival record of parliamentary democracies. If one of their central arguments for

making the country go through a wrenching process of overhauling the constitution

is that the new parliamentary form will improve the chances of political stability

and democratic consolidation in the country as proven by the comparative record,

the exposure of how shaky the methodological bases on which this claim rests cannot

but inflict a serious blow to the credibility of this argument. Either the Filipino

parliamentary advocates generate new evidence to salvage the democratic survival

claim or drop this particular argument in favor of highlighting other arguments for

20 PUBLIC POLICY


justifying the drastic shift in the form of government as a solution to the political ills

of the country.

However, the more fruitful conceptual direction to take for those who argue

the crucial relation between the type of political institutions a country has and its

chances of democratic consolidation is to move away from the grand, ideal-typical

distinctions that the parliamentary position in the Philippines has taken and move

towards tackling the more specific variations in the form of government and in the

other political institutions that have impact on the functioning of a particular form

of government. This direction must be pursued both on comparative grounds and

on the country-specific level of the Philippines.

In arguing for the superior capacity for democratic survival of the parliamentary

over the presidential form, parliamentary advocates in the Philippines like Abad

have depicted the presidential form as a homogenous type, disregarding the

important fact that presidential democracies in the developing world are marked

by significant variations in the powers of the president and the legislature. In turn,

scholars contend that these significant variations play important roles in the

performance, quality, capacity, and, ultimately, in the survival of presidential

democracies.

This approach is best exemplified by Mainwaring and Shugart who stress that

the effects of the dual democratic legitimacy and fixed terms on executive-legislative

coordination and conflict are mediated by the effects of the balance of legislative

powers between the executive and legislative branches particular to a country. They

argue that where presidential powers are strong, meaning that the presidents have

significant powers to influence legislation such as veto powers and legislative decree

powers, "the ability of the congress to debate, logroll, and offer compromises on

conflictual issues confronting the society is sharply constrained. Instead, the

presidency takes on enormous legislative importance and the incumbent has

formidable weapons with which to fine tune legislation to fit his or her whims and

limit consensus building in the assembly." (Mainwaring and Shugart 1993, 14) In

short, where the president's legislative power is strong, his or her capacity to encroach

upon a larger arena of lawmaking deemed by legislators to be properly belonging to

the legislature becomes greater, hence, potentially exacerbating conflicts with the


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legislative branch. On the other hand, where the presidential powers are weaker,

the opportunity to widen the areas where the president will seek to arrive at

compromises with the legislature on policymaking is enhanced.

Mainwaring and Shugart point out that it is "probably no accident" that

presidential democracies (which include the Philippines) that score "very high" in

their system of scoring presidential powers are those that suffered democratic

breakdowns while those with the lowest scores have been the most stable

presidential systems:

In this respect it is probably no accident that some of the most obvious

failures among presidential democracies have been systems that score very

high according to Table 3: Brazil's 1946 regime, Chile before the 1973 coup,

and the Philippines, for example. Colombia's former regime (1958-1991) ;

also scored quite high; it had a questionable record as a stable democracy

and its presidential powers were recently attenuated. At the other end of

the scale of presidential powers we find the three oldest presidential

democracies, Costa Rica, the United States, and Venezuela, all with scores 29

of 2 or less.

Since there is a near-universal consensus among scholars studying the Philippine

executive that the powers of the Philippine president have been dominant over the

legislative branch, there is a wealth of starting-point literature that can be used to

investigate which among the powers of the Philippine president may have helped

produce the inefficient, at times turbulent, and in 1972, fatal executive-legislative

relations in the country. For while the local parliamentary position blames the

country's presidential form of government for the problematic executive-legislative

relations that are said to threaten the survival of Philippine democracy, it may yet

be the case that the problems are not caused by the form of government per se but,

if Mainwaring and Shugart are correct, by, among others, the skewed division of

powers between the executive and legislative branches, a problem that other

presidential democracies may have helped successfully mitigate by granting less

powers to their executive.

22 PUBLIC POLICY


Inseparable from this conceptual task is the investigation of the roles of other

political institutions that may help explain the performance and longevity of a

particular presidential form of government a country has. Here, the most important

political institution usually identified by scholars is the country's party system. In

turn, the characteristics of the party system, against the contention of some

parliamentary advocates, are affected not only by the form of government, but equally

(if not more so) by the electoral system.

For example, Haggard argues that a country's party system is as important a

factor as the form of government to explain executive-legislative relations.30

He

identifies party discipline as one of the most important features of the party system.

According to him, "the key variable in party discipline is the relative strength of the

party leadership vis-a-vis the individual politician." (Haggard 1997, 139) If there is

strong party leadership, the prospect of enforcing the party program becomes greater.

Equally important, Haggard argues that party strength affects not only intra-party

dynamics but also the design of legislative institutions: "Strong parties are more

likely to favor rules and institutions that further buttress party discipline, such as

strong oversight or control committees, extensive agenda-setting and committee

assignment powers for party leaders, and weak policy committees." ( 139) Such

arrangements have been identified elsewhere in the constitutional design literature

as measures that facilitate executive-legislative coordination and minimize gridlock.

This feature of the party system for Haggard is largely determined not by the

form of government a country has but by its electoral system. One electoral feature

he discusses is whether voters choose parties or candidates. According to him, an

electoral system that allows the voters to choose the parties rather than the candidates

gives little incentives for the politician to deviate from the party platform. Conversely,

an electoral system that allows the voters to elect the candidates rather than the

parties makes the cultivation of personal vote more attractive to the politician than

following party lines. Thus, between these two options, it is when the voters choose

parties that will most likely create the incentives for more party discipline and

cohesion (141).

In the case of the Philippine party system, there is the same near-universal

consensus among scholars that political parties in the Philippines are grossly


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undisciplined and that this lack of discipline has seriously affected the performance,

capacity, and quality of Philippine democracy. The bone of contention, however, is

to explain what has caused this perversion, with some scholars pointing to pervasive

I. . 31 h I f Ph·1· . d 32 h ' patron-c 1ent ties, t e c ass nature o 11ppme emocracy, t e country s

personalistic political culture,33

the nature of Filipino elites (more specifically elite

families),34

and, more recently, the presidential form of government itself.35

Largely

ignored is the crucial role played by the country's single-member district electoral

system for electing the legislators to the Lower House.

Local parliamentary advocates might learn from one of their own on this topic.

Joel Rocamora, one of the most perceptive local parliamentaristas, traces the

pathologies of the Philippine party system as partly rooted in the country's electoral

system. Although he believes that the presidential form of government plays a role

in the current indiscipline of Philippine political parti~s, he gives equal emphasis to

the single-member district electoral system that the Philippines has used from the

start of the American period and has adopted under both its 1935 and 1987

Constitutions.36

He argues that one of the most important constitutional reforms

for the development of a far more disciplined, programmatic party system is the

significant expansion of the current party list for marginalized sectors under the

1987 Constitution or the shift to a full-blown proportional representation (PR)

based electoral system:

24

What we need is the revision and expansion of the existing party list

system, or an outright shift of the whole system to PR. If voters choose

between parties instead of individual candidates, it will lessen the intensity

of personal and clan contests which are the main sources of violence and

money politics. Parties will then be required to strengthen the organizational

and programmatic requirements for electoral victory. Minimally, parties will

be forced to distinguish themselves from each other enough for voters to

make choices. The shift in the center of gravity of organizational work away

from individual candidates will force parties to strengthen themselves

organizationally. (Rocamora 2002, 24-25)

PUBLIC POLICY


Policy implications

At the policy level, if there is some truth to the criticisms raised against the

claimed superior empirical record of the parliamentary system in ensuring democracy,

then the justifications for the necessity of a wholesale change of the constitution to

accommodate a change in the form of government have been overstated by the

Filipino parliamentary advocates. In order to improve the chances of avoiding regime

breakdown and of enhancing democratic consolidation and deepening, the needed

changes as they relate to the issue of the form of government of Philippine democracy

may not be in terms of overhauling the form of government but in terms of more

modest institutional tinkering in the existing form of government (e.g., reforms

involving the powers of the executive) or in the other political institutions such as

the electoral system (e.g., reforms involving the reworking and expansion of the

party list) that need not involve a wholesale change of the constitution. In the final

analysis, these institutional fine-tunings might even be far more effective and sensible

than overhauling the form of government itself.

conclusion

The debate to change the 1987 Philippine Constitution has run almost a decade

now. Yet, through the years, the debate has largely remained a one-sided affair. Up

to now, the claimed superior record of the parliamentary over the presidential system

stands unchallenged in the Philippine debate on the forms of government. While

Filipino parliamentary advocates are able to appropriate works that lend support to

the claimed superiority of the parliamentary over the presidential system in ensuring

democratic survivability, they fail to appropriate works that are critical of the pro

parliamentary position. At the same time, defenders of the presidential form of

government of the constitution have failed to challenge the central arguments of

the pro-parliamentary position in the Philippines.

It is in the light of this one-sided affair of the forms-of-government debate in

the Philippines that this paper employed the other side of the comparative

constitutional design literature. Filipino parliamentary advocates picked up the work


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of Stepan and Skach which offered a number of impressive quantitative results

showing that parliamentary democracies are superior over presidential democracies

in their democratic survival rate and, hence, in avoiding regime breakdown. However,

the findings of Stepan and Skach did not remain unchallenged. As this paper has

shown, other constitutional design scholars like Gasiorowski, Haggard, Kaufman,

Mainwaring, Power, and Shugart are one in criticizing the work of Stepan and Skach

as suffering from serious selection bias and spurious correlation. Critics are also one

in arguing that, once a different set of methodological criteria is used from that

employed by the two scholars, a different picture emerges which undermines the

findings on the superiority of the parliamentary over the presidential form of

government especially as these findings relate to the Third World experience.

If their criticisms are considered, then this paper argued that the Filipino pro

parliamentary position is bound to suffer some serious implications at the conceptual

and policy levels. Conceptually, these criticisms undermine the soundness of the

argument of this position on the superior democratic survival record of parliamentary

democracies. They also point to the conceptual direction of studying the more

specific variations in the form of government and in the other political institutions

that impact on the functioning of a particular form of government in order to better

highlight the relation between the type of political institutions a country has and its

chances of democratic consolidation. At the policy level, these criticisms undermine

the political logic and necessity of a wholesale change in the constitution based on

the rationale that the proposed parliamentary form of government would be more

able than the existing presidential form to promote the stability of Philippine

democracy.

On the whole, the paper sees its significance not only in introducing the other

side of the debate in this specific argument but in demonstrating the importance of

a more systematic employment of comparative insights that would, among others,

give a fuller appreciation of the range of positions available in the constitutional

reform debate.37

While the paper only criticized the democratic survival argument,

one of the central arguments of the pro-parliamentary position which in some circles

has become the conventional wisdom largely because it has remained unchallenged,

it is hoped that the paper has pointed the way to a more full-blown critique of the

26 PUBLIC POLICY


overall parliamentary position in the Philippines through the employment of

alternative comparative literature on constitutional design that is skeptical of the

claims of the superiority of one form of government over another.

Notes

1 This assessment does not only come from pro-parliamentary scholars but from two of the most articulate defenders of the presidential form of government, Matthew Shugart and John M. Carey. They acknowledge that: "The suggestion that presidential democracy is prone to breakdown, leading to authoritarian government, is the most troubling of all the criticisms levded by adherents of parliamentarism." (Shugart and Carey 1992, 36)

2 This democratic regime survival is also understood in the democratization literature-but not

always consistently-as democratic consolidation or democratic stability. Although this factor is the most salient, it is but one of the vectors of the claimed superiority of parliamentary over presidential democracies. Among the other vectors of the claimed superiority of the parliamentary over the presidential form of government are: superior efficiency in enacting legislation (i.e., better executive-legislative coordination); superior accountability in governance (i.e., more flexibility in recalling leaders who have lost their mandate to govern); better representation of non-majoritarian interests (i.e., more conducive to multiparty systems, power-sharing, and coalition-forming); stronger inducement for more disciplined political parties (i.e., more programmatic parties); better economic performance (i.e., more effective functioning of political

institutions related to economic policymaking); superior incentives for a better functioning bureaucracy (i.e., less patronage involving civil service posts and better bureaucratic oversight functions); and superior set-up in promoting cheaper elections (i.e., election of prime minister

by parliament is less costly than direct national elections of the president). 3 According to Arend Lijphart, the debate between presidential and parliamentary government is

in fact much older than modem democracy itself: "The relative merits of these two forrris of democracy have been debated for a long time-considerably longer than the existence of modem democracy, which was not fully established anywhere (if we take the requirement of universal suffrage seriously) until the beginning of the twentieth century." (Lijphart 1992, 1)

4 This, of course, is the famous "third wave" of democratization. From only 39 democracies in

the world in mid-197 4, constituting only 27 percent of all the independent states, the number peaked at 120 at the end of 2001, representing more than 63 percent of all the independent

states (Freedom House 2001). 5 See these three quotes below which are representative of the strong consensus in the

constitutional design literature that the renewed concern with the superiority of one form of government over another has been spurred by this democratic wave and the question of what form of government would help consolidate these new democracies: "Ine struggle to consolidate the newdemocracies--especiaUy those in Eastem Europe, Latin

America, and Asia-has given rise to a wide-ranging debate about the hard choices conceming


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economic restructurin& economic institutions, and economic markets. A similar debate has focused on democratic political institutions and political markets. This literature has produced provocative hypotheses about the effects ofinstitutions on democracy. It fonns part of the ~ew institutionalism' literature in comparative politics that holds as a premise that 'political democracy depends not only on economic and social conditions hut also on the design of political institutions. "'(Stepan and Skach 1993, 1) (emphasis in the original). "Over the past decade, comparativists devoted renewed attention to the fonnal aspects of politics: rules, organizations, procedures, and constitutions. Simultaneous];; the worldwide movement toward democratization inspired a large and creative literature on regime transition and consolidation. By the early years of this decade these two trends had cross-fertilizeci producing an emerging research program on the institutional design of new democracies. The synthesis of two literatures produced a question whose real-world relevance can hardly he understated· Which institutional arrangements are best suited to promote the consolidation of the unprecedented number of young democratic regimes?" (Power and Gasiorowski 1997,

123-124). "The 1980s were a time of growth in a suhfield of political science that has come to he known as the ~ew institutionalism' .... There is a renewed fqcus on the importance of political institutions in accounting for the success or failure of democracy. Recent advances of democracy in Central and Eastem Europe and other parts of the globe have given impetus to the study of designing constitutions and the consequences of institutional choice. Olci long unchallenged assumptions about the efficacyofpresidentialism in Latin America have been seriously challenged in recent years. "(Shugart and Carey 1992, 1)

6 As Abad states in his paper: "The principal question that will be addressed is this: 'Why is a parliamentary system a more appropriate framework of government, compared to a presidential system, in improving the capacity of government to function more effectively and in facilitating the consolidation of democracy in the Philippines?'" ( 1997, 50)

7 In his work, Abad draws heavily from the 1994 work of Juan Linz (3-87) and from the 1993 collaborative work of Stepan and Skach (1-22) cited above in making the case that the parliamentary form of government would be more conducive to the goal of democratic consolidation in the Philippines.

8 Tangco also uses the Stepan and Skach article to argue for the superior democratic performance of the parliamentary form of government. But his discussion on the Stepan and Skach work is limited to a one-paragraph quotation. Abueva, on the other hand, merely replicates Abad's argument on democratic survivability.

9 Abad quotes Linz this way: "Linz attributes this problem to an inherent structural weakness in a presidential system: the tenure of the president is fixed independent of the legislature and the legislature can survive without fear of dissolution by the executive. This feature derives from the

separate but coexisting democratic legitimacy enjoyed by the executive and legislative branches, being both directly and popularly elected." ( 1997, 60)

10 This time, the equally distinguished pro-parliamentary scholar, Arend Lijphart, is used by Abad to buttress his argument: "Lijphart goes along with this view, but at the same time holds that this is only part of the explanation. For him, 'the real problem is ... that everyone-including the

28 PUBLIC POLICY


president, the public at large, and even political scientists-feels that the president's claim (to

legitimacy) is much stronger than the legislature's. Consequently ... the feeling of superior

democratic legitimacy may make the president righteously unwilling and psychologically unable

to compromise."' (1997, 60) 11 Abad notes that: "In a number of developing countries, when the legislature is intransigent and

refuses to compromise or bow down to political pressure and a serious crisis threatens to

embroil the country, the administration-stalemated, powerless and deeply frustrated-is often

left with no other choice but to resort to extra-constitutional measures. Martial law, or rule by

decree, becomes an option. The case of Alberto Fujimori in Peru comes to mind. Fujimori, to

justify martial rule and ruling by decree on April1992, blamed the lack of progress in Peru

squarely on an uncooperative congress." (1997, 62)

12 Abad uses the 1992 Philippine Congress as a case in point. As he argues: "At the time of the

proclamation of congressional winners in 1992, the party of the administration, Lakas-NUCD,

was a minority in the House of Representatives with only 39 out of 200 seats, or around 20%.

The rest of the seats were spread out to seven other parties, with the Lakas ng Demokratikong

Pilipino (LDP), the National People's Coalition (NPC) and the LiberalPartycontrollingmajority

of the seats with 87, 39 and 13 members respectively. ... After a year of intensive recruitment by

the administration, Lakas-NUCD gained 69 more seats to control the lower house with 108

seats, while the LDP was reduced to less than a third with only 25 seats. The ordinary voter has

come to accept the proliferation of 'political butterflies' as a justifiable act of political survival in

a system that rewards, not party loyalty, but a politician's ability to ingratiate himself to an all

powerful, spoils-dispensing president." ( 1997, 62)

13 As Abad himself notes: "In 1972, Marcos used the same excuse for closing down Congress and

imposing 'constitutional authoritarianism' in the Philippines." (1997, 62)

14 See this quote from Abad: "Thus, unexpected events may intervene, like fundamental flaws in

judgment or serious presidential scandal or indiscretion for which the president is called upon,

by popular clamor, to resign from office. Will a presidential government, with its rigid political

process, adjust better to crisis? Most likely not, especially when the president is

unyielding .... There is the option of voluntary resignation through pressure from party leaders,

the media and public opinion. But given the psychology of politicians, resignation is highly

unlikely to happen. Moreover, the move will encounter opposition from the constituency that

brought the discredited president to power .... Then there is the extreme measure of impeachment,

which is difficult and complicated to execute successfully. Apart from the heavy burden of

establishing sufficient evidence of misconduct, it also seems implausible that a legislative majority

will support these proceedings, since members of the president's party would have to go along

with the impeachment process. Thus, it is almost impracticable to remove even the most

corrupt and inefficient president from office." (1997, 64)

15 As Abad argues: "Thus, the problem that arises as a result of the so-called instability of

parliamentary democracies are (sic) simply 'crises of government, not regime.' The availability

of deadlock-breaking devices and decision mechanisms in a parliamentary regime help (sic)

ensure that issues of government do not deteriorate into crises of the regime." (1997, 65)


Torres

16 Raymond Gastils's Democracy Scale rates countries according to their "political rights" and "civil liberties." See Stepan and Skach, "Constitutional Frameworks and Democratic

Consolidation," footnote 5, p. 3. 17 Stepan and Skach do not rule out three facts: ( 1) that "the more democratic" countries chose

parliamentary regimes at independence; (2) that many of the democratic survivors are island states; and (3) that all but two (Papua New Guinea and Nauru) are former British colonies. Of these three, Stepan and Skach are able to respond only to the British colonial heritage. They argue that "factors other than British colonial heritage are related to the democratic evolution and durability." This is because when Stepan and Skach isolated the 50 former British colonies from the original set of 93 countries, they found out that 13 of the 34 British colonies that began as parliamentary systems during their independence evolved into continuous democracies for the 1980-1989 period while none of the 5 former British colonies that began as presidential systems evolved into a democracy for the 1980-1989 period, and also none of the 11 that began as ruling monarchies evolved into a democracy for the same period. For Stepan and Skach's discussion, see "Constitutional Frameworks and Democratic Consolidation," pp. 11-13. (Note, however, that in contrast, Stepan and Skach's critics like Mainwaring and Shugart consider Papua New Guinea and Nauru as having British colonial heritage.)

18 For example, they insist that if the results of the data on the 91 countries "were strictly numerical observations, the chances of this distribution occurring randomly would be less than one in one thousand." (Stepan and Skach 1993, 11)

19 In the most recent local pro-parliamentary (as well as pro-federalism) book, a highly abridged version of the article of Skach and Stepan that appeared in World Politics is reproduced. See Stepan and Skach, "Parliamentarism vs. Presidentialism," in Jose Abueva et al, eds., Towards a Federal Republic of the Philippines with a Parliamentary Government: A Reader( Quezon City: Center for Social Policy and Governance Kalayaan College, Local Government Development Foundation, LihokPideral-Kusog Mindanaw, and Konrad-Adenauer-Stiftung, 2002), pp. 183-185.

20 Spurious correlation in this context is defined by two of Stepan and Skach's critics this way: "If a background condition that is conducive to democracy is correlated with parliamentarism,

then any attempt to correlate parliamentarism and democracy may be spurious unless some effort is made to control for background conditions." (Mainwaring and Shugart 1997, 24)

21 Although as earlier mentioned, Stepan and Skach did not rule out the fact that the successful democratic survivor states in the sample included many microstates, they did not explain the impact that being a small island state has on the odds to survive as a democracy.

22 However in Shugart's article with Mainwaring, he considers Israel as having a British colonial heritage. See Table 1.2, Mainwaring and Shugart, "Presidentialism and Democracy in Latin America," pp. 22-23.

23 Effective number of parties as defined by Markku Laakso and Rein Taagepera is "the number

of hypothetical equal-size parties that would have the same total effect on fractionalization of

the system as have the actual parties of unequal size," Laakso and Taagepera, "Effective Number of Parties: A Measure with Application to West Europe," Comparative Political Studies 12

30 PUBLIC POLICY


(April 1979) as cited by Stepan and Skach, "Constitutional Frameworks and Democratic

Consolidation," footnote 14, pp. 5-6. 24 Although Germany was not a parliamentary system per se, Mainwaring and Shugart argue that

its constitution contains parliamentary features that to some extent were responsible for its failure. Among the parliamentary features of its constitution are "the need to construct cabinet coalitions that could maintain majority support and a provision for dissolution." (1997, 20)

25 In addition to this list of unsuccessful parliamentary systems, Shugart also notes Bangladesh, Pakistan, Sudan, Thailand, and Turkey as among the parliamentary systems that have records of military intervention. See "Parliaments Over Presidents?," p. 169.

26 The two scholars lift the democratic transition data from the Political Regime Change Dataset developed by Mark Gasiorowski in an earlier work. The countries in this dataset have a

population of at least 1 million in 1980 in order to exclude microstates. For a further explanation of how they winnowed their data, see footnote no. 11 in Power and Gasiorowski, "Institutional Design and Democratic Consolidation," p. 130.

27 As Shugart notes, "this is the only part of the less developed world that has significant experience-however--discontinuous with presidential democracy." (1995, 170) The same argument is raised by Power and Gasiorowski: "The exclusion of Latin America from examination of the prospects for presidential democracy in the Third World is p. serious shortcoming because Latin America is the only part of the Third World with any significant experience with presidential democracy." (1997, 129)

28 The two scholars sum up best their argument and their note of caution: "In summary, presidentialism is more likely to be adopted in Latin America and Africa than in other parts of the world, and these parts of the world may have more formidable obstacles to democracy regardless of the form of government. On the other hand, parliamentarism has been the regime form of choice in most of Europe and in former British colonies (a large percentage of which are microstates), where conditions for democracy may be generally more favorable. Thus, there are reasons to be cautious about the observed correlation between constitutional form and democratic success, impressive though this correlation may at first appear." (Mainwaring and Shugart 1997, 29)

29 Mainwaring and Shugart offer this qualifier to their argument: "Obviously there is no perfect

correlation between presidential powers and stable democracy; two countries that have low scores (Argentina and Bolivia) have broken down frequently, and two with high scores (Chile 1932-73 and Colombia 1958-91) survived for a long time. Nevertheless, the fact that the most stable presidential democracies have had weak presidential powers is suggestive." (1993, 14) They can add to the anomalies in their list Venezuela where Hugo Chavez as president was able to abolish the legislature and maneuver a new constitution in 1999 which, among others, dramatically increased executive powers over the legislature.

30 "This review does not imply complete agnosticism on the question of the effects of parliamentary

versus presidential rule. However, it suggests that the effects of this fundamental constitutional

choice are contingent on other components of institutional design, particularly the party system." (Haggard 1997, 133)


Torres

31 See Carl Lande, "Leaders, Factions, and Parties: The Structure of Philippine Politics." Yale University Southeast Asian Studies Program Monograph Series No.6. (1965).

32 See Amado Guerrero, Philippine Society and Revolution (Manila: Pulang Tala Publications,

1971). 33 For a discussion, see David Timberman, A Changeless Land· Continuity and Change in

Philippine Politics (Manila and Singapore: Bookmark and Institute of Southeast Asian Studies,

1991). 34 See Alfred McCoy, "%1 Anarchy of Families': The Historiography of State and Family in the

Philippines," in Alfred McCoy, ed., AnAnarchyofFamilies: State and Family in the Philippines (Quezon City: Ateneo de Manila University Press, 1994), pp. 1-32.

3 5 In addition to Abad' s work, see the articles in the book Abu eva et al. edited, Towards a Federal Republic of the Philippines with a Parliamentary Govemment.

36 See Joel Rocamora, "Political Parties in Constitutional Reform," in Abueva et al. eds., Towards a Federal Republic of the Philippines with a Parliamentary Government. According to Rocamora:

"Our electoral system, and the actual practice of elections have been one of the most important factors shaping political parties. The intensely personalized character of parties derive partly from the fact that individual candidates are elected in a 'first past the post' system." (2002, 23)

3 7 As I have argued in a separate paper: "while a cpmparative perspective is no guarantee that we would get it right, a comparative perspective tends to be more hard-edged than a parochial one. We can put to our advantage the arguments of this literature by appraising its analyses in the

light of our own local research questions and cohcems. Tapping the works of first-rate scholars who have worked on these similar questions in their entire careers may easily shorten the time we need to reach the answers to our own constitutional questions. Perhaps as important, by surveying the literature we also become more aware of the vast array of positions and the extent of the debate on specific proposals which would in tum guarantee that we would not only be familiar with one side of the argument." (Torres 2001, 19-20)

32 PUBLIC POLICY


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Rey Magno Teves, Gaudioso C. Sosmefi.a, Jr., Clarita Carlos, and Michael

Mastura, eds. Towards a federal Republic of the Philippines with a parliamentary

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Kalayaan College, Local Government Development Foundation, Lihok Pideral

Kusog Mindanaw, and Konrad-Adenauer-Stiftung.

_____ . 1997. Should the Philippines turn parliamentary: The challenges of

democratic consolidation and institutional reform. In Soliman Santos, Jr.,

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Abueva, Jose. 2002. Dissatisfaction with the way our democracy works. In Jose

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Michael Mastura, eds. Towards a federal Republic of the Philippines with a

parliamentary govemment: A reader. Quezon City: Center for Social Policy and

Governance, Kalayaan College, Local Government Development Foundation,

Lihok Pideral-Kusog Mindanaw, and Konrad-Adenauer-Stiftung.

_____ . 2002. Response to the usual objections to federalization and

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Government Development Foundation, Lihok Pideral-Kusog Mindanaw, and

Konrad -Adenauer-Stiftung.

_____ . 2002. Towards a federal Republic of the Philippines with a

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-----. 1995. Let's make our presidential system work. Today 4-7 July.

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Michael Mastura, eds. Towards a federal Republic of the Phjfippines with a

parliamentary government: A reader. Quezon City: Center for Social Policy and



Diamond, Larry. 1999. Developingdemocrac_v: Jbward consolidation. Baltimore:

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Guerrero, Amado. 1971. Philippine society and revolution. Manila: Pulang Tala

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Haggard, Stephan. 1997. Democratic institutions, economic policy, and

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countries. Baltimore: The Johns Hopkins University Press.

Haggard, Stephan and Robert Kaufman. 1995. The political economy of democratic

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Lande, Carl. 1965. Leaders} factions} and parties: The structure a/Philippine politics.

Yale University Southeast Asian Studies Program Monograph Series No.6.

Lijphart, Arend. 1992. Introduction. In Arend Lijphart ed. Parliamentary versus

presidential government. New York: Oxford University Press.

Linz, Juan. 1994. Presidential or parliamentary democracy: Does it make a

difference? InJuanJ. Linz and Arturo Valenzuela, eds. The failureofpresidential

democracy, volume one: Comparative perspectives and Volume two: The case

of Latin America. Baltimore and London: Johns Hopkins University Press.

Mainwaring, Scott and Matthew Soberg Shugart. 1997. Presidentialism and

democracy in Latin America: Rethinking the terms of the debate. In Scott

Mainwaring and Matthew Soberg Shugart, eds. Presidentialism and democracy

in Latin America. Cambridge: Cambridge University Press.

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-----. 1997. Conclusion: Presidentialism and the party system. In Scott

Mainwaring and Matthew Soberg Shugart, eds. Presidentialism and democracy inLatinAmerica. Cambridge: Cambridge University Press.

_____ . 1993. Juan Linz, presidentialism, and democracy: A critical appraisal.

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Power, Timothy J. and Mark J. Gasiorowski. 1997. Institutional design and

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Center for Social Policy and Public Mfairs and the Philippines-Canada Human

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Shugart, Matthew So berg. 1995. Parliaments over presidents? journal of democracy 6/2 (April): 168-172.

Stepan, Alfred and Cindy Skach. 2002. Parliamentarism vs. presidentialism. In

Jose Abueva, Rey Magno Teves, Gaudioso C. Sosmefia, Jr., Clarita Carlos, and

Michael Mastura, eds. Towards a federal Republic of the PhJ!ippines with a

parliamentary government: A reader. Quezon City: Center for Social Policy and

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Lihok Pideral-Kusog Mindanaw, and Konrad-Adenauer-Stiftung .

. 1993. Constitutional frameworks and democratic consolidation: ------Parliamentarism versus presidentialism. World politics 46/1 (October): 1-22.

Tangco, Pablo. 2002. What makes the parliamentary system superior to the presidential

system. In Jose Abueva, Rey Magno Teves, Gaudioso C. Sosmefia, Jr., Clarita

Carlos, and Michael Mastura, eds. Towards a federal Republic of the Philippines

with a parliamentaJY govemment: A reader. Quezon City: Center for Social Policy

and Governance, Kalayaan College, Local Government Development Foundation,


_____ . 1995. A guide to adoption of a parliamentary government for the

Philippines. Paper presented at the National Conference on Constitutional

Reforms. Manila Hotel, 12 and 13 July.

______ . 1994. The executive in the parliamentary system of government.

Paper presented at The First National Conference on Parliamentary Government.

Westin Philippine Plaza, 4 and 5 December.

Tayao, Edmund. 2002. Consolidating Philippine democracy before it's too late. In

Jose Abueva, Rey Magno Teves, Gaudioso C. Sosmefia,Jr., Clarita Carlos, and

Michael Mastura, eds. Towards a federal Republic of the Philippines with a

parliamentaJY government: A reader. Quezon City: Center for Social Policy and



Timberman, David. 1991. A changeless land- Continuity and change in Philippine

politics. Manila and Singapore: Bookmark and Institute of Southeast Asian

Studies.

Torres, Crisline G. 2003. A review of the pro-parliamentary critique of the presidential

form of government of the 1987 Philippine Constitution. Unpublished

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______ . 2001. The never ending cha-cha beat: How should progressives

dance? Political brief9/7 (November-December): 2-31.

______ . Forthcoming. The Philippine pro-parliamentary position and the

comparative constitutional design literature. Philippine political science journal

36 PUBLIC POLICY

Multiple Constituencies, Bureaucratic Efficiency and

Rational Choice in Public Sector Management

NICETO S POBLADOR

Introduction

Easily one of the hottest topics nowadays in the business world is that of

corporate governance and the related issues of corporate responsibility and managerial

ethics. Serious discussions on these issues have long been held both in academe

and among business circles, but these have turned more serious and acrimonious as

a result of the recent corporate scandals in the United States. At the heart of the

matter is the issue of greed in the corporate world. Not only has the acquisitiveness

of individual managers been denounced from all sides, but indeed, what have

traditionally been accepted as legitimate motives of the business enterprise have

increasingly been called to question.

Poor governance and abuse of authority have long been a major concern in

government, of course, but nothing as unsettling an issue as the Enron case has

rocked the public sector in recent times, certainly not in this country. For all the

continuing public revulsion against bureaucratic incompetence, corruption and abuse

of authority, serious debates on public sector governance have been relatively muted.

Poblador

The Need for a Rigorous Theoretical Framework for the Analysis of Bureaucratic Behavior in the Public Sector

The reason for the glaring neglect of serious theoretical debates on bureaucratic

behavior in government is the absence of a rigorous theory of bureaucracy. In public

sector management literature, there is no theoretical framework as robust as the

neo-classical theory of the firm to serve as basis for such discourse. To put it in

another way, the typical government bureau has no clearly articulated objective

... there is no meaningful criterion to determine the rationality of the choices

made by public sector managers, much less

how efficiently their agencies are performing.

function to serve as basis for determining

whether or not government agencies are

performing efficiently.

While it is true that managers of public

organizations are mandated to achieve

certain goals-for example, to produce so

many units of output for specific

constituencies, or to perform their

responsibilities within certain specified

resource restrictions or prescribed

procedures-these are more in the nature of constraints imposed on them from

without rather than true organizational objectives which they are supposed to pursue

in earnest (Wilson 1989). There is no single variable corresponding to profits that

the bureau manager is supposed to maximize. In the language of linear programming,

the specified constraints enable decision makers in government bureaus to define

their feasible set, that is, the region where they are free to operate, but they don't

have an objective function to maximize. Hence, there is no hypothetical optimal or

equilibrium solution to serve as basis for action. Consequently, there is no meaningful

criterion to determine the rationality of the choices made by public sector managers,

much less how efficiently their agencies are performing. They have no clearly defined

standards for showing that one feasible course of action is preferred to another.

Within the feasible set of options, public sector managers can operate with relative

impunity and the possibility of taking courses of action that are inimical to some

if not indeed to all-of their constituencies is great.

38 PUBLIC POLICY

Multiple Constituencies, Bureaucratic Efficiency and Rational Choice in Public Sector Management

As Shafritz and Hyde readily admit,

There is little, if any, agreement on the standards and measurement of

performance to appraise a government manager .... Government managers

rarely have a clear bottom line, while that of a private business manager is

profit, market performance, and survival. (1997, 387)

With undisguised bafflement, Oliver Williamson wrote,

The public bureaucracy is a puzzle. How is it that an organization form

that is so widely used is also believed to be inefficient-both in relati,pn to

a hypothetical ideal and in comparison with private bureaucracies? (306)

To illustrate our point, consider a typical business firm that seeks to maximize,

say, its market value 1

• It's objective function takes the form

V = f(x 1), 1 = 1, 2, ... , n (1)

where V is the firm's market value, and x is the set of goods and services i

produced by the firm. The firm seeks to maximize V subject to the budget constraint

(2)

where B is its authorized expenditures for the period, and c is the cost per unit i

of the ith product.

Suppose the firm has two outputs, x andy. In Figure 1, the line segment MN

shows the various combinations of x andy that the firm can produce with its given

budget. The contours I through I represent combinations of the two products that I 4

yield different values ofV Applying the "strong" rationality criterion, the firm will

choose combination b of the two products which maximizes the firm's market

value. This is the firm's optimalposition.


Poblador

ProductY

M

14 13

12 11

0~----------------------~~---------N Product X

Figure 1: Choices open to the Business Firm

Suppose the firm were originally at point a and it is considering the alternative

actions of moving to either point c, d or e. Applying the "weak" rationality criterion,

a choice from among these options is rational from the standpoint of the firm if it

will put tile firm in tile best possible position among these options. Tile obvious

choice in this case is to move to combination c as this brings the firm to the highest

possible iso-value contour. Any other choice would have been irrational from the

standpoint of the firm. The move to combination e is especially egregious as this

would actually reduce tile firms market value.

Consider now a public bureau that is mandated to serve two constituencies,

for example, an agency that provides technical assistance to small and medium

enterprises (call this product x) and financial support for aspiring entrepreneurs (y).

To facilitate easy comparison, let us assume that this bureau has exactly the same

budget as the private firm in our previous example.

Suppose that this agency is mandated by the government to produce the

minimum amounts of x and yof the two services.

In Figure 2 below, the agency's feasible set is defined by the triangle MNO,

and its managers are free to chose any combination of its two services within that

40 PUBLIC POLICY


set. If the agency's goal is to minimize its expenditures, they may choose the

combination 0, leaving them free to either realize a surplus, or to divert there sources

thus freed for other purposes, including serving their own personal interests.2

Alternatively, they may choose any other combination within the set, including

combination b which exhausts the budget.

ProductY

M

a • • c

Ymin t-----,:-.-----------..---0

0 '-----:-':X:-m-in--------:-N-:----P-ro-d-uct X

Figure 2: Choices open to the Government Bureau

The point we wish to stress here

is that because the government

agency has no well defined objective

function corresponding to Eq. (1)

above, its managers will be at wits'

ends in determining whether or not a

course of action from among a

number of feasible alternatives will

yield better results than the current

level of performance. For example, in

moving away from point a, which

among combinations c, d and e is the

most preferred? Without a

.. . because the government agency has no well defined objective function corresponding to Eq. (1) above, its managers will be at wits' ends in determining whether or not a course of action from among a number of feasible alternatives will yield better results than the current level of performance.


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hypothetical set of iso-value curves similar to those shown in Figure 1, the best

course of action is impossible to ascertain. Determining the optimal solution is of

course out of the question. Technically, any combination of the two products that

fall within the feasible set, including the minimum quantities mandated by higher

authorities, qualifies the bureau as having met its objectives.

From these simple hypothetical cases, we can only conclude that a clearly

defined objective function is an essential ingredient of an economic theory of

bureaucratic behavior. Without one, neither the rationality of choice of bureau

managers nor the economic efficiency of the agencies they manage can be established

with any degree of certitude.

Rational Choice In Private sector M~nagement

In classical microeconomic theory, the goal of the firm is to maximize profits,

and by our loose definition of the term, any decision that enhances profits is rational.

Applying this criterion in firms that are managed by their owners poses no

difficulty because profit maximization is obviously in the interest of the owner

manager. However, problems arise in applying this rationality norm in most other

forms of business organization where the owners of the firm are not necessarily the

same persons as those who run the day-to-day affairs of the enterprise. In most (but

certainly not all) business corporations, managers have no claim to the firm's residual

income. While corporate shareholders seek to maximize the market value of their

shares (which reflects the long-run profitability of the enterprise), managers seek to

maximize their incomes and to enhance the marketability of their professional

services. The principal-agent problem arises precisely because of conflicts of interests

between the owners of the firm (the principals) and the professional managers who

run the business for them (their agents).

There are however reasonably effective mechanisms by which to co-align the

interests of principals and agents, mainly by linking compensation and promotion

to corporate performance. Thes1 arrangements are governed by contracts which

describe the terms and conditions of employment of company managers and

workers. However, no matter how elaborately designed these contracts are, they

42 PUBLIC POLICY


are never complete in specifying all possible contingencies that may arise during the

period of employment. Due to information asymmetries between principals and

agents and opportunistic behavior on the part of managers)/ profits are never

maximized because part of the firm's resources are very likely to be diverted to

serve the personal interests of the managers.3

These obvious limitations notwithstanding, corporate managers can still be

assumed to earnestly pursue the financial objectives of their employers because

doing so is in keeping with their efforts to maximize their own economic well being.

Rational Choice In Public sector Management

Public Choice Theory, the theoretical framework that underpins current thinking

in public governance, draws heavily from the principal-agent theory of the firm 4

• In

public choice theory, voters are considered to be the main principals while their

elected officials are their direct agents. These elected officials, working on behalf of

those who put them in office, are supposed to undertake programs and provide

services that are intended to serve the public interest. However, they seldom do so

in practice because they are more interested in enhancing their own political and

economic fortunes. If there is anything at all that they seek to maximize, it is their

votes (Downs 1957), taken here as proxy for their personal interests, which include

power, income and the prestige that go with their positions (Weingast 1984 and

Downs 1957).

Politicians maximize their votes by

currying favors not to the voters directly

but to organized political groups and

powerful members of the community who

can deliver the votes. These power blocks

within the body politic have interests that

do not necessarily coincide with those of

society as a whole. 5They pursue their own

political and economic interests by

engaging in a variety of rent-seeking

. .. elected officials ... are supposed to undertake programs and provide services that are intended to serve the public interest. However, they are more interested in enhancing their own political and economic fortunes.

VOLUME VII NUMBER 2 (July· December 2003) 43

Poblador

behavior, such as by actively lobbying politicians and government officials to support

their causes. Politicians accede to their demands in exchange for the votes that they

can deliver. Thus, while politicians make choices that are rational from the standpoint

of their selfish political and economic goals, these are seldom in the interest of

society as a whole.

To implement their political agenda, politicians appoint officials to manage the

bureaucracy and to run the day-to-day operations of government. At this level,

politicians serve as the principals for whom their appointed department heads and

bureau officials act as agents. It is in the personal interest of these agency managers

to implement programs as directed by those who put them in office. It is therefore

only to be expected that their choices will favor their political benefactors more

than the constituencies that they are supposed to serve. As a rule, agency managers

As a rule, agency managers have no

strong incentives to serve the public

interest.

have no strong incentives to serve the public interest.

This problem is compounded by the fact that the

entire government bureaucracy consists of layer upon

layer of bureaucrats, one level acting as principals to

those immediately bellow them (Moe 1984). The

lowest level bureaucrats who actually deliver services

directly to their constituencies are several layers

removed from the electorate and are therefore relatively insulated from them. In

the absence of extensive and effective monitoring and control mechanisms, it is too

far-fetched to expect them to dedicate themselves to the public interest. In pursuing

their own personal goals (which take the form of higher salaries and promotions),

lower-level managers of public agencies will tend to do the bidding of those who

put them in office, subject only to applicable laws and existing administrative rules

and procedures, if at all.

Suffice it to say that even the most well-meaning of agency managers cannot

truly serve the public interest because they are subject to a plethora of ambiguous

and often conflicting signals that are imposed on them from various sources. By

contrast, managers of private firms have a single, clear-cut objective: to maximize

returns on their employers' investment. The realization of their own individual

goals depend in large measure on their success in creating value for the firm, and it

44 PUBLIC POLICY


is therefore in their interest to run a tight ship. To do otherwise would expose them

to the harsh judgement of the "invisible hand" of market competition.

In public choice theory, all major actors in the public arena- the electorate,

their elected officials, and those appointed by them to manage the bureaucracy

are assumed to be utility maximizers and are therefore expected to behave rationally

(Boston, et al. 1996). They are, however, driven by different and frequently

conflicting objectives. What may be rational or efficient from the perspective of the

individual bureaucrats may not be so with reference to the economic interest of the

constituencies that they are supposed to serve, and even less so in terms of the

economic interests of society (Simon 1997 and Steiss 2003).

Institutional sources of Bureaucratic Inefficiency

It is truly ironic that even when public agency managers are sincerely concerned

about the well-being of their constituencies, they cannot be efficient under the

institutional arrangements in which they operate. Aside from the absence of a well

defined objective function for the public bureau, there are many other factors that

contribute to bureaucratic inefficiency.

Inherent Limitations of Bureaucratic organization

The bureaucratic organization, with its emphasis on adherence to rules, strict

conformity to operational procedures, task specialization and administrative

accountability, is generally considered to be ineffective in achieving stated

organizational goals. While Max Weber has claimed that bureaucratic organization

brings technical efficiency to the highest possible levels (1973), most subsequent

writers on organization and management have argued that bureaus of the Weberian

mould tend to be economically inefficient.6

Excessive controls, they claim,

unnecessarily limit the range of choices open to managers and prevent them from

responding creatively and in a timely manner to continually changing circumstances.

As a result, they fail to create economic value due largely to missed opportunities.

Moreover, strict adherence to established rules and procedures and extreme

authoritarianism in the organization tend to stifle individual initiative and discourage


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efforts to exceed minimum acceptable levels of performance. Finally, carried to

extremes, division of labor and task specialization encourage bureau managers to

pursue the goals of their own units rather than those of the organization as a whole,

and, as a result, fail to combine their complementary activities to create value through

synergy.

Incompetence in the Government Bureaucracy

Incompetence in the government bureaucracy stems from a number of factors.

To begin with, the odds are great that less than capable individuals are recruited

into public service. In the private sector, job applicants are evaluated largely on the

basis of their training and experience, and only the most qualified for the job are

hired. This is seldom the case in the public sector where appointments to

Since their contribution to agency performance is

difficult to measure in any meaningful way, it is

easy for public agency officials to conceal their

administrative positions are based largely on

personal considerations rather than on

technical or managerial capabilities.

Additionally, a good deal of self-selection

takes place among job seekers, the more

competent among whom shy away from

government positions in favor of better-paying

jobs and greater opportunities for professional

incompetence. advancement in the private sector.

Once in office, political appointees have

little incentive to develop their professional skills and to excel on the job. Since

their contribution to agency performance is difficult to measure in any meaningful

way, it is easy for public agency officials to conceal their incompetence. For the

same reason, promotions and salary adjustments are usually made on the basis of

criteria other than accomplishment, such as length of service, strict compliance

with established procedures, and most contemptibly, subservience to their superiors

and political patrons. It is not s11rprising therefore that government bureaus are

mostly under incapable hands.

To be sure, their generally lower levels of technical and managerial competence

do not necessarily make public sector officials any less rational than their counterparts

46 PUBLIC POLICY


in the private sector, at least not insofar as their self-seeking behavior is concerned.

However, because they are generally endowed with less cognitive and technical

skills, their choices can only be expected to be much less optimal. They may be

rational but, in the words of Nobel Laureate Herbert Simon, they are more boundedly so (1997, 88).

Bureaucratic Integration and Transactions costs

In managing their supply chains, private firms limit their productive activities

to those in which they posses the highest level of technical competence, and acquire

other required physical inputs and services from outside suppliers and distributors.

In entering into these strategic arrangements, firms incur what are called transactions

costs. These are costs that are intended to insure that the terms of contract are

carried out to the letter.7

The optimal range of activities that a firm will undertake

(or the degree to which it is vertically integrated) is that which minimizes the sum

of their production and transactions costs. 8

As a rule, managers of government agencies are loathe to outsource peripheral

activities within their administrative responsibilities even if doing so will result in

greater cost effectiveness in their operations. The reason, quite simply, is that

spinning off costly or redundant activities to private firms or to other government

agencies will reduce the size of their bureaus and therefore runs counter to their

personal interest.

Inefficiency in the Allocation of output

In the private sector, firms provide goods and services to customers in exchange

for the prices paid for them. Prospective customers will purchase their products

only if they perceive higher values in them than the prices they are required to pay.

Those for whom the perceived value of a product is less than the price will not

purchase the product at all. In private-sector transactions, price serves as the

mechanism by which economic goods are made available only to those who will

realize an economic surplus from their purchase. Except where there are significant


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external effects in production or consumption, the price system insures an efficient

allocation of economic goods among their users.

In the public sector, there is no such mechanism to allocate output efficiently.

Even where bureaucrats are benevolent, they can never be efficient in distributing

their products. In most societies, privately consumed government services such as

education and health services are grouped into "slots" that are allocated to

government agencies for distribution to deserving citizens (Banerjee 1997). However,

agency managers are unable to observe the value of these services to their customers.

By taking their words at their face value, they are often misled into providing the

goods to users who have far less need for them than others. The result is a distribution

of goods that is non-Pareto optimal.9

What coals do Bureaucrats Pursue?

In the absence of something akin to profit maximization as an objective, what

goals do government bureaucrats typically seek in practice? For want of a theoretically

elegant model of choice to serve as a guide for action, public choice theorists have

looked at a number of surrogate measures of bureaucratic performance. We focus

on two: budget maximization and cost minimization.

Budget Maximization

Niskanen (1971) has shown that self-seeking bureaucrats typically attempt to

justify and to perpetuate their sinecures by attempting to maximize their budgets.

This objective obviously also serves the interests of the politicians who put them in

office as these would provide them extra leverage in expanding their political power

bases. Pursuing such a goal is obviously rational from the bureaucrats' standpoint

because it enhances their income potential and the prestige that goes with high

office. However, this certainly does not serve the public interest.

Maximizing the size of the bureau (as measured by the level of its expenditures)

implies that the agency will extend its activities up to or even beyond the point

where the total value of output is exactly equal to their budgets. Under the usual

concavity assumptions, these levels of activities are non-optimal.

48 PUBLIC POLICY


In Figure 3, the quantity of output is

measured along the horizontal axis and the

nominal value of output to society along the

vertical axis. The agency's budget is also

indicated along the ordinate. The line OB

represents the budget in relation to output and

assumes a constant average cost. The curve V

shows the value of output to society at different

self-seeking bureaucrats typically attempt to justify and to perpetuate their sinecures by attempting to maximize their budgets.

levels of operation. Suppose the agency starts with a budget of B . At this level of I

operation, the bureau produces OQ units of output and contributes ab in net I

economic value to society. Increasing the budget to B is rational from the standpoint 2

of both the agency managers and of society as this enables the bureau to increase its

contribution to the community's economic wellbeing to a1b

1 ( > ab). At this level of

operation, the bureau produces OQ units of output and its net contribution to

social welfare is maximized at a1b

1. AAy further increases in its budget beyond this

point will result in a net decline in welfare. Producing output OQ with a budget 3

(total cost) OB will yield a net value of zero to society. Increasing the budget 3

beyond B will actually destroy value. Ironically, such moves are consistent with the 3

maximization of the incomes of both the bureaucrats and their political sponsors

and are therefore rational from their perspectives. Budget; Value of Output

a'

v

""------L-.....L_ _____ ___L_ ___ ___j___ Quantity 0 o, 02 03 O, of Output

Figure 3: Maximization of the Agency's Budget


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Loss Minimization.

Lane ( 1993) has noted that in the public choice theory framework, economic

inefficiency does not necessarily imply inefficiency in the internal operations of the

bureau, or that waste is flagrantly tolerated. To the extent that they are evaluated

partly on the basis of the cost -effectiveness of their operations, bureaucrats sometimes

attempt to minimize the cost of producing a given level of output.

In Figure 3, bureau managers may seek to shift the budget line OB to OB I

through deliberate attempts to reduce the per unit cost of output. Thus, if the agency

has decided on producing Q units of output, it may attempt to minimize the total

cost of producing that amo~nt to OB 1

• In this way, it is able to generate a"b" in 3

economic welfare. This strategic move would have been rational from society's

viewpoint since it will generate a positive increment in economic value. However,

the process does not necessarily end here. The improved cost picture will enable

self-seeking agency managers (with the usual backing of their sponsors) to increase

output to OQ and still operate "within budget," so to speak. Indeed, improvements 4

in the agency's internal operations may serve to justify further budgetary allocations.

As it turns out, cost minimization is often just a subterfuge for expanding the bureau!

A Value-Maximization Model of Bureaucratic Behavior

In searching for an alternative theoretical model for explaining, or more

appropriately, prescribing choice criteria in government, we must abandon the

traditional Weberian definition ofbureaucracy.10

Instead, we define the government

bureau as an institution intended to create value for society and to allocate this

among its members. By this definition, the government bureau is viewed as an

entity that is mandated to serve the interests not only of its constituencies but those

of all its stakeholders taken altogether. 11

In a typical business firm, the stakeholders include the owners of the business

enterprise (or shareholders, in the case of publicly-owned corporations), employees,

customers, and the community or society at large. The "owners" of a government

bureau are the members of society, as represented by the electorate. We call the

direct beneficiaries from its activities constituencies rather than customers for the

50 PUBLIC POLICY


reason that they normally do not pay for the services that they receive. Otherwise,

both private firms and government agencies, as well as non-profit organizations and

other forms of productive institutions essentially have identical sets of stakeholders.

In some cases, a number of stakeholders of a government bureau may have

coincident interests. For example, a welfare agency

that serves the needs of street children also benefit

the parents, commuters, and all of society.12

Quite

often, however, the different constituencies served

by the government bureau have conflicting interests,

and the interest of one can only be served by

sacrificing some benefits to others. Typically, there is

As it turns out, cost minimization is often just a subterfuge for expanding the bureau!

no way of telling whether the benefits accruing to some outweigh the damage done

to the economic well-being of others. Such situations arise when there are significant

external diseconomies associated with an activity. For example, by setting up

protective tariffs on imported cement, the government serves the interests of the

cement industry. However, this is made possible at the cost of higher prices to

consumers. In many cases of this nature, the gainers gain less than what the losers

lose.

The profit maximization model of the firm has recently fallen into disrepute

because it looks at the interest of only one of the firms many stakeholders, namely

the owners of the firm, or its shareholders. In its place, stakeholder theory has

assumed increasing prominence in the recent management literature.13

According

to this theory, managers should show concern for the interests of all groups that

have a legitimate stake in the corporation. This alternative conceptual framework

has served as the main rationale for current thinking on corporate governance

(Poblador 2002).

However, stakeholder theory, as currently articulated, is flawed for several

reasons:

( 1 )It fails to specify the corporation's objective function in terms of a single,

well-defined variable and therefore fails to identify an optimum or equilib

rium point. Because of this, it does not provide a theoretical basis for ratio

nal choice. This model in particular fails to provide managers with the ratio-


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nal basis for establishing trade-offs between the conflicting interests of their

stakeholders. As a consequence, decision makers are at a loss in determin

ing whether one course of action is preferred over another.

(2)In the absence of a well-articulated criterion for rationality and objective

measures of performance, managers have to be "empowered" to exercise

discretion, subject only to incompletely specified contracts. As a result, cor

porate managers are able to maneuver within their areas of accountability

and divert resources to unintended purposes. This in turn requires more

monitoring and supervision and thus increases what are called agency costs.

(3) Stakeholder theory politicizes the corporation by sharply drawing the bound

ary lines among the various stakeholders. As a result, the enterprise emerges

as a zero-sum game, and stakeholders are put itt a confrontational relation

ship vis-a-vis one another (Poblador 2002).

For all these reasons, the currently accepted interpretation of stakeholder theory

is equally inapplicable to government bureaus, all the more so because oversight

mechanisms are generally much weaker in the public sector.

On a purely theoretical plane, it is not only difficult but impossible to

simultaneously maximize the separate interests of all stakeholders, certainly not

when these interests are incompatible.

How, then, can the enterprise fully serve the collective interests of all its

stakeholders?

A possible way out of this dilemma is to state the goal of the productive

organization in both the public and private sectors in terms of maximizing economic

value in general and not just that accruing to a particular stakeholder or group of

stakeholders. By stating the organization's objective function in terms of a single

maximand, it becomes possible to define rationality and economic efficiency. More

importantly, it enables us to determine, or at least approximate, the appropriate

trade-off among the interests of the different stakeholders in the enterprise.

Estimating the economic value created by a private firm for its customers is a

relatively straightforward endeavor because this can be gauged directly from the

prices that their customers are willing to pay for their products and services. As we

52 PUBLIC POLICY


have noted earlier, customers who purchase their products and services are those

who value them more highly, or at least as much as the prices that they pay for

them. Those who do not purchase a product can be assumed to attach less value for

it than the price. By entering into market transactions with their customers, there is

therefore reasonable assurance that firms create economic surplus for them. Finally,

the existing market prices for both outputs and inputs enable business firms to

factor externalities into their cost estimates with relative ease, and in this way address

more effectively the economic interests of their other stakeholders.

There is no such price mechanism in the public bureaucracy to guide public

agencies in their decisions on the levels of output and on how to allocate their

outputs among their different constituencies. There being no price to separate those

who are willing to purchase their products from those who are not, the differential

valuation of their services among the users cannot readily be established. The

unavoidable consequence is inefficient distribution and hence, less than maximized

welfare for their constituencies. Alternative ways must therefore be explored to

gauge the value that public agencies create for their intended direct beneficiaries as

well as those who are indirectly affected by their activities.

Private firms go to great lengths to study their markets and to know their

customers better. Progressive companies typically conduct periodic market studies

(or demand analysis) the findings of which serve as basis for their product design

and pricing strategies. Government agencies should do no less.

Taking their cue from their counterparts in the private sector, managers of

government agencies can estimate the value placed by their constituencies on the

goods and services they produce by looking at a number of indicators of consumer

preferences. Economics textbooks list a number of determinants of demandwhich

include income, prices of substitutes, and relevant personal circumstances of

consumers. Where income figures are hard to come by, agency administrators may

conduct lifestyle checks on their constituencies to determine their capacity to obtain

their services from alternative sources. Most goods and services provided by

government agencies have close substitutes in the private sector. The prevailing

prices of these products provide a good basis for establishing the perception of

value of the services that they offer to their constituencies. For example, tuition fees


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charged by private universities provide administrators of state universities useful

inputs for determining their own tuition and scholarship policies.

In many cases, consumers themselves provide signals of their preferences. For

example, patients who adamantly insist on superior medical treatment are most

likely to be the ones who attach little value to free medical services offered by

government hospitals. Those who queue up early for their share of publicly provided

services are more likely than not to value these services more highly than late comers.

In most cases, self selection automatically eliminates potential users of government

services. These include patients who choose to go to private hospitals rather than

seek the services of government hospitals or health clinics, as well as lawbreakers

who would rather seek the legal services of private lawyers rather than those of a

public defender.

Once the demand for its output has been approximated, a government bureau

will be in a much better position to decide on how to allocate its services between

its constituencies and among the members of a particular constituency. Let us

consider a number of hypothetical situations.

The Simplest case: serving A Single constituency

The lineD in Figure 4 is the estimated demand curve for the services rendered

by a government agency to a particular constituency. Output is assumed to be

produced at a constant cost of Oc per unit. With an unlimited budget, the agency

maximizes its contribution to value by producing OQ units of output. At this level

of operation, the total value generated by the bureau is indicated by the area abc

which is the difference between the value of the output to the users (area abQO)

and the total cost of production ( cbQO). It can readily be seen that any other level

of output will yield a lower net economic value. If the agency's budget were set at I I I

a lower level cb Q 0, the agency will produce OQ units of output, and total value

generated is the lightly shaded area aa1b

1c. If the agency is able to increase its budget

11 II II by the amount bb Q Q and produce additional output QQ , the increase in total

cost will exceed the corresponding increase in value to consumers, and net economic

54 PUBLIC POLICY


value declines by the heavily shaded area bb11

a11

. This clearly demonstrates that

the goal of maximizing an agency's budget without limit is not compatible with the

goal of maximizing value overall.

Cost per unit of Output; Value of Output

a

0 Ql Q

Figure 4: Maximizing Value for a Single Costituency

D

Quantity of Output

Even in this simple situation, the agency faces the serious problem of

determining how to allocate its output among the members of its constituency, all

of whom are presumably entitled to it. In Figure 4, the budget -constrained agency

must make certain that only consumers whose reservation prices are indicated along

the portion aa1 of the demand curve are served, and those who value the product at

less than a 1 Q

1 (i.e., those whose reservation prices lie along the portion of the demand

curve further to the right of point a1

) are not. In identifying the individuals who are

entitled to the agency's service (i.e., those who attach a value the product that is

greater than its average cost), the agency may use estimates of the various demand

parameters discussed earlier (i.e., income, prices of substitutes, etc), along with a

variety of signals coming from the customers themselves.


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serving Either one constituency or Another

Suppose now that the agency may provide its service to either one constituency

or another, for example, one of two communities in need of additional facilities for

child care. For simplicity, let us assume identical costs in both communities but

that the need is more intense in one community than in the other. In Figure 5, D a

and D are the demand curves for the needed facilities in Communities A and B,

respec~ively, and Oc ( = Oc 1

) is the corresponding cost per child of producing the

required facilities. Under the assumed demand conditions, greater value will be

generated by constructing the facilities in Community A rather than in Community

B. Facilities good for OQ pre-schoolers will be built at a total cost of cbQ 0, and

net value generated is indicated by the area abc. Had the facilities been built in

Community B, less value (a 1b

1 c

1) would have been generated. This simple illustrative

The services of a government bureau

should be provided to those constituencies where more value is

generated.

exercise yields this general rule: The seJVkes of a

government bureau should be provided to those

constituencies where more value is generated

The experience of the Metro Manila

Development Authority with sidewalk vendors

along EDSA serves as a good illustrative example

of a situation where public facilities may be enjoyed

by either one constituency or another. In this case,

the economic value of the use of sidewalks to

commuters who traverse EDSA must be weighed against the value of these sidewalks

to vendors in terms of the income they are able to realize from their use. In deciding

to clear the sidewalks of vendors, the MMDA has obviously calculated that the

value of the use of sidewalk to commuters (in terms largely of additional incomes

earned due to the easing of traffic) far outweighs the income loss to the vendors by

depriving them of their venue to ply their trade.

56 PUBLIC POLICY

Value, cost per unH of Output

a


Value, cost per unit of Output

a1

0~------------~----------Qa Quantity 0

of Output

Constituency A Constituency B

Figure 5: Value Creation for Either of Two Constituencies

serving Multiple constituencies

Quantity of Output

Let us now consider the more typical case where the public agency

simultaneously serves several constituencies. In Figure 6, D and D are the demand a b

curves for two different services provided by the agency to Constituents A and B,

respectively. These products cost Oc and Oc per unit, respectively. In the absence a b

of a budget constraint, the welfare-maximizing levels of output are OQ of product a

X and OQ of product Y b

If the total agency expenditures allowed are less than the amount necessary to

produce the value-maximizing levels of output, the agency must allocate its budget

between its two constituencies in such a way that the last unit of expenditure will

yield equal net increments to value for both. In the diagram, the agen9's budget is

set at B = c dQ 10 + c d

1Q

10 . In order to maximize value created in both

a a b b I I constituencies, the agency must produce OQ and OQ of the two products.

With this allocation, the last unit of expenditu;e will yield td in marginal value for

Constituency A and b'd' ( = bd) for Constituency B, and total value generated is

the sum of the shaded areas abdc and a1b

1d

1c . Any other allocation scheme will

yield less total value. a b


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Value and cost per unit of product x

OL_ ______ -L~----~--------a! a. Quantity

of x

Constituency A

Value and cost per unit of product y

0

Constituency 8

Figure 6: Maximizing Value for Two Constituencies

Implications on Performance Evaluation and compensation of Bureau Administrators

Quantity of y

In arguing for value maximization as the ultimate goal of public-sector

management, we must also rethink the criteria for rewarding government bureaucrats

in order to make their personal interests coincide more closely with those of their

constituencies and of society as a whole. The prevailing standard set of performance

evaluation criteria used in the government bureaucracy should give way to one that

is more in keeping with value maximization. In particular, rather than basing their

compensation and promotion on how closely government bureaucrats adhere to

prescribed rules and regulation of the government bureaucracy, or how adequately

they have provided specified amounts of services to particular constituencies, they

should be evaluated on the basis of how much value they have generated overall. In

this way, the interests of the individual bureaucrats are harmonized with those of

their constituencies and other stakeholders in their agencies. What is then rational

from the standpoint of their individual economic interests also becomes rational

with respect to the interest of their constituencies and of society as a whole.

58 PUBLIC POLICY


Endnotes

1 The market value of a firm reflects the market's assessment of its profitability.

2 Resource diversion in organizations is discussed in Jensen and Meckling (1976).

3 Williamson (1985); Milgram and Roberts (1992); Jensen and Meckling (1976).

4 Seminal works in the field include those of Buchanan and Tullock (1962) and Niskanen

( 1971 ). An excellent introductory summary of the basic tenets of this school of thought can be

found in Felkins (2001).

5 Prendegrast (2003); Bennedsen (2000); Self (1985).

6 Among the early detractors ofWeber and the so-called scientific management school are Douglas

McGregor (1960), Rensis Likert (1961), and Daniel Katz and Robert Kahn (1978).

7 Transactions cost also include potential loss of opportunities arising from being locked into a

contractual arrangement that may has cease to be advantageous to the organization.

8 Williamson (1985). See also Besanko (2004) and Milgram and Roberts (1992).

9 That is, a redistribution of goods from users who value the products less to those who value.

them more is bound to increase economic welfare overall.

10 Max Weber (1947) formulated a theory of bureaucracy that stresses the rational-legal

characteristics of modem organizations. In the Weberian (i.e., "classical") tradition of organization

theory, an act is rational if it conforms to formally established rules and procedures.

11 The intended beneficiaries are easy enough to identify for certain government bureaus but not

for others. For those that provide direct benefits such as health, welfare and education, the

"customers" are warm bodies that can readily be identified. But for many others, for example,

the military and the foreign service, the beneficiary is society itself and not any particular group

of individuals.

12 Providing such a service is said to have significant positive external effects.

13 See, for example, Donaldson and Preston (1995); Wheeler and Sillanpaa (1977).


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References

Banerjee, Abhijit. 1997. A theory of misgovernance. Quarterly joumal of economks.

1289- 1332.

Bennedsen, Mortem. 2000. Political ownership. joumal of public economics 76:

559- 581.

Besanko, David, et al. 2004. The economks of strategy. New York: Wiley.

Boston, Jonathan, et al. 1996. Public management: The New Zealand model New

York: Oxford U. Press.

Donaldson, Thomas and Preston Lee E. 1995. The stakeholder theory of the

corporation: Concepts, evidence and implications. Academy of management

review20: 65-91.

Downs, A. 1957. An economic theory of democracy. New York: Harper and Row

Felkins, Leon. 2001. Introduction to publk choice theory. unpublished manuscript

[online]. Available from World Wide Web: (http://www.magnolia.net/-leonf/

sd/pub-choice.htrnll

Freeman, R. E. 1984. Strategic management: A stakeholder approach. Boston:

Pitman Publishing.

_____ and William H. Meckling. 197 6. Theory of the firm: Managerial

behavior, agency costs, and ownership structure.joumal of financial economics

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Katz, Daniel and Robert Kahn. 197 8. The social psychology of organizations. New

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Laffont, Jean-Jacques. 2002. Public economics yesterday, today and tomorrow.

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Lane, Jan-Erik. 1993. The public sector: Concept~ models and approaches. London:

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Levine, Charles H., Guy B. Peters and Frank J. Thompson. 1990. Public

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Likert, Rensis. 1961. New pattems of management New York: McGraw-Hill.

McGregor, Douglas. 1960. The human side of enterprise. New York: McGraw-Hill

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Milgram, Paul and John Roberts. 1992. Economics, organization and management.

Englewood Cliffs, N.J.: Prentice Hall.

Moe, T. 1984. The new economics of organization. American journal of political

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Poblador, Niceto S. 2002. Stakeholdership, corporate responsibility and the ethics

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Prendegrast, Canice. 2003. The limits of bureaucratic efficiency. Journal of political

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Self, P. 1985. Political theories of modern government: Its role and reform. London:

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Shafritz,Jay M. and Albert C. Hyde.1997. Classics in public administration. New

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Simon, Herbert A. 1997. Administrative behavior: A study of decision-making

processes in administrative organizations. 41

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Steiss, Alan Walter. 2003. Strategic management for public and nonprofit

organizations. New York: Marcel Dekker, Inc.

Weber, Max. 1973. From Max Weber: Essays in sociology. New York: Oxford U.

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Weingast, B. 1984. The congressional bureaucratic system: A principal-agent

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Williamson, Oliver E. 1999. Public and private bureaucracies: A transactions cost

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_______ . 2000. The new institutional economics: taking stock, looking

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Mix of Resources in Seven Devolved Antique Hospitals and

their Corresponding Output/ Outcome Indicators, 1998-2002:

Policy Implications Fernando M Sison and Feman Rene M Autajay

Introduction

In a Health Sector Reform Agenda monograph series published by the

Philippine Department of Health, the performance of provincial and district

hospitals was generally described as poor (DOH 1999). This study was undertaken

after the implementation of Republic Act No. 7160 which mandated, among

other things, that provincial, district, and municipal hospitals be devolved to the

provincial governments. In a Samar study, it was discovered that 25- and lO-bed

hospitals were economically inefficient to maintain (Rillon, et. al 2002) after

hospitals were devolved to the local government units in 1993. In a study by the

Economic Development Foundation, which was commissioned by the Department

of Health and looked into the effects of devolving hospitals to the local government

units, one of the findings was that internal revenue allotments (IRAs) received by

the provinces were inadequate to finance the costs of devolution. Since there was

no separate funding allocated for the costs of devolution, provinces had to finance

these out of their IRA and, consequently, they experienced shortfalls in their

operating budgets. Because of this situation, the local government units had to

Sison & Autajay

substantially decrease their support for devolved units. Infrastructure projects

were considered by some local executives to be more important than health services

or public health programs. Consequently, funding of the latter was neglected.

One of the recommendations of the study was to extend assistance in conducting

studies to determine the viability of inter-local government unit collaboration in

the form of user-charging for a more effective and efficient hospital operation.

Hence, it is important to continually assess the effects and the progress so far

achieved in the implementation of devolving public hospitals to local government

units.

64

The objectives of this research study are:

1) To describe the profile of the primary and secondary public hospitals in

Antique using the following indicators:

(a) Proxy Indicators of Efficiency (Averaged from 1998-2002)

(i) Bed Occupancy Rate

(ii) Cost per In-patient Discharge

(iii) Cost per In-patient Day

(b) Proxy Indicators of Quality of Care (Averaged from 1998-2002)

(i) Gross Death Rate

(ii) Net Death Rate

(iii) Infant Mortality Rate

(iv) Fetal Death Rate

( v) Maternal Mortality Rate

(vi) Neonatal Death Rate

(vii) Cesarean Section Rate

2) To explore possible mechanisms which can be adopted or developed to

augment the budget for health services in municipal and district hospitals

to ensure continued operations and viability of these devolved hospitals by

studying the oper\ltional and financial reports of the seven devolved hospi

tals in Antique province;

3) To determine the relative mix of resources used in these hospitals and to

establish relationships between the mix of resources of these hospitals and

their corresponding output or outcome indicators which can consequently

PUBLIC POLICY

Mix of Resources in Seven Devolved Antique Hospitals and their Corresponding Output/Outcome Indicators, 1998-2002: Policy Implications

be used for planning and for policy formulation and development especially

insofar as hospital reforms are concerned.

Materials and Methods

This is a descriptive-analytical study which utilized the following operational

and financial reports of the seven devolved hospitals in Antique province for the

years 1998-2002: 1) hospital statistical reports, 2) itemized hospital collections, 3)

itemized statement of expenditures, and 4) hospital assets listings. Operational

and financial rates and ratios were computed, averaged from 1998-2002, analyzed,

compared with each other, and interpreted.

Hospital data were categorized into two groups according to implementing

bed capacity (25 beds and::;; 15 beds). The three secondary and one primary 25-

implementing beds hospitals therefore comprised one group while all the three 15-

and 10-implementing beds primary hospitals comprised the second group.

Categorizing these hospitals into these two groupings ensured a homogenous patient

mix, disease patterns, manpower complements within each category.

The following seven devolved hospitals of Antique province were included in

this study:

Name of Hospital Implementing Hospital

Bed Capacity Classification

1. Valderrama Municipal Hospital (VMH) 10 Primary

2. Bugasong Medicare Community

Hospital (BMCH) 15 Primary

3. Pedro Gindap Municipal Hospital (PGMH) 15 Primary

4. Culasi District Hospital (CDH) 25 Secondary

5. Gen. Leandro L. Fullon General Hospital (GLLFGH) 25 Secondary

6. Pres. Diosdado Macapagal Hospital (formerly Gov.

Mamerto Portillo District Hospital) (PDMH) 25 Primary

7. Ramon Maza Sr. Memorial DistrictHospital (RMSMDH) 25 Secondary


Sison & Autajay

By definition, a primary hospital has the service capability to render primary

care services in medicine, pediatrics, obstetrics and minor surgery. A secondary

hospital, on the other hand, renders gynecology, general surgery, ophthalmology,

anesthesia and other ancillary services in addition to the services provided by a

primary hospital.

The proxy indicators used in this study were performance indicators, such as

bid occupancy rate, and financial indicators, such as average total expenditures.

These indicators were correlated with output indicators such as average total in

patient days of care and average in-patient discharges among the hospitals in the

two categories, input mix indicators such as the full time employees per implementing

bed, and output-input mix indicators such as average cost per patient day and average

cost per discharge. Their formulae are given in Annex 1.

The proxy indicators of quality of care used in this study are composed of

seven rates which are commonly used in studies involving hospital operations.

Their defining formulae are given in Annex 1.

In this study, proxy indicators of economic efficiency are defined as follows:

• Bed occupancy rate- 70% (based on Hospital Medical Records Manage

ment Manual, DOH, ld Edition)

• Cost per in-patient day- approaching PhP 1,550.00/day (based on PhP

1,539.00 for uninsured patient, DOH, 1999)

• Cost per discharge- approaching PhP 6,000.00 (for four days of hospital

ization, based on PhP 5,881.00, DOH, 1999)

In this study, the proxy indicators of quality of care are defined as follows

(based on Hospital Medical Records Manual, DOH, ld Edition):

• Gross Death Rate- below 3%

• Net Death Rate- below 2.5% (acceptable by Western standards)

• Infant Mortality Rate- below 2% (acceptable by Western standards)

• Fetal Death Rate- below 2%

• Maternal Mortality Rate -up to 25%

• Cesarean Section Rate- 3-4% (acceptable by Western standards)

66 PUBLIC POLICY


Results

Pres. Diosdado Macapagal Hospital, in the cluster of 25-implementing beds

hospitals, and Bugasong Medicare Community Hospital, in the grouping of~ 15

beds, were the most efficiently run in terms of their input-output mix or ratios. This

means that they had the lowest resources or inputs (e.g., full time employees, full

time employees per implementing bed, personal services, salaries, total budget)

while still having comparable output indicators as the other hospitals in their

respective categories (e.g., admissions, discharges, patient days of care, total

revenues) (Tables 1-2).

TABLE 1. Average Operational & Financial Statistics for Four 25-lmplementing Beds

Hospitals in Antique, 1998 -2002

Implementing FTE

FTE per Implementing Bed

Personal Services

Salaries

Admissions

Discharges

Patient Days of Care

Total Budget

Total Revenues

Total Expend.

Culasi District

Hospital

(5 yr. ave.)

47

3.006

Php 7,486,044

Php 4,515,600

1,377

1,417

5,911

Php 8,405,554

Php 530,635

Php 8,382,516

Gen. Leandro

L. Fullon

Gen. Hosp. (4 yr. ave.)

43

2.745

Php 6,631,230

(5 yr. ave.)

Php 3,882,176

(5 yr. ave.)

1,612

1,762

5,865

Php 8,103,169

Php 405,133

Php 7,460,529

VOLUME VII NUMBER 2 Guly- December 2003)

Pres. Diosdado

Macapagal Hosp.

(3 yr. ave.)

40

2.5

Php 6,287,998

(5 yr. ave.)

Php 3,779,079

(5 yr. ave.)

1,672

1,708

5,798

Php 8,869,322

Php 633,563

Php 7,248,711

Ramon Maza Sr.

Memorial District

Hospital

(5 yr. ave,)

46 (4 yr. ave.)

2.27 (4 yr. ave,)

Php 7,881,541

Php 4,636,426

2,566

2,664

7,605

Php 8,858,664

Php 727,195

Php 9,060,465

67

Sison & Autajay

TABLE 2. Average Operational & Financial Statistics For the Two 15-lmplementing Beds

Hospitals & One 10-Beds Hospital in Antique, 1998-2002

Bugasong Medicare Pedro Gindap Valderrama

Community Hosp. Municipal Hospital Municipal

(BMCH) (PGMH) Hospital

5 Years' Average 4 Years' Average (VMH)

4 Years' Average

Implementing FTE 23.5 (4 yr. ave.) 27 21

FTE/Implementing Bed 1.96 (4 yr. ave.) 2.79 2.69

Personal Services Php 3,913,515 Php 4,432,828 Php 3,245,144

(5 yr. ave) (5 yr. ave.)

Salaries Php 2,277,686 Php 2,676,826 Php 1,934,465

(5 yr. ave.) (5 yr. ave.)

Admissions 1,147 1,127 576 (3 yr. ave.)

Discharges 1,188 1.126 561

Patient Days of Care 4,464 4,288 2,812

Total Budget Php 4,779,955 Php 5,089,368 Php 3,863,484

(5 yr. ave.)

Total Revenues Php 215,021 Php 248,808 Php 142,401


Total Expenditures Php 4,316,090 Php 5,030,826 Php 3,569,918


The average gross and net death rates of the 25-implementing beds hospitals

and the~ 15 beds hospitals were within comparable ranges. Average infant mortality

rates and fetal death rates were similarly comparable. Average maternal mortality

rates and neonatal death rates were either zero or near zero. Cesarean section rate

was zero for all hospitals except for Culasi District Hospital which had a rate of 8.

(Tables 3-4).

The range of the average bed occupancy rate of the 25-implementing beds

hospitals was 63-83% while that of the~ 15 beds hospitals was 77-82% (Tables 3-

4).

68 PUBLIC POLICY


TABLE 3. Averages of Selected Hospital 0 perations Indicators of Four 2 5-lmplementing

Beds Hospitals i n Antique, 1 998-2002

Culasl District Gen. Leandro L. Pres. Diosdado Ramon Maza Sr.

Hosp. (CDH) Fullon Gen. Macapagal Memorial District

(5 yr. ave.) Hosp. (GLLFGH) Hosp. (PDMH) Hosp.

(4 yr. ave.) (3 yr. ave.) (5 yr. ave.)

Gross Death Rate 3.098 1.95 1.77 1.49

Net Death Rate 1.1 0.18 1.01

Infant Mortality Rate 0 1.56 0.11 0

Fetal Death Rate 0 2.06 0 0.15

Maternal Mortality Rate 0 0 0 0

Neonatal Death Rate 0 0.15 0.30 0

Cesarean Section Rate 8 0 0 0

Bed Occupancy Rate

(Implementing) 65% 64% 63% 83%

TABLE 4. Averages of Selected Hospital Operations I ndlcators of Two 15- Implementing Beds Hospital & One 10-Beds Hospital In Antique, 1998-2002

Bugasong Medicare Pedro Gindap Valderrama Municipal

Community Hospital Municipal Hospital Hospital

(BMCH) (PGMH) (VMH)

5 Yr. Ave. 4 Yr. Ave. 4 Yr. Ave.

Gross Death Rate 2.008 2.31 1.65

Net Death Rate 0.49 0.515 0.04

Infant Mortality Rate 0.25 1.12 0

Fetal Death Rate 3.16 0 0

Maternal Mortality Rate 0 0 0

Neonatal Death Rate 0 0 0.81

Cesarean Section Rate 0 0 0

Bed Occupancy Rate

(Implementing) 82% 78% 77%


Sison ft Autajay

Selected financial parameters point to the efficient performance of Pres.

Diosdado Macapagal Hospital in terms of having the lowest average total

expenditures, highest average net income, highest average profit margin among the

hospitals in the same category (Table 5). Contributory to its good financial

performance was its having the highest average percentage of PhilHealth patients

which resulted in its having the highest average total in-patient revenues and average

total outpatient revenues (Table 6).

Bugasong Medicare Community Hospital, which was in the~ 15 beds hospitals

cluster, likewise had the highest average net income and highest average profit margin.

Its efficient performance was due to its having the lowest average cost of in-patient

discharge, average cost of in-patient day and average total expenditures on the one

hand, and higher average total in-patient days of care and average in-patient

discharges on the other. Table 7 compares this hospital to the other hospitals in the

same category.

The four 25-implementing beds Antique hospitals had a range ofPhP 2,421.00

-4,142.00 for the average cost per discharge and a range ofPhP 842.00-1,029.00

for the average cost per patient day (Table 5).

TABLE 5. Averages of Selected Financial & 0 perational Parameters of Four 25-

Implementing Beds Hospitals In Antique, 1998-2002

Culasi District Gen. Leandro L. Pres. Diosdado Ramon Maza Sr. Hospital Fullon Gen. Macapagal Memorial District

(CDH) Hosp. (GLLFGH) Hosp. (PDMH) Hospital (RMSMDH)

5 Yr. Ave. 5 Yr. Ave. 5 Yr. Ave. 5 Yr. Ave.

Total Budget Php 8,405,554 Php 8, 103,169 Php 8,869,322 Php 8,858,664

Total Revenues Php 530,635 Php405,137 Php633,563 Php727,195

Total Expenditures Php 8,350,516 Php 7,460,529 Php 7,248,711 Php 9,060,465

Net Income Php 585,674 Php 1,047,777 Php 2,154,353 Php 525,394

Cost per Inpatient

Discharge Php4,142 Php3,030 Php2,984 Php 2,421

Cost per Inpatient Day Php 1,029 Php925 Php877 Php842

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TABLE 6. Averages of Selected Financial & 0 perational Parameters ofF our

25-lmplementing Beds Hospitals in Antique, 1998 • 2002

Culasi DistrictGen. Leandro L Pres. Diosdado Ramon Maza Sr.

Hospital Fullon Gen. Macapagal Hospital Memorial District

(CDH) Hosp. (GLLFGH) (PDMH) Hospital (RMSMDH)

5 Yr. Ave. 4 Yr. Ave. 3 Yr. Ave. 5 Yr. Ave.

PhiiHealth Patients % 21 6 25 15

Charity Patients % 63 88 52 54

Pay Patients % 22 6 23 32

Total Inpatient

Revenues Php405,869 Php 192,484 Php482,533 Php 500,021


Total Outpatient

Revenues Php 124,773 Php 196,093 Php225,160 Php 179,532


TABLE 7. Averages of Selected Financial & 0 perational Parameters Of Two

15-lmplementing Beds Hospitals & One 1 0-Beds Hospital in Antique, 1 998-2002

Bugasong Medicare Pedro Gindap Valderrama Municipal

Community Hospital Municipal Hospital (VMH)

(BMCH) Hospital (PGMH) 5 Yr. Ave.

5 Yr. Ave. 5 Yr. Ave.

Total Budget Php 4, 779,955 Php 5,089,368 Php 3,863,485 (4 yr. ave.)

Total Revenues Php 215,021 Php 248,808 Php 142,401

Total Expenditures Php 4,316,090 Php 5,030,826 Php 3,569,918

Net Income Php678,886 Php 307,350 Php 328,215 {4 yr. ave.)

Cost per Inpatient Discharge Php2,620 Php 3,047 {4 yr. ave.) Php 4,788 {4 yr. ave.)

Cost per Inpatient Day Php 687 Php 986 {4 yr. ave.) Php 936 {4 yr. ave.)


Sison & Autajay

TABLE 8. Averages of S elected Financial & Operational Indicators of Two 1 5-lmplement

ing Beds Hospitals & One 10-Beds Hospital in Antique, 1998-2002

Bugasong Medicare Pedro Gindap Valderrama

Community Hospital Municipal Municipal

(BMCH) Hospital (PGMH) Hospital (VMH)

5 Yr. Ave. 4 Yr. Ave. 4 Yr. Ave.

Phil Health Patients % 8 8 13

Charity Patients % 12 85 61

Pay Patients % 84 7 28

Total Inpatient Revenues Php 108,441 Php 80,870 NA

Total Outpatient Revenues Php 106,508 Php 121,437 NA

The range of the average cost per discharge in the ~ 15 implementing beds

Antique hospitals was PhP 2,620.00-4,788.00 while the range of the average cost

per in-patient day for the same hospitals was PhP 687.00-986.00 (Table 7).

Discussion

In a 2001 study of 24 primary hospitals (grouped into <25 beds and ~ 25

beds) in four provinces (Benguet, Laguna, Samar, Eastern Leyte), Maligat (2002)

found that hospitals with ~ 25 beds had slightly more than the required hospital

personnel (91 actual vs. 90 required) while hospitals with< 25 beds had less actual

personnel (21) than the required number (26). It can be deduced that the 25-

implementing beds Antique hospitals had actually less full-time personnel compared

to the number in Maligat's study while the ~ 15 beds hospitals had comparable

numbers. Hence, it would seem that a primary hospital can still manage to perform

efficiently even if its manpower is less than the required or standard number.

The cesarean section rate of 8% of Culasi District Hospital, though higher than

the zero rate of comparable hospitals in the same category and higher than the 3-4%

acceptable by Western standards, is still in the acceptable range when compared to

the findings of Lawas (1997) in his 1988-1995 study of secondary government

72 PUBLIC POLICY


hospitals across the Philippines. Lawas found cesarean section rates of 29 in 1995

and 47 in 1993.

The bed occupancy rates of the hospitals in the two categories were even

better than the rates found by Lawas (1997) in his study of similar categories of

hospitals across the Philippines from 1993-1995 and the bed occupancy rates in

this study were likewise better than the rates found by Maligat (2002) in his study

involving similar categories of hospitals in 4 provinces. Thus, the Antique hospitals,

aside from being run efficiently, were moreover managed well in terms of providing

quality of care.

Economies of scale played a crucial role in the attainment of the good results

by the Bugasong Medicare Community Hospital in relation to the proxy indicators

of efficiency since it was able to achieve lower unit costs by apportioning or allocating ' its operating costs over a greater number of patients, compared to the other hospitals

in the same category.

Comparing the unit costs of the Antique hospitals with this study's earlier

definitions of the proxy indicators of economic efficiency and with those computed

by Maligat (2002) in his study involving comparable hospitals in four provinces, the

Antique hospitals were more efficiently run (range of PhP 2,421.00-4,142.00 for

the average cost per discharge for the four

25-implementing beds Antique hospitals as against Maligat's finding of

PhP5, 112.00 mean cost per discharge for 8 hospitals in 4 provinces and the DOH's

cost per discharge of PhP 5 ,881. 00 set in 1999 based on four days of hospitalization).

In relation to cost per in-patient day, the

Antique 25-implementing beds hospitals' range of average cost per in-patient

day was PhP 842.00- 1,029.00 while the mean cost per in-patient day of the 8

hospitals in Maligat's study was PhP 1,373.00 and the DOH's cost per in-patient

day was PhP 1,539.00 in 1999.

The disparity is even more glaring when the ~ 15 beds Antique hospitals are

considered. The range of the Antique hospitals' average cost per discharge was

PhP2,620.00- 4,788.00 as against the mean cost per discharge of 13 hospitals in

Maligat's study ofPhP 25,983.00 and the DOH's PhP 5,881.00. In relation to cost

per in-patient day, the range for the Antique~ 15-implementing beds hospitals was


Sison ft Autajay

PhP 687.00-986.00 compared to that in Maligat's study which was PhP 11,121.00

and the DOH's PhP 1,500.00. It is worthwhile to mention that the 15-implementing beds Bugasong Medicare

Community Hospital was able to attract the highest percentage of pay patients

among all the hospitals, with the revenues used to augment its budget. The percentage

of pay patients of three 25-implementing beds hospitals were over 20 per cent which

It is heartening to note that the three better performing 25-

implementing beds hospitals have been strategizing to

conform to the hospital reforms options of the Health Sector

Reform Agenda by increasing hospital revenues through

increased PhiiHealth reimbursements of medical and

surgical cases and attracting more pay patients.

also worked to their advantage in the

sense that the additional revenues

from these patients supplemented

the hospitals' budget. Another

incidental discovery, attributed to

the co-author coming from and

working in the area, is that the 25-

implementing beds Pres. Diosdado

Macapagal Hospital (formerly

Gov. Mamerto Portillo District

Hospital) was recently assigned a

surgeon as its chief of hospital and

this resulted in more surgical paying

patients being serviced by the hospital

and an increased PhilHealth

reimbursement of surgical cases

attended to in the hospital which contributed to its favorable financial performance.

Culasi District Hospital has also been attracting more surgical pay patients and

more PhilHealth reimbursements for surgical cases as well, since a surgeon occupied

the Chief of Hospital position. This is not to imply, however, that having more

PhilHealth reimbursements for surgical cases and having more paying surgical

patients, will negatively impact on equity or will be disadvantageous to the poor

patients since the three better performing 25-implementing beds hospitals had an

average range of 52-63 percentage of charity patients despite having an average

range of 15-25 percentage of PhilHealth patients and an average range of 22-32

percentage of pay patients. Charity patients still comprised the major share of these

74 PUBLIC POLICY


hospitals' patients and the bed occupancy rates of these hospitals were in the 63-83

percentage range, which implies that there were still beds which any patient could

occupy, whether paying or charity.

It is heartening to note that the three better performing 25-implementing beds

hospitals have been strategizing to conform to the hospital reforms options of the

Health Sector Reform Agenda by increasing hospital revenues through increased

PhilHealth reimbursements of medical and surgical cases and attracting more pay

patients. The next step would be ensuring fiscal autonomy by increasing revenue

collection from revenue-generating activities such as revolving funds for cost

generating areas, and increasing the percentage of PhilHealth reimbursements

through PhilHealth wards and private rooms, and developing cost sharing

mechanisms with the local government units (LGUs) served by these hospitals.

Since the mandate of health financing and delivery is shared between the LGUs

and PhilHealth, this results in the LGUs sharing in the premium contribution of

their indigent residents who can be enrolled and subsequently be entitled to either

in-patient or outpatient services. The LGUs can optimize their health expenditure

budget either through their own health program by direct provision or channelling

their resources to PhilHealth's Medicare para sa Masa which provides in-patient

and outpatient benefit packages.

Conclusion

Based on both the proxy indicators of economic efficiency and of quality care

used and defined in this study, the 25-implementing beds and the~ 15-implementing

beds Antique hospitals were performing efficiently while providing quality of care.

Average bed occupancy rates were nearly 70% for the three 25-implementing beds

hospitals and over 70% for all the ~ 15 implementing-beds hospitals. All the hospitals

had an average cost per discharge and average cost per in-patient day which were

less than the defined cost based on the DOH standard and which were found to be

lower than the figures quoted in other studies. The seven proxy indicators of quality

of care were comparable within hospitals belonging to the same category and were

found to be either lower or within acceptable levels compared to DOH standards

and the rates quoted in other studies.


Sison & Autajay

Recommendations

Conducting regular or periodic reviews, analyses and interpretation of

operational and financial statistics and computation of selected operational and

financial rates and ratios will definitely improve the management and operations of

the seven devolved hospitals in the province of Antique because these could aid

the local or provincial chief executives and hospital chiefs in planning and decision

making. This function can be undertaken by a Financial Planning and Monitoring

Committee in the hospital. The DOH issued Department Memorandum No. 183

s. 2000 which mandated the separation of the Finance Section/Division from the

Administrative Section/Division in all government hospitals and directed the

implementation of policy guidelines and standard operating procedures on financial

management reforms in the context of the HSRA. This memorandum was the basis

for the creation of Financial Planning and Monitoring Committees. Since the six

Antique hospitals have been performing well operationally and financially based on

their 1998-2002 performance, they are ripe for the creation of Financial Planning

and Monitoring Committees since the Provincial Health Officer, the DOH-CHD

head and some other chiefs of hospitals already obtained their master of hospital

administration degree from the University of the Philippines Manila College of

Public Health. Trained in interpreting financial reports, price and rate setting and

cost procedures, improved financial management system (e.g., efficient billing and

collection), they can: (1) develop cost sharing mechanisms with the LGUs served

by their hospitals and inform the LGUs about the hospitalization costs of their

constituents particularly the primary and secondary cases; (2) help ensure timely

remittance ofLGU contributions for the Sponsored Program; (3) target that 50%

of total treatment cost in LGU hospitals be shouldered by PhilHealth, 30% from

LGU subsidy, and maintain 20% out-of-pocket participation from the patients; (4)

increase the enrollment to Individually-Paying Program of PhilHealth by identifying

organized groups, and establishing enrollment desks in their hospitals.

Eventually the LGU hospitals can undergo rationalization of their development

projects to prioritize their upgrading to meet Philippine Health Insurance

Corporation's accreditation standards. They can enhance cost recovery schemes

without compromising equity objectives. In addition, they can introduce guidelines

76 PUBLIC POLICY


for socialized cost recovery schemes because their cost per in-patient and cost per

discharge for 1998-2002 were lower than the DOH standards and those obtained

in other local studies. The situation is ideal because ( 1) Region VI is a convergence

site which means it has provinces (Capiz and Iloilo) or highly urbanized cities that

are considered advanced implementation sites in the Health Sector Reform Agenda

Implementation Plan, (2) the Governor of Antique is fully supportive and committed

to the health development of the constituents of the province and provides the

necessary environment for effective governance, (3) the DOH -Center for Health

Development head, the provincial health officer, the chiefs of hospitals have the

requisite academic preparation, qualifications, skills, and work experience to

implement the strategies targeting the hospital reforms options.


Sison & Autajay

ANNEX 1. Formulae of Proxy Indicators of Economic Efficiency and Quality of Care Used in the Study

The proxy indicators of economic efficiency are: (Averaged from 1998-2002)

1.1 Bed Occupancy Rate = Annual Census x 100 Implementing Bed Capacity x 365

1.2 Cost per Inpatient Discharge= Inpatient Operating Expenses where

Total Inpatient Discharges

inpatient operating expenses represented 70% of total operating

expenses based on ratio of inpatient to outpatient expenditures

which was 70:30

1.3 Cost per Inpatient Day = Inpatient Operating Expenses where

Total Inpatient Days

inpatient operating expenses represented 70% of total operating

expenses based on agreed ratio of inpatient to outpatient expenditures

which was 70:30

The proxy indicators of quality of care are: (Averaged from 1998-2002)

78

1.1 Gross Death Rate = total number of deaths !including newborns) for the period x 100 total number of discharges (including deaths & newborn deaths)

1.2 Net Death Rate= deaths (including newborns)- those under 48 hrs. for the period x 100

total number of discharges (including deaths & newborns)- deaths

under 48 hrs. for the period

1.3 Infant Mortality Rate = total number of newborn deaths for the period x 100

total number of newborn infant discharges (including

deaths) for the period

1.4 Fetal Death Rate = total number of intermediate & late fetal deaths for the period x 100

total number of maternal (obstetric) discharges (including deaths)

1.5 Maternal Mortality Rate = total number of deaths of obstetrics patients for the period x 100

total number of discharges (and deaths) of obstetric patients

for the period

1.6 Neonatal Death Rate = total no. of infant deaths occurring w/in 28 days of birth x 100

total no. of newborn infants discharged including deaths

during the period

1. 7 Cesarean Section Rate = total number of cesarean sections performed in the period x 100

total number of deliveries in the period

PUBLIC POLICY

< 0 t""" c ~ tr1

< ...... ......

z c ~ IJj tr1 :::0 N

Q ~

-< 0 (b (') (b

3 cr (b .... N 0 0 \jJ

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STUDY VARIABLES

Four 25-lmplementing Beds Primary and Secondary Hospitals and Three ::::;15 Implementing Beds Primary Hospitals in Antique Province whose Operational Statistical and Financial Reports will be Reviewed and Analyzed, and whose Operational and Financial Rates and Ratios will be Computed, Averaged from 1998-2002, Compared, & Interpreted

Documents Studied/Reviewed (5-Year Period): • Hospital Statistical Reports • Itemized Hospital Collections • Itemized Statement of

Expenditures • Hospital Asset Listings

~ Proxy Indicators of Economic Efficiency: (Averaged from 1998-2002)

• Average Implementing Bed 1/)

Occupancy Rate "0 Q)

• Average Cost per Discharge Q) c:

• Average Cost per Patient Day "0 Based on DOH 1999 Standards and Related Studies Q)

I;:: Done by Local Authors E

Q)

Proxy Indicators of Quality of Care: (Averaged :5! from 1998-2002)

• Gross Death Rate • Net Death Rate • Infant Mortality • Fetal Death Rate • Maternal Mortality Rate • Neonatal Death Rate • Cesarean Section Rate

Based on Allowable Ranges (Local & Foreign) as Contained in the Department of Health's Medical Records Management Manual, 2"" Edition

Health Sector Reform Agenda - Hospital Reforms, Health Care Financing, Health Sector Financing

~

~

~

FORMULATION OF HEALTH SYSTEM RESEARCH PLAN

Determination of trends, prospects

and potential

Determination of mechanisms through which the internal revenue allotments are augmented or supplemented

Determination of the mix of resources of each category of hospitals and correlation with output and outcome indicators (input-output mix)

~ ~

H ~ ~ ~

1/)

"0 Q) Q) c: "0 Q)

I;::

t Q) (.)

14-- ~

I ASSESSMENT

KEYAREASOF CONCERN

Operational and Financial Rates and Ratios

Proxy Indicators of Economic Efficiency

Proxy Indicators of Quality of Care

Relevance to Policies in Relation to Hospital Reforms and Health Sector Financing in the Context of the Health Sector Reform Agenda

I

OUTPUT

Assessment of Input, Output and Outcome, Input-Output Mix Parameters based on:

~ 1) Proxy Indicators of Economic Efficiency

2) Proxy Indicators of Quality of Care

Policy Implications on Hospital Reforms Options & Health Sector Financing Based in the Context of the Health Sector Reform Agenda

!

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Sison & Autajay

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Avestruz, F. S. 1992. A study of Philippine hospital management and administrative systems. PIDS Project No. DOH/91-92/05 (Final Report).

Caragay, R.N. et. al. 2002. MarketstudyforaproposedhospitalinPalo, Leyte. UP

Manila College of Public Health and University Research and Resource

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Department of Health. Hospital medical records management manual.ld Edition.

Health Finance Development Project, DOH.

Department of Health-Health Policy and Planning Bureau. 2004. National objecdves for health-technical working groups proceedings. August 19, Sept. 23, Oct. 7,

Oct. 14, Oct. 21, Oct. 28, 2004.

Gorra, E. 1993. Documentation of the hospital budget and management review.

Department of Health, USAID Contract No. 492-0446-C-00-2114-00.

Health Finance Development Project (DOH-USAID). Final report. Retained

Hospitals Study. Project No. 492-0446.

Health Sector Reform Agenda Philippines 1999-2004. 1999. HSRA monograph series no. 2. Department of Health, Manila, Philippines.

Lawas, N.D. 2001. An exploratory study on the demand for services of public and

private hospitals in the Philippines. The UP Manila journal. 6: 3.

____ . 1997. An exploratory study on hospital performance in the Philippines.

The UP Mam1a journal. 3: 3. Maligat, R.A. 2002. Performance of Philippine primary and secondary government

hospitals after the devolution. The UP Manila journal. 7: 2.

Rillon, E. et. al. 2002. Strategic analysis of the hospital system of Eastern Samar.

UP Manila College of Public Health and University Research and Resource

Development, Inc.

Villaverde, M.C., et. al. 2003. Baseline surveys for the national objectives for health Philippines 2000 (J.Vl I). Department of Health. March 2003.

Villaverde, M.C. 2003. Implementing the health sector reform agenda in the

Philippines. HSRA monograph series no. 4. Department of Health. March 2003.

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Villaverde, M.C., et. al. 1999. National objectives for health Philippines, 1999-

2004. HSRA monograph series no. 1. Department of Health. June 1999.

Zingapan, S. 1992. Analysis of supply and market for hospital seiVices. PIDS Project

No. DOH/91-92 (Final Report).


Mainstreaming the Rights-Based Approach in

HIV I AIDS Prevention: Learning Experiences from the Philippines

NYMIA PIMENTEL SIMBULAN

1. The AIDS Epidemic in the Philippines

The HIV/AIDS problem continues to wreak havoc worldwide with the

heaviest toll being shouldered by the developing world. For the past two

decades, the AIDS epidemic, considered by most states and governments as

one of the most pressing problems of the world today, has had devastating

impact on the lives, structures and development of individuals, families,

communities and nations. This can be gleaned from the loss of productivity,

erosion of incomes, rising cost of medical, hospitalization and funeral expenses,

premature deaths of productive workers and adults, decline in national

investments and earnings, increased investments in HIV/AIDS prevention,

care and support programs and life-prolonging antiretroviral drugs-all of which

are experienced by individuals, families and governments. The HIV/AIDS

problem has undermined whatever development gains have been achieved by

governments and has further heightened impoverishment in already poor

countries. As of December 2003, about 3 million people have died of AIDS and 5

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million people have been recently infected with HN, bringing to a total of 40 million

the number of people globally living with the virus (http://www. unaids.org ... ). More

than two-thirds of these cases are found in low and middle-income countries.

Moreover, a total of 14 million children have been orphaned by AIDS as of the end

of 2001 (UNAIDS July 2002, 8).

In the Asia-Pacific region, an estimated 7.4 million are now living with HIV

Over one million people have acquired the virus in 2003 while about half a million

are estimated to have died of AIDS in 2003 (http://www.unaids.org ... ). About 2.1

million young people, aged 15-24 years, are living with HIV (UNAIDS & WHO

2002, 7).

No country has been spared by the AIDS epidemic. Countries rich and poor,

developed and underdeveloped, continue to witness and experience the shocking ' . economic, political and social consequences of HIV/AIDS and recognize the tar

worse destruction the epidemic is capable of producing if no decisive actions are

taken by peoples and governments worldwide. Thus, the challenge posed at the

beginning of the new millennium was developing an effective global response to

arrest the further spread of the epidemic.

The severity of the problem and the determination of the world's governments

to combat HIV/ AIDS have been demonstrated in an unprecedented move last June

2001, when a Special Session on HIV/AIDS of the United Nations General

Assembly was convened to discuss and map out targets and goals in its collective

resolve to combat the epidemic worldwide. The Declaration of Commitment on

HIV/AIDS signed by the various heads of states and governments was an important

product of this meeting. It serves both as a basis for global action and a yardstick

for political accountability (UNAIDS July 2002, 11).

Unlike in its Asian neighbors, specifically Thailand, Indonesia and Cambodia,

the AIDS prevalence in the Philippines remains to be low and the increase slow.

Since the identification of the first HIV/AIDS cases in 1984, it has been able to

maintain the <0.1 percent prevalence rate among adults aged 15 to 49 years

(UNAIDS 2002 Update, 2). As of June 2003, there were 1,892 HIV positive cases

reported, 68 percent (1,280) of whom were asymptomatic while 32 percent (612)

84 PUBLIC POLICY

Mainstreaming the Rights-Based Approach in HIV I AIDS Prevention:

Learning Experiences from the Philippines

were AIDS cases at the time of the report. Sexual intercourse continues to be the

dominant mode of transmission (86%). (See Table 1 and Figure 1)]

Reported Modes of

Transmission

Sexual Transmission:

Heterosexual contact

Homosexual contact

Bisexual contact

Blood/blood product

Injecting Drug Use

Needle prick injuries

Perinatal

No exposure reported

Table 1

REPORTED MODE OF TRANSMISSION, HIV/AIDS REGISTRY

1984 TO JUNE 2003 (N=1,892)

Jan. 1984- June 2003 Jan-June 2003

N = 1,892 n = 96

1,192 72

336 18

96 6

13 0

6 0

3 0

27 0

219 0

Source: NEG-DOH. HIV/AIDS Registry (NHSSS), June 2003.

Of the 1,892 HIV positive cases, 32 percent (600) were overseas Filipino

workers (OFWs). Most of the cases were in the 20-39 age bracket. In terms of

distribution by sex, more HIV/AIDS cases have been reported among females

between 20-29 years old while most infections among the males have occurred in

the 30-39 age group (NEC-DOH 2003). All regions in the country have reported

HIV I AIDS cases.

The "low and slow" character of the AIDS epidemic in the Philippine has been

attributed by the UN AIDS and experts to the early response of the country against

HIV/AIDS, as well as other factors. These include the low partner exchange rate

among prostituted women, low proportion of males patronizing commercial sex,

the archipelagic character of the country and the low prevalence of injecting drug

use (HAIN, NEDA & UNDP 2002, 18-22; Chin, et al. 1998, S88-89; UNAIDS

2002 Update, 2; UNAIDS, 2002; Dare et al. 1998, S5).


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Figure 1: HIV Ab Seropositive Cases by Year, 1984 to June 2003 (N=1,892)

Source: NEC-DOH. HIVIAIDS Registry (NHSSS), June 2003.

The early response of the Philippines toward the issues and concerns posed by

HIV/AIDS builds the strong foundation of the country's HIV/ AIDS program. The

multisectoral participation in policy development, prevention and care programs of

the various sectors in the country produced a high level of awareness and

understanding among the general public on the disease ( Simbulan & Balanon 2003,

6).

Various programs were undertaken by the government, non-government

organizations (NGOs), private/business sectors and even the Church against the

epidemic. Active surveillance and monitoring of the epidemic have been put in

place. In 1992, the Philippine National AIDS Council (PNAC), the coordinating

body in-charge of overseeing multisectoral efforts and activities geared towards

awareness, prevention and care, was created. It was instrumental to the passage of

the National AIDS Act, a comprehensive law that provides prevention and care

directions towards HIV/AIDS in the country (DOH-National AIDS-STD

Prevention & Control Program 1999, 1; 1-WN, NEDA & UNDP 2002, 18-22).

Another factor contributory to the "low-slow" character is the geographical

make-up of the Philippines. Its archipelagic character slows down population

mobility within the country, therefore contributing to the slow spread of the disease.

86 PUBLIC POLICY

Mainstreaming the Rights-Based Approach in HIV I AIDS Prevention: Learning Experiences from the Philippines

Likewise, to some extent, since the country is detached from the mainland Southeast

Asia, the spread of the epidemic in the continent does not have a significant effect

on the country compared to those sharing land borders like Thailand, Cambodia

and Vietnam. According to reports, the early outbreak of the epidemic crossed the

borders of the African countries, America, Australia and parts of the Western Europe.

However, the virus reached Asian countries mainly through sex tourism and injecting

drug use. Compared to other Asian countries, the Philippines was not as exposed

to tourism during the 80's although the existence of the US bases in the country

may have contributed to the entry and spread of the virus. The Philippines receives

relatively less visitors, about two million annually,

compared to other Asian countries like Thailand,

which receives six million visitors every year

(HAIN, NEDA & UNDP 2002, 18).

Sexual intercourse is the dominant mode of

transmission of HN, specifically facilitated by

unprotected sex with multiple partners. However,

... most studies concur that Filipinos are generally conservative when it comes to their sexual behaviors ...

in the Philippines, most studies concur that Filipinos are generally conservative

when it comes to their sexual behaviors/practices manifested in their one-partner

patronage and the low proportion of males patronizing commercial sex (HAIN,

NEDA & UNDP 2002, 19; Chin, et al. 1998, S88-89; Dore, et al. 1998, S5).

Moreover, the partner exchange rate of Filipino female sex workers have been reported

to be lower compared to other Asian countries.

Furthermore, the Philippines has a low incidence of injecting drug use (IDU)

and that the sharing of syringes and needles occurs among a small circle of drug

dependents (HAIN, NEDA& UNDP 2002, 19). What is prevalent in the country

constituting the serious drug problem, is the misuse of drugs like cough syrups,

sniffing of chemical substances like Rugby and acetone, and smoking of marijuana

and shabu or poor man's cocaine.

However, although the country has a low HIV/ AIDS prevalence rate, the number

of reported cases has slowly and consistently increased through the years. Experts

believe there is no reason to expect that the "low and slow" character of the epidemic

will remain to be so (PNAC 2000, 2). In fact, there are doubts if the available


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estimates about prevalence are accurate and reliable because of the gaps or limitations

in the current system of monitoring the disease in the country. It has been observed

that before 1993 when the passive surveillance system was used to monitor HN/

AIDS cases, the number of reported cases was less than 100 per year. When the

DOH established the National HIV Serologic Surveillance System (NHSS) in

1993, the number of reported cases increased to more than 100 a year. Yet the

system in place covers only the so-called high -risk groups (HRG) namely, registered

prostituted women, freelancers, men who have sexual intercourse with other men

(MSM) and injecting drug users (IDU). Moreover, the surveillance is done only in

a number of sentinel sites throughout the country and these are the cities of Quezon,

Pasay, Angeles and Baguio in Luzon, cities of lloilo and Cebu in the Visayas, and

the cities ofDavao, Gen. Santos and Zamboanga in Mindanao (DOH 2001, 6-8).

More importantly, all the known ways of transmitting the infection and factors

that will lead to the further spread of the disease are present in the country. These

Figure 2: HIV Ab Seropositive Cases by Gender & Age Groups, 1984 to June 2003 (N= 1,892)

Note: Before 1993, seven (7) cases had no reported age and sex.

Source: NEC-DOH. HIVIAIDS Registry (NHSSS), June 2003.

88 PUBLIC POLICY


include a flourishing commercial sex industry, a high proportion of prostituted women

testing positive for ulcerative STis like syphilis, a high percentage of mobile or

migrant population, substantial level of casual sex between young men and women,

blood transfusion under unsafe conditions, low and incorrect condom use and

gender inequality (Balk et al. 1999, 82; HAIN, NEDA & UNDP 2002). As the

experience of other countries in the Asia-Pacific region has shown, many of which

have started also with a "low and slow" pattern of the epidemic, if no decisive and

concerted national action is undertaken to arrest the spread of the infection, it is

just a matter time before the country is confronted with an explosive epidemic.

11. Evolution of the country's Response to HIV!AIDS

Prevention has primarily been the emphasis of the country's response to the

AIDS problem. The "low and slow" character of the epidemic has been the

determining factor in the overall character of the various HN/ AIDS programs and

activities undertaken since the first AIDS case was identified way back in 1984.

Concomitantly, in countries with limited resources like the Philippines, prevention

programs are considered to be the most appropriate and cost-effective means of

addressing the epidemic, though this does

not mean leaving out care and support and

treatment programs for those already

infected and affected by the disease.

The country's response to the AIDS

epidemic has followed the general course of

the global response. When it was first

.. . prevention programs are considered to be the most appropriate and costeffective means of addressing the epidemic ...

detected in 1984, HN/AIDS was viewed and treated more as a problem of

individual behavior, particularly those engaged in high-risk behaviors. Using the

traditional biomedical paradigm, the orientation of most intervention programs then

was directed toward behavior change through increased knowledge about HN/ AIDS and safer sex practices. Other measures like the screening of blood and blood

products for HN, using sterile injection equipment among drug users, and avoiding

pregnancies by HN-infected women, for particular high-risk groups, were advocated

(Tarantola 2000, 1). Emphasis was likewise placed in the development of programs


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and projects which reduced the risks of acquiring the infection or eliminated the

conditions which made people vulnerable to HIV/AIDS.

During this early stage in the country's response, efforts both by the government

and civil society groups had focused on education and information programs side

by side with risk-reduction intervention programs. With the so-called high-risk

groups such as prostituted women and men who have sex with men (MSM) as

principal targets, programs implemented were in the areas of education and

information dissemination on HIV/AIDS, development of IEC materials, peer

education and training, and condom distribution. Education and information

materials centered on the dissemination of basic information about the nature of

the disease, i.e. modes of transmission, differences between HIV and AIDS, ways

of prevention and correct condom use. Other projects undertaken involved training I

of peer educators/counselors, raising the capability of prostituted women to negotiate

with their male clients and teaching them creative ways of practicing safer sex like

putting the condom through the mouth, and condom distribution.

The provision of clinic-based services such as the formulation of the National

STD Case Management Guidelines (DOH-PNAC 2000, 34-35) and the conduct

of serological surveys in particular sites in the country and with prostituted women

as initial targets, were also manifestations of the dominance of the biomedical

paradigm in the response to the HIV/ AIDS problem. Efforts to strengthen the

capability of the health care system like the education and training in AIDS education

of DOH personnel and those in private STD clinics in Metro Manila, the skills

enhancement activities in the early detection and treatment of sexually transmitted

diseases of health personnel in the Social Hygiene Clinics (SHCs) were also

undertaken. Moreover, medical protocols like the use of the Syndromic Approach

in the detection of STDs among prostituted women were developed. Medical

personnel assigned in SHCs have even undergone training in the use of the said

protocol.

As the AIDS epidemic continued to infect and affect millions, the global

response started to take a more comprehensive character. Governments and civil

society groups started to realize and recognize HIV/ AIDS not only as a public health

problem, but also a development problem especially since it was becoming apparent

90 PUBLIC POLICY


that those bearing the brunt of the epidemic were also the impoverished and

marginalized sections of the Third World. Addressing the HN/AIDS problem did

not only entail convincing people to refrain from engaging in high-risk behaviors

which increased their chances of acquiring the disease. More importantly, it required

dealing with the conditions which made people vulnerable. As Peter Piot and Susan

Timberlake asserted, HN/ AIDS extends beyond the physical health of the

individual. It thrives in the economic, social and political environment in which

individuals live (Piot & Timberlake 1998, 2). The health and well being of people

are very much related and influenced by the economic, political and socio-cultural

factors. Consequently, the economic, political and socio-cultural structures, .. policies

and programs of a nation have an impact on the people's health. In the case of HN/

AIDS, this meant confronting the economic, social and political determinants of

the disease.

Furthermore, as the problems of discrimination and stigmatization of people

infected and affected by the disease heightened, the link between HN/AIDS,

development and human rights became evident. Human rights violations manifested

in the form of poverty, powerlessness, lack of access to essential social services and

gender inequality, were viewed both as the societal basis of people's vulnerability to

HNI AIDS and the condition which limited the choices of people with HN/ AIDS

which further subjected them to human rights violations and discrimination in their

communities. On the other hand, discrimination and marginalization have

discouraged individuals at risk from seeking the necessary support like counseling

and testing, consequently aggravating their marginalized status (Tarantola 2000,

2). Thus, the vicious cycle of poverty,

discrimination and human rights violations has

become deeply entrenched in the midst of the

poor and marginalized people of the Third

World.

The connection between HN/AIDS,

development and human rights has eventually

led to an expansion of the global response

beyond the biomedical paradigm. Grounded

VOLUME VII NUMBER 2 Ouly ·December 2003)

The connection between HIV/AIDS, development and human rights has eventually led to an expansion of the global response beyond the biomedical paradigm.

91

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in health and human rights principles, the global response to HIV/AIDS has put

emphasis on the role and obligations of governments, the multisectoral approach,

people's participation and empowerment as exemplified in the principle of greater

involvement of people with HIV/AIDS (GIPA), international solidarity and

cooperation, and distributive justice.

In recent years, the recognition of the link between HIV/AIDS, development

and human rights has been manifested in the formulation of a declaration endorsed

by the United Nations member states on June 2001. The United Nations General

Assembly Special Session on HIV/AIDS Declaration of Commitment (UNGASS

DoC) is a historic document signifying the recognition of state leaders that HIV/

AIDS is a serious development problem which can only be decisively addressed by

scaling up both the national and international responses to the pandemic. The

UNGASS DoC indicates the awareness of member states thaf the respect, protection

and fulfillment of human rights is at the core of the fight against HIV/AIDS; that

combating the epidemic is a major responsibility and obligation of the state. Thus,

states should ensure that the necessary legal, procedural, budgetary, institutional

and other mechanisms are in placed so that the human rights, particularly of persons

living with HIV/AIDS (PLWHAs) and vulnerable groups, are not violated.

In the Philippines, these global developments both in the perception and

approach to the AIDS epidemic had started to be seen in the various aspects of

HIV/AIDS work sometime mid-1990s. Among the indications of the Philippine

government's recognition of the importance of adopting a rights-based approach

(RBA) to the HIV/AIDS problem were the following:

92

1. Creation of the Philippine National AIDS Council (PNAC), a multisectoral

body which \Wls initially tasked to act as an advisory body to the President

on HIV/AIDS matters but later transformed into a policy-making body on

HIV/AIDS with the passage of Republic Act 8504. The existence of the

PNAC illustrates the recognition of mobilizing all sectors/groups in society

and of the importance of GO-NGO partnership to effectively combat the

epidemic (Department of Health-Philippine National AIDS Council. 2000.

Seizing the Opportunity: The 2000-2004 Medium Term-Plan for Acceler

ating the Philippine Response to HIV/AIDS). As pointed by the World

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Health Organization (WHO), civil society groups, including organizations

of people living with HN/AIDS, play a crucial role in the promotion of a

rights-based approach HN/AIDS agenda at all levels of interve.Ptions

global, national and even local (WHO 2003).

2. Formulation and endorsement by former Pres. Fidel V. Ramos of the Phil

ippine National HN/AIDS Strategy (1995). Contained in this document

are important human rights principles in combating HN/AIDS (DOH

PNAC 1995, 7-21)

• Respect and protection of the rights of PLWHAs namely, the

right to live and participate with dignity, self-respect and without dis

crimination in the community; to have access to health care, employ

ment, education, travel, housing and social welfare as are available to

others; to have access to timely, accurate, adequate, appropriate and

relevant information about HN infection/AIDS and its prevention; to

privacy, including the right to decide about disclosure of his/her HN

status; to a full and satisfying sex life, without putting his/her partner at

risk; to bear and raise children, if they choose; to legal representation;

and to participate in the planning, formulation and implementation of

programs.

• Empowerment of people as a means of preventing HIV trans

mission through their having access to timely, accurate, adequate, ap

propriate and relevant information and resources.

• All HIV antibody testing should be voluntary with guaranteed

confidentiality and adequate pre- and post-test counseling.

Since the start of the country's response to the AIDS epidemic, manda

tory HN-antibody testing had been rejected as a policy by the Philip

pine government (HAIN, NEDA & UNDP 2002). The "window pe

riod" which takes up to six months for the HN antibodies to be de

tected in the test, makes mandatory testing ineffective and a waste of

resources. What is instead emphasized is encouraging people to go for

voluntary testing that is grounded on informed decision making with

counseling as a means of protecting the rights of individuals. This also


94

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entails making available and accessible testing facilities/services with

competent and responsible health personnel.

• The formulation of socio-economic development policies and

programs should include consideration of the impact of HIV

infection and AIDS. Economic and social development improves

people's ability to avoid HN/AIDS by eliminating the conditions which

make them vulnerable to the disease. Making jobs, schools, hospitals,

housing, food, roads and bridges available and accessible increase

people's choices and enhance their capability to combat HN/AIDS.

Likewise, creating an enabling environment where the people's economic

and social rights like the rights to work, just and favorable remunera

tion, education, housing, social security, and freedom of thought, con

science and religion (UDHR 1948) are protected, respected and ful

filled will reduce people's vulnerability to HN/AIDS.

• Judicious allocation of resources in HIV/AIDS programs. The

allocation of resources to HN/AIDS programs is one gauge of a

government's political will to combat the epidemic. The uneven expo

sure of people to the infection entails that resources especially if these

are limited should be rationally allocated giving priority to the vulner

able groups.

3. Formulation of the different Medium -Term Plans on AIDS Prevention and

Control (1988-93, 1993-99 and 1999-2004). These documents reflect the

government's recognition of the importance to come up with a national

plan on HN/AIDS to guide the country's response in combating the epi

demic. The formulation of plans of action and policies is part of the obliga

tion of the state to take the necessary measures including legislative, ad

ministrative, budgetary, to systematically address the HN/AIDS problem

in the country.

4. The promulgation of Republic Act 8504 or the Philippine AIDS Prevention

and Control Act of 1998. The law, which is the first of its kind in the Asia

Pacific region, is another concrete step taken by the Philippine government

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to safeguard the human rights particularly of PLWHAs. Among the impor

tant provisions of the law are the emphasis placed on HN education in

schools, workplaces, communities, for Filipinos going abroad and for tour

ists and transients; the prohibitions on mandatory testing; protection of

PLWHAs from discrimination in the workplace, schools, health facilities;

and the promotion of medical confidentiality.

5. The Philippine government's endorsement of the UNGASS Declaration of

Commitment (UNGASS DoC). Being a signatory to the declaration is in

dicative of the recognition by the Philippine government of its obligations

to protect, respect and fulfill the human rights primarily of PLWHAs by

creating the conditions necessary to enable them to live a life of dignity in

society. This includes ensuring they have access to care and support and

treatment, as well as, their involvement in the formulation and implemen

tation of policies, and the development of programs.

Furthermore, the current efforts of the national government through the

Commission of Human Rights (CHR) to raise the level of knowledge and

understanding of government officials and staff on human rights concepts and

principles, international human rights instruments and mechanisms, indicate its

commitment to mainstream the RBA in governance and development. Capability

building and skills enhancement programs in development planning, budgeting,

monitoring and evaluation, are also being conducted in the various line agencies of

government like the Departments of Health, Education, Justice, Interior and Local

Government, ForeignMfairs, Budget and Management, and the National Economic

Development Authority.

On the part of civil society groups, mainstreaming the RBA may be gleaned

from the efforts taken by HN/ AIDS N GOs in education and information, advocacy,

networking and organizing work. Many NGOs have been instrumental in the

formation of Local AIDS Councils (LACs) and other HN/AIDS formations at the

municipal, city and provincial levels. They have taken concrete efforts to establish

and strengthen relationship and coordination with local government units (LG Us)

in the development and implementation ofHN/AIDS programs. They have also


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been active in education and information, advocacy, networking and organizing

work. Through their involvement in PNAC, NGOs, AIDS-service organizations

and organizations of PLWHAs have been able to successfully work for the passage

of an AIDS law in the country.

The adoption of the RBA in the response to HIV/AIDS requires more than

knowing and understanding human rights concepts and principles. It entails a

paradigm shift on how a problem is perceived and consequently, how it is treated.

It requires a strong political will and commitment on the part of governments, and

organizing and mobilizing of people, who, in the final analysis, will make all the

difference in the fight against HIV/AIDS

111. The Rights-Based Approach: An Empowering Strategy

HIV/AIDS and human rights are interrelated and interdependent. While the

problem of HIV/ AIDS is indicative of the existence of human rights violations, it is

only through the respect, protection and fulfillment of human rights that the

prevention and control of HIV/ AIDS can be effected. It is also under this condition

... the human rights perspective in HIV/AIDS stresses that the

epidemic cannot be treated separately or independently

from existing socio-economic structures and power relations.

that those infected and affected by the

disease can live a life of dignity and

worth in society.

Using the human rights framework

in addressing the HIV/ AIDS problem is

a recognition of the multifaceted and

multidimensional nature of the

epidemic. It signifies that the HIV/

AIDS problem is caused not only by the risky behaviors of individuals like

unprotected sex with multiple partners, intravenous drug use, etc. It also means

that structural and systemic factors have a role to play in making people vulnerable

to and/or acquire the disease. It points out that the HIV/ AIDS problem and related

issues need to be approached beyond the levels of the individual and the family;

that the human rights perspective in HIV/AIDS stresses that the epidemic cannot

be treated separately or independently from existing socio-economic structures and

96 PUBLIC POLICY


power relations. Thus, an effective and decisive means to respond to the HIV/

AIDS epidemic is ensuring the full realization of the people's human rights.

It is the obligation of every State to protect, respect and fulfill the human rights

of its people as a means of ensuring a positive and effective response to the HIV/

AIDS problem. It is principally responsible in creating the conditions, instituting

the mechanisms and providing the necessary resources and support services that

will ensure the realization of the people's human rights. Meanwhile, civil society

plays a crucial role in putting the government to task. The development and

promotion of a human rights consciousness and culture among the people are,

therefore, necessary in the protection of human rights and achieving HIV/AIDS

related public health goals.

The rights-based approach (RBA) in HIV/AIDS prevention is not simply a

strategy or a framework. It is a process anchored on the principles of health and

human rights which assert the following: (http://www.un.or.th ... ; UN-OHCHR

2002)

1. All individuals regardless of who they are, what they are, where

they are, have human rights because they are human beings. Hu

man rights are freedoms and entitlements every individual is born with and

has a rightful claim. These form the foundation or basis of his/her dignified

existence. This means that a person with HIV/ AIDS have the same rights as

a person without HIV/AIDS because they are both human beings. The pres

ence of the virus does not make a person less human.

A person with HIV/ AIDS like everyone else has a moral claim to basic health

care. As Chapman (1993) stated: the universalityofthe right to health care

requires that the definition of a specific entitlement be guaranteed to all

members of our society without discrimination on the basis of financial

means, employment status, disabilities, residence, gende~; or racial or eth

nic background

2. The whole range of human rights-civil, political, economic, so

cial and cultural rights-are indivisible, interdependent and in

terrelated. Human rights have equal status and importance. They are in

extricably intertwined with one another. Violation of one right means viola-


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tion of other rights. For example, the advent of HIV/ AIDS towards the end

of the 201h century had provided an additional dimension to the stigma and

discrimination being experienced by the impoverished and marginalized

who are likewise those vulnerable to and infected by the disease. They are

the very same people whose economic rights like the right to employment

and decent wage have long been violated, consequently resulting in their

social rights (e.g., the right to health, education and housing) being com

promised.

3. Human rights define and regulate the relationship between the

people as claim holders and the State as duty-bearers. Human

rights are freedoms and entitlements which the people can legally claim

and demand from the State. The State has the principal duty and obliga

tion to protect, respect and fulfill these rights. Thus, the State including the

various branches of government- executive, legislative and judiciary - can

be made accountable for any breach or failure to perform its duties and

obligations to the people.

The State's obligation to respect, protect and fulfill human rights has legal

bases and is enshrined in the various laws, legal statutes, treaties, covenants and

international human rights instruments signed and ratified by the government. In

the case of the Philippines, the 1987 Philippine Constitution, the Universal

Declaration of Human Rights (UDHR, 1948), the International Covenant on Civil

and Political Rights (ICCPR, 1966), the International Covenant on Economic, Social

and Cultural Rights (ICESCR, 1966), Convention on the Rights of the Child ( CRC,

1989), Convention Against Torture and Cruel, Inhuman or Degrading Treatment or

Punishment (CAT, 1984), ConventionAgainstRacialDiscrimination (CERD, 1965),

and Convention on the Elimination of All Forms of Discrimination Against Women

( CEDA W, 1979), are among the major human rights documents which provide the

legal bases for the government's accountability to its human rights obligations. At

present, the Philippine government is a signatory to 23 international human rights

instruments.

The above mentioned documents in addition to the UNGASS DoC to which

the Philippine Government is also a signatory, means that in the context of HIV/

98 PUBLIC POLICY


AIDS, the government is legally bound to respect, protect and fulfill the human

rights of people with HIV/AIDS.

The obligation to respect requires states to ensure that their laws,

policies, and practices do not directly or indirectly discriminate based on

HIV or AIDS status. Government should ensure that national laws, policies

and their activities and programmes directly and indirectly affecting

prevention, care and support take full account of human rights principles,

and should review and reform that might that might hamper the ability of

its population to take preventive action against infection or hinder access to

services for care, treatment and support. The obligation to protect requires

states to take measures that prevent HIV/AIDS-related discrimination by

third parties, and the obligation to fulfill requiresstates to adopt appropriate

legislative, budgetary, judicial, promotional, and other measures that address

HIV/AIDS related discrimination and that compensate those who suffer

such discrimination (Maluwa, Aggleton & Parker 2002, 9 & 17).

Moreover, in the case of HIV/AIDS, the State obligation to protect, respect

and fulfill human rights means the state and its agencies are mandated to create the

conditions, institute the mechanisms and provide the resources, necessary to ensure

the prevention and control of the epidemic, and realization of the human rights of

those infected and affected. This entails formulating the appropriate policies and

laws that will facilitate the implementation of programs related and which have an

impact on health and HIV/AIDS; putting-up the necessary infrastructures and

systems and ensuring these are accessible to the people; and allocating sufficient

funds and resources to answer the health needs and requirements of the population,

especially the vulnerable groups and those already infected. Failure to fulfill these

obligations indicates an abandonment of the state of its responsibility to the people

and constitutes a violation of the people's right to health.

Related to State accountability is the justiciability of human rights. This means

that claim holders or the citizens can take legal actions and redress if and when the

State and its agents fail to comply with its human rights obligations or engage in

actions that violate human rights.


100

Simbulan

4. People's participation in all aspects of society that impact on

their lives is upheld as a critical strategy. In the various stages in the

development ofHIV/AIDS prevention programs, the formulation of strate

gic plans and policies, the identification of appropriate methodologies and

activities, budgeting, monitoring and evaluation of programs, the active in

volvement of individuals, families, communities, sectors, and most espe

cially the vulnerable groups and those infected and affected by the disease

is ensured. Creating the conditions and providing the resources that will

allow people to actively, freely and meaningfully participate in decision and

policy-making processes is what the RBA is all about. This is contrasted to

ceremonial consultation activities that are usually undertaken by the duty

bearers or government officials with claim holders of human rights to give a

semblance of people's involvement, as many of us in the past may have

experienced in our interaction with government at various levels. In ensur

ing people's participation, attention and priority is given to persons with

HIV/AIDS and vulnerable sectors. Trust in the people's capacities and power

to transform themselves and their social environment is consistently recog

nized and upheld. Thus, the spirit behind the concept greater involvement

of persons with HIV/AIDS (GIPA) promoted by the UNAIDS is in the

light of the RBA.

5. People's empowerment is at the core of the RBA. Strategies that

contribute to the enhancement and development of the people's capacities

and potentials to enable them to become active participants and competent

decision-makers in the attainment of human and social development are

explored and maximized. High value is placed on education and conscious

ness-raising, organizing and mobilizing activities as effective ways of em

powering peoples and communities. Through their organizations, people

become aware and are exposed to the whys, whats and hows of daily exist

ence and that of their society. They gain confidence in the process of con

fronting difficulties and solving problems, weighing their options and deter

mining their priorities. They learn to become resourceful and creative. In

other words, the people come to realize and appreciate their power as a

PUBLIC POLICY


collective, what that power can do for them and how to use it towards the

attainment of human and social development.

6. The priority given to the impoverished, marginalized and vulner

able sections of the population is a principle advocated by the

RBA. Although human rights are universal and should be enjoyed by every

one, the RBA stresses that particular attention be given to groups or sectors

who, for a long time, have been discriminated and marginalized because of

their status and societal factors. These include women and children, over

seas migrant workers, adolescents and young adults, prostituted women

and prisoners. Programs, policies and initiatives are directed toward issues

of equality, equity and discrimination since a goal is to decisively address

and remedy power imbalances between groups in society.

IV. The RBA as Applied in work Among Prostituted women

The work of a number of women NGOs with HIV/AIDS-related programs

among prostituted women is replete with lessons on the use of RBA and its

empowering effects on this marginalized group in Philippine society. Groups like

Women's Education, Development and Productivity, Research and Advocacy

Organization (WEDPRO), Bukluran ng Kababaihan sa Lansangan, Inc. (BUKAL),

Buklod ng Kababaihan (BUKLOD) and Likhaan are examples of some of these

groups.

Prostitution is illegal in the Philippines. This explains why prostituted women

are viewed and treated more as offenders/criminals rather than victims, a condition

which makes them highly vulnerable to discrimination and abuse especially in the

hands of law enforcement personnel, including police women. The dominant

perception of women in prostitution as immoral, low and dirty, home-wreckers,

promiscuous and vectors of diseases is implicitly used as justification for treating

them without dignity and respect, for applying violence and for the lack of basic

services extended to them by government. When services are available, for instance,

the requirement for women working in karaoke bars, beer gardens, massage parlors,

dubs, etc. to submit themselves for mandatory medical screening/check-ups in Social


Simbulan

Hygiene Clinics (SHC), the law is intended more to ensure that the women are

free from certain diseases like STis. In exchange, they are issued "pink cards" or

social hygiene cards which indicate they are clean and fit to work. The spirit of the

law is not to safeguard the health and well-being of the women workers, but more

to protect customers from acquiring infections when they patronize the products

and services of these entertainment establishments (Interview with an AIDS NGO

officer 2003).

The application of the RBA in the work among prostituted women is

demonstrated in several important components ofHIV/ AIDS programs and activities

of women's NGOs. These include the following:

102

1. Education and consciousness-raising. Regular topics discussed in-• elude basic human rights concepts and principles, women's rights, gender

inequality, CEDAW and other human rights instruments, women's issues

like VAW-prostitution, domestic violence, sex trafficking, etc., other na

tional issues like the globalization, the war against terror, foreign debt, death

penalty, etc.

2. Capability-building and skills enhancement. Training programs are

integral parts of work among prostituted women which are intended to ex

pand their capacities. They are usually exposed and provided skills and

experiences in paralegal work, gender-sensitivity, counseling, advocacy and

lobby work, livelihood, etc. where they get to learn new ideas and find them

selves in new situations which are not commonly encountered in their daily

routine.

3 . Organization and mobilization. An important gauge of empowerment

is recognition by individuals faced with similar interests, needs and prob

lems of the need to organize themselves. One such group is that of prosti

tuted women, which has been able to get organized through the help of

women NGOs and use this formation to assert their rights through educa

tion and information, advocacy and networking with other sectors in soci

ety.

4. Advocacy and networking. These are part of the day-to-day activities of

NGOs as a means of educating, getting the support and mobilizing the

PUBLIC POLICY


public and civil society groups. Forums and dialogues with government of

ficials, conferences, exhibits, political actions like pickets and rallies are

examples of activities undertaken to get the attention and support of people

to the issues and concerns of prostituted women.

5. Provision of services. Providing concrete services needed by the target

clients is commonly used as an initial strategy to get their attention and

interest. These include medicaVhealth examination and treatment, STI re

ferrals, distribution of condoms, counseling, legal assistance, livelihood, etc.

6. Fund generation. An organization will not be able to sustain itself, its

activities and projects without funds. NGOs together with prostituted

women conduct fund-raising activities such as selling goods/products, sub

mitting project proposals, etc.

In a focus group discussion (FGD) conducted last December 2003 among a

group of streetwalkers or prostituted women not attached to any entertainment

establishment, the participants shared the changes which have taken place in their

lives after their involvement in NGO work. According to the women, the education

and training sessions on human rights which they received from the women's N GO

helped in making them aware of their rights and the causes of their marginalized

status in society. Knowing that they had the support of NGO workers made them

confident and determined in fighting for the ideas they espoused. Whereas before

they were timid and passive when face to face with police authorities, now they are

able to assert their rights and negotiate. As shared by an interviewee in one of her

encounters with police authorities:

.... Naniniwala silang masama kami at sinisigawang mga jokards lang

naman kayo, a. Ano ba ang ka rapatan nyong magreklamo? Sir, sabi ko, kahit po kami na ang naabuso? Dahil po ba pulis yung nang-abuso sa amin,

wala kaming karapatan? Ang sabi sa amin, customer is always right.

( .... they [policemen] believe we are bad and shouted that were just

"jokards" [street label for prostitutes]. What right do you have to complain?

Sir, I told him, even if we are the ones abused? Is it because a policeman is

involved that we lose our rights? He told me, "Customer is always right".)


Simbulan

A milestone in the work of NGOs among prostituted women was the holding

of the First National Conference of Women Victims-Survivor of Prostitution last

October 21, 2003 in Olongapo City, and attended by about 100 women. In a

statement issued by the conference participants, they have asserted that prostitution

cannot be considered work; that prostitution cannot be labeled "sex work". Although

women earn money from prostitution, they detest the sex and violence that go with

the activity. Every minute, women in prostitution face the risks of getting infected

with sexually transmitted diseases including HIV/AIDS, being beaten up and abused,

even getting killed. Thus, they consider prostitution a gross violation of human

rights, a glaring form of inhuman treatment.

As part of asserting their human rights, the conference participants have put

forward the following calls to the Philippine government:

1. Repeal !aws which treat women in prostitution as criminals and offenders;

they should be treated as victims of the system of prostitution and should

be accorded all forms of protection. Instead, a law should be passed to

criminalize those who exploit and traffic women and children, pimps and

clients of prostituted women, owners and/or operators of businesses, which

sell sex, brothels and other establishments, used as fronts for prostitution.

2. Provide protection to all victims of prostitution and trafficking based on

human rights principles, and

3. Provide comprehensive and sustained assistance and support to women

victims-survivors of prostitution.

Furthermore, in mainstreaming the rights-based approach in addressing the

concerns and problems of women in prostitution and in order to safeguard their

rights against various forms of violations committed by the State and its agents, the

following recommendations are being put forward:

104

• Raise the level of knowledge and understanding of the police forces and

other law enforcement agencies on human rights concepts and principles in

order for them to be conscious of their human rights obligations. These can

be done by integrating human rights courses, including the various human

rights instruments like the Convention Against the Elimination of all Forms

PUBLIC POLICY


of Discrimination Against Women (CEDAW), Convention on the Rights of

the Child (CRC) and Convention Against Torture and Cruel, Inhuman or

Degrading Treatment or Punishment (CAT), into the formal education and

training of policemen and officers, holding of seminars, forums and work

shops on human rights issues and topics.

It is also important that gender orientation and gender-sensitivity training

and workshops be included in the education and training of law enforcers. By making

policemen and officers, including those assigned to the Women and Children's

Desk in police stations nationwide, gender sensitive and aware of the rights of women

and children, human rights violations committed in the course of police operations

may be lessened, if not stopped, in the treatment and handling of prostituted women

and children.

• Raise the level of awareness and understanding of health personneVstaff on

human and patients' rights. Conduct human rights, gender-orientation and

sensitivity seminars, forums and workshops among health personnel par

ticularly those assigned in Social Hygiene Clinics (SHCs) nationwide. There

is a need to raise the consciousness of health personnel especially those

directly dealing with prostituted women, in ensuring that women's rights

are respected, protected and ful£lled every time they undergo routine check

ups in SHCs as a requirement in the renewal of their work permits. Are

orientation of the purpose and manner by which the regular pap smear women

working in restaurants, bars and entertainment establishments are made to

undergo is necessary so that the interest and welfare of these women be

comes the foremost concern. The rights of women as patients like the right

to medical care and humane treatment, information, privacy and confiden

tiality, and informed consent, should be upheld and protected by public

health personnel at all times.

• Improve the level of knowledge and understanding of patients, including

prostituted women, about their rights as individuals and as patients. Incor

porate topics on human and women's rights in the health education pro

grams and services of patients in public health facilities and SHCs. Patients


Simbulan

should be made conscious of their rights and taught skills on how they can

exercise and defend these rights in promoting their health and well-being.

v. conclusion

Governments and the international community now acknowledge that HIV

and human rights are closely linked; that human rights violations are the very

conditions contributing to the spread of HIV/ AIDS and making people vulnerable

to the disease. This perception of the HIV/ AIDS epidemic, more than ever, stresses

the urgency of mainstreaming the rights-based approach (RBA) in every country's

response.

The RBA has provided a broader and clearer view of the determinants of the

spread and impact of HIV/AIDS. From the original biomedical and traditional

public health approach, a paradigm shift grounded on the principles of health and

human rights has led the global response to address, not only health factors but

moreso, issues of economic inequities, powerlessness, gender inequality, mobility

and insecurity (Tarantola 2000, 2). A multisectoral and multipronged response

involving the mobilization of civil society groups including people with HIV/ AIDS

has been recognized as critical to effectively deal with the AIDS problem. Non

government, people's and sectoral organizations have proven to be reliable partners

of governments in the development and implementation ofHIV/AIDS prevention,

care and support programs in various parts of the globe. Composed of highly

competent and dedicated workers, civil society organizations have consistently taken

a leading role in the fight against HIV/ AIDS. Experiences have shown that especially

with government support at the local and national levels, NGOs, POs, CBOs,

ASOs and organizations of PLWHAs, can accomplish much in undertaking sustained

intervention efforts toward mitigating the impact of and reducing people's

vulnerability to, the disease.

106 PUBLIC POLICY


REFERENCES

Balk, Deborah, LitaJ. Domingo, Grace T. Cruz & Tim Brown. 1999. HIV/AIDS.

Adolescent sexuality in the Philippines. Corazon M. Raymundo, Peter Xenos &

Lita J. Domingo (editors).

Chapman, Audrey R. 1993. Exploring a human rights approach to health care reform.

American Association for the Advancement of Science.

Chin, James, Anthony Bennett & Stephen Mills. 1998. Primary determinants of

HIV prevalence in Asia-Pacific countries. AIDS12(supplement B): S87-91.

Department of Health (DOH). 2001. Status and trends of HIWAIDS in the

Philippines: The 2001 technical report of the National HIWAIDS Sentinel

Surveillance system.

Department of Health-National AIDS -STD Prevention & Control Program. 1999.

PNAC report 1992-1998.

Department of Health-Philippine National AIDS Council. 1995. Philippine national

HIWAIDS strategy.

Department of Health-Philippine National AIDS Council. 2000. Seizing the

opportunity: The 2000-2004 medium term-plan for accelerating the Philippine

response to HIWAIDS.

Dore, Gregory J., Tim Brown, David Tarantola &John M. Kaldor. 1998. HIV and

AIDS in the Asia-Pacific region: An epidemiological overview. AIDS

12(supplement B): S1-10.

Health Action Information Network (HAIN), National Economic & Development

Authority (NEDA) & United Nations Development Programme (UNDP).

2002. A matter of time: HIWAIDS and development in the Philippines. Pasig

City: Paradigm Printers.

Maluwa, Miriam, Peter Aggleton & Richard Parker. 2002. HIV- and AIDS-related

stigma, discrimination, and human rights: A critical overview. Health and human

rights.

NEC-DOH. 2003. HIWAIDSregistry.

Piot, Peter & Susan Timberlake. 1998. HIV/AIDS and human rights: Continued

commitment in the second decade. Health and human rights.


Simbulan

Philippine National AIDS Council (PNAC). January 2000. HIVIAIDS country profile: Philippines. Quezon City: Health Action Information Network.

Philippine National AIDS Council (PNAC). March 2000. Initiating local responses

to HIVIAIDS: A guidebook. Simbulan, Nymia Pimentel & Virginia Balanon. March 2003. HIVIAIDS in the

Philippines and development opportunities for VSOP interventions in HIV/ AIDS work. (Unpublished paper).

Tarantola, David. 2000. The shifting HN/AIDS paradigm: Twenty years and

counting. Health and Human Rights. United Nations. 1948. Universal declaration of human rights. United Nations Office of the High Commissioner for Human Rights (UN

OHCHR). 10 September 2002. Draft guidelines: A human righ'ts approach to poverty reduction strategies.

UNAIDS. July 2002. Report on the global HIVIAIDS epidemic. UNAIDS & WHO. December 2002. AIDS epidemic update. UNAIDS. 2002. Philippines epidemiological fact sheets on HIV/AIDS and sexuaUy

transmitted infections. Update.

Women's Education, Development and Productivity, Research and Advocacy

Organization (WEDPRO). October 2003. Unpublished report on the human rights situation of women in the Philippines.

World Health Organization (WHO). 2003. The world health report 2003: Shaping the future. 51.

Interview with an AIDS NGO officer. December 2003.

http://www.un.or.th/ohchr/database/database.asp

http://www.unaids.orw'wad/2003/Epiupdate2003 _ en/Epi03 _ 02 _ en.htm

108 PUBLIC POLICY

ABOUT THE AUTHORS

DR FEMAN RENE M AUTAJAY is a Medical Specialist IV,

Department of Health Representative to the Antique Provincial Health Board,

and Antique Provincial Health Team Leader of the Center for Health

Development No.6, Iloilo City. He finished his MD at the West Visayas State

University College of Medicine in 1992 and recently earned his Master of

Hospital Administration degree at the UP Manila College of Public Health

where he was president of his batch. With his newfound knowledge and newly

acquired skills, he is passionately embarking on programs and projects to improve

the health care delivery system in Antique with the full support of the provincial

governor, Hon. Salvacion Zaldivar Perez.

NICETO S POBLADOR has taught at the University of the Philippines

for a cumulative period of over thirty years, and has had teaching stints at the National

University of Singapore and the City University of Hong Kong. His main research

interests are in the fields of organization analysis and applied microeconomics. He

has published extensively in these areas both here and abroad. His more recent

works are in the areas of public-sector governance and the economics of strategy.

Since he took early retirement from the University of the Philippines in 1998, Dr.

Poblador has been active in the lecture circuit and has been publishing extensively

in both academic journals and the popular press. He is currently completing a

manuscript on a book provisionally titled Contemporary Issues in Administration:

Selected Essays.

NYMIA PIMENTEL SIMB ULAN is an associate professor of sociology

at the College of Arts and Sciences, University of the Philippines Manila and a

doctor of public health (Dr PH). She has undertaken research and published articles

on topics like sexually transmitted infections, HN/AIDS and women prisoners,

health and globalization, health and human rights, the Philippine health care system

including health care financing and patients' rights. Since the early 1990s, Dr.

Simbulan has been actively involved in the human rights movement in the country.

She is currently the Executive Director of the Philippine Human Rights Information

Center (PhilRights), an institute engaged in human rights research and information

110 PUBLIC POLICY

dissemination activities on various human rights issues. She is also the co-chairperson

of the Medical Action Group, Inc. (MAG), a human rights NGO committed to

the promotion of the people's right to health and engaged in the delivery of health

services to victims of human rights violations in the country.

DR. FERNANDO M SISON is an Associate Professor in the Department

of Health Policy and Administration of the UP Manila College of Public Health.

He is also an affiliate faculty of the UP Manila Open University (Distance Education

Program). Dr. Sison teaches Health Care Finance and Accounting, Economics of

Health, Cost Benefit Analysis and Hospital Information System. He obtained his

BSBA and MD degrees from the University of the Philippines and pursued his

Masteral studies (health planning and economic development) at the University of

Michigan School of Public Health, Ann Arbor, Michigan, USA.

CRISLINE G TORRES is an assistant professor at the Department of

Political Science, University of the Philippines-Diliman. Aside from this Public Policy paper, she has written two more works on the presidential-parliamentary

debate in the Philippines. The first is a more extensive research paper funded by

and submitted to the UP-CIDS entitled ''A Review of the Pro-Parliamentary Critique

of the Presidential Form of Government of the 1987 Philippine Constitution." In

it, she surveys and criticizes eight major arguments of the pro-parliamentary position

in the Philippines by marshaling the comparative constitutional design scholarship

critical of the pro-parliamentary position. The second is a forthcoming article in the

Philippine Political Science foumalwhich critically reviews the argument raised by

Filipino parliamentary advocates that the parliamentary system is superior to the

presidential system in promoting a more efficient and harmonious executive

legislative relations.


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IN THIS ISSUE


CRISLINE G TORRES This paper argues that the claim made by Filipino parliamentary ad,·ocates of the superior

democratic sur\' ivai record of parliamentary over presidential systems has remained unchallenged f(>r

two reasons. First is the one-sided appropriation of the comparati,·e insights to the local debate on the

form of government.

Second is the failure both of the local opposition against the shift in form of government and of

the local sl\eptics of parliamentary democracy to confi·ont head on the theoretical validity of the

democratic survival record of the parliamentary democracies as ath-anced in the Philippines.

Given the one-sidedness of the constitutional change debate in the Philippines, this paper

undertakes the first step towards presenting the other side of the comparative output on this issue of

democratic sun·i,·ability.


NICETO S POBLADOR Public Choice Theory, the theoretical framework that underpins current thinking in public

governance, draws heavily from the principal-agent theory of the firm. In public choice theory, , ·oters

are considered to be the main principals while their elected officials are their direct agents. These

elected officials, worl\ing on behalf of those who put them in office, are supposed to undertake programs

and provide services that are intended to serve the public interest. !Iowe,·er, they seldom do so in

practice because they are more interested in enhancing their 0\\'11 political and economic fortunes. If

there is anything at all that they seek to maximize, it is their \'Otes (Downs 1957), taken here as proxy

for their personal interests, which include power, income and the prestige that go " ·ith their positions

(Weingast 1981· and Downs 1957).


FERNANDO M SISON and FEMAN RENE M AUTAJAY This is a descripti,·e-analytical study which utilized the following operational and financial

reports of the seven devolved hospitals in Antique province for the years 199H-2002: I) hospital

statistical reports, 2) itemized hospital collections, s) itemized statement of expenditures, and 1-) hospital assets listings. Operational and financial rates and ratios were computed, m·eraged from 1998-

2002, analyzed, compared with each other, and interpreted.

Mainstreaming the Rights-Based Approach in HIV/AIDS Prevention: Learning Experiences from the Philippines

NYMIA PIMENTEL SIMBULAN Using the human rights framework in addressing the HlV I AIDS problem is a recognition of the

multifaceted and multidimensional nature of the epidemic. It signifies that the HIV I AIDS problem is

caused not only by the risl\y behaviors of indi,·iduals like unprotected sex with multiple partners,

intravenous drug use, etc. It also means that structural and systemic factors have a role to play in

making people vulnerable to and / or acquire the disease. It points out that the HlV I AIDS problem

and related issues need to be approached beyond the Je,·els of the individual and the family; that the

human rights perspective in HIV I AIDS stresses that the epidemic cannot be treated separately or

independently from existing socio-economic structures and power relations. Thus, an effective and

decisive means to respond to the HIV I AIDS epidemic is ensuring the full realization of the people's

human rights.

Democratic Survivability and the Parliamentary Critique of the ...

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