Determining the Functionality of Local Health Boards in the Philippines: Perspectives from Local Government Units

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Guerrero, Paolo C. Encarnacion This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7169520/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In the Philippines, Local Health Boards (LHBs) are the cornerstone of a decentralized health system by coordinating local health priorities, budgeting, and implementation. However, their performance remains highly variable across different regions. While national policies set the groundwork for Universal Health Care (UHC), actual service delivery hinges on local functionality. This study sought to define the constructs that define functionality of local health boards in the Philippine context, drawing from the experiences and perspectives of those directly involved in local health governance. Methods We conducted a series of in-depth focus group discussions (FGDs) with members of LHBs across four different provinces in the Philippines. Participants included local chief executives, health officers, barangay representatives and civil society leaders. The discussions were designed to explore governance dynamics, barriers to implementation, and enabling conditions for effective board performance. Thematic analysis was employed to identify recurring patterns and insights from the narratives. Results Across all provinces, the most consistently cited determinant of a functional LHB was the active engagement and political will of the local chief executive (LCE). While national frameworks and mandates exist, their successful localization depends heavily on whether the LCE prioritizes health. Participants highlighted significant operational barriers, particularly in fund utilization, due to stringent national guidelines that limit spending flexibility. A proactive and well-resourced Technical Working Group (TWG) was identified as vital in operationalizing LHB decisions and bridging policy with practice. Additionally, community engagement efforts were found to be vulnerable to political transitions, especially when frontline workers such as Barangay Health Workers (BHWs) lack protection from changes in local leadership. Conclusion The functionality of LHBs is shaped less by formal compliance and more by the quality of local governance and institutional support. The political commitment of the LCE, when combined with a capable TWG and mechanisms to shield community health workers from political transitions, significantly enhances board performances. As the Philippines moves toward full implementation of Universal Health Care (UHC), reinforcing the governance capacity of LHBs offers a pragmatic and necessary pathway to more responsive and resilient local health systems. Health Governance Local Health Boards Health Policy Philippines Decentralization Figures Figure 1 1. Introduction The decentralization of governance, a move towards empowering sub-national entities, has been a cornerstone of public sector reforms in many developing nations. In the Philippines, this transition was formally enshrined in the Local Government Code of 1991 (Republic Act 7160), a landmark legislative act that fundamentally reconfigured the relationship between national and local government units [ 1 ]. This mandate devolved significant administrative and fiscal powers, most notably in the critical domain of health services, with the objective of fostering a more localized and responsive healthcare system [ 2 ]. A key mechanism established by this framework was the creation of local health boards (LHBs) at the provincial, city and municipal levels. Envisioned as a primary forum for localized health governance, these boards were tasked with facilitating community participation, enhancing the efficiency of health service delivery, and tailoring health programs to the specific needs of local populations [ 3 , 4 ]. While the initial mandate for LHBs was significant, their role has continued to expand, particularly with the enactment of the Universal Health Care (UHC) Act of 2019 (Republic Act 11223). This landmark legislation elevated the function of LHBs from advisory bodies to pillars of health systems integration, emphasizing their critical role in ensuring equitable access to healthcare for all Filipinos [ 5 , 6 ]. Functional LHBs are now recognized as indispensable for their successful implementation of UHC [ 7 ], serving as the primary local governance mechanism for strategic allocation of resources, coordination of services, and meaningful engagement with diverse communities. They are responsible for a range of critical functions, including the formulation of local health plans, management of local health funds, and oversight of health facilities [ 8 – 10 ]. Despite these clear mandates, many LGUs continue to face persistent challenges in establishing and maintaining the full functionality of their LHBs. The operational effectiveness of these boards is often hampered by a confluence of factors, including limited technical expertise among board members, insufficient financial allocations for health programs, and inadequate infrastructure to support health service delivery [ 3 , 10 , 11 ]. The uneven capacity of LGUs to perform their devolved health functions has been a long-standing issue in the Philippines, leading to disparities in health outcomes across different localities [ 10 , 12 ]. Furthermore, challenges in ensuring effective inter-sectoral collaboration and community engagement can hinder the LHBs ability to develop health programs that are truly responsive to local needs [ 10 ]. Recognizing these challenges, providing targeted technical assistance to LGUs becomes paramount for the effective operation of LHBs. This support encompasses crucial guidance on organizational setup, strategies for resource mobilization, and the practical implementation of health programs. Such technical assistance is vital in helping LGUs develop robust strategic health plans, rigorously monitor and evaluate health outcomes, and ensure consistent compliance with national health standards. This comprehensive support not only bolsters the intrinsic capacity of local health systems but also contributes directly to the overarching national goal of achieving universal health coverage in the Philippines. By proactively addressing identified gaps through dedicated assistance, LGUs can significantly enhance their health systems' capacity, elevate the quality of health service delivery, and ensure that health programs are both sustainable and genuinely responsive to community needs. The primary purpose of this study is to explore and determine the constructs significant to the functionality of Local Health Boards in the Philippine context. This study aims to provide empirical insights that can inform the development of practical tools and guidance for LGUs, thereby enabling them to establish and sustain effective LHBs that can significantly enhance healthcare service delivery. 2. Methodology 2.1 Study Design This study employed a cross-sectional exploratory qualitative research design. This design was chosen to gather in-depth insights into the lived experiences, persistent challenges, and successful practices of LHB members across various localities. Ethical clearance was received from the Research Ethics Review Panel (RERP) of the De La Salle University tagged with a project code: 2025 − 269. The study was deemed low risk since the study does not pose more than minimal risk or harm to the participants, does not involve participants from the vulnerable groups, involves use of anonymous or anonymized laboratory/pathology samples or stored tissues or data, and is not sensitive in nature and does not generate vulnerability. 2.2 Study Setting and Participants FGDs were strategically conducted in selected provinces across the Philippines, specifically Laguna, Aklan, Saranggani, and Benguet. Participants in the FGDs comprised a diverse group of LHB members including Provincial Health Officers (PHOs), Municipal Health Officers (MHOs), DOH Medical Officers (DMOs), Sangguniang Bayan (SB) members, DILG representatives, and Civil Society Organization (CSO) representatives. 2.3 Data Collection Data were systematically collected through semi-structured Focus Group Discussions (FGDs), which were conducted in adherence to established ethical standards. Prior to participation, all individuals were provided with clear and comprehensive information about the purpose, process, and intended use of the study through an informed consent procedure. Participants voluntarily agreed to take part and were assured of their right to withdraw at any time without consequence. To protect privacy, all responses were anonymized during data handling and reporting, ensuring that no personal identifiers were linked to any of the shared insights. The questionnaire centered on the roles of the LHBs, challenges encountered, notable achievements, core functions, strategies for resource mobilization, approaches to community engagement, methods for monitoring and evaluation, identified training needs, and the influence of national policies. 2.4 Data Analysis Collected data were transcribed and coded through NVivo 15. Subsequently, these were analyzed by two authors through the six phases of thematic analysis as identified by Braun and Clarke [ 23 ]: familiarization, coding, searching for themes, reviewing themes, defining and naming themes, and writing the report. 3. Results A total of 4 FGDs were conducted consisting of 83 participants from the four study sites. The thematic analysis of the FGD transcripts revealed several key themes and sub-themes that highlight the intricate interplay of internal dynamics, external influences, and the adaptive strategies employed by LHBs. Table 1 provides an overview of these identified themes and their corresponding sub-themes. Table 1 Key Themes and Sub-Themes on LHB Functionality Main Theme Sub-Themes Roles, Responsibilities, and Evolving Structure of LHBs Shifting Paradigms from Advisory to Managerial/Policy-Making Body The Double-Edged Sword of Expanded Membership Dynamics of Leadership and Political Will LCE Engagement as the Primary Determinant of LHB Vitality The "MLGP Effect" and its Limitations Resource Mobilization and Financial Management The Paradox of "Money is There, But Hard to Spend" Strategic Inclusion of Finance Officers as a Best Practice for Resource Flow Meeting Effectiveness and Decision-Making Processes The Tension Between Mandated Regularity and Practical Feasibility The Critical Role of the TWG in Driving LHB Effectiveness Community Engagement and Participation BHWs as the Unsung Heroes and Vulnerable Link in Community Engagement Deep Dives and Town Halls as Effective Mechanisms for Authentic Community Voice Monitoring and Evaluation (M&E) Practices The Gap Between Program-Level M&E and LHB Functionality Assessment Visual Data as a Catalyst for LCE Action Training and Capacity Building Needs The Sustainability Challenge of Capacity Building Amidst Political Cycles The Critical Gap in Financial Management and Policy Development Skills Impact of National Policies and Regulations The Double-Edged Sword of National Mandates: Compliance vs. Contextual Relevance The Unfulfilled Promise of the Magna Carta for Health Workers 3.1 Evolving Structure of LHBs The structure of the LHB has undergone significant transformation, moving beyond the initial framework outlined in the Local Government Code. This expansion has been particularly pronounced with the advent of the Universal Health Care (UHC) Act and various DILG memoranda, leading to the inclusion of a more diverse range of stakeholders [ 13 ]. These now encompass Civil Society Organizations (CSOs), members of local finance committees, and even barangay captains, reflecting a deliberate effort towards broader representation. A participant articulated this evolution, stating that "The LHB transformed from a mere advisory body to the manager of the SHF". This transformation signifies a fundamental shift in the LHB's mandate, moving beyond mere recommendations to direct operational and legislative influence. Initially, LHBs were primarily conceived as advisory bodies, offering guidance to local chief executives on health matters. However, with the implementation of UHC and specific directives from DILG, their roles have expanded to include active management of the Special Health Fund (SHF) and direct involvement in drafting and endorsing policies and resolutions. This expanded role necessitates a different set of competencies, such as expertise in financial management and policy drafting, and a clearer understanding of their legal authority. It appears that these new requirements are not yet fully internalized by all LHB members or LGUs, creating a potential gap in their operational capacity. The expansion of LHB membership, while intended to foster broader representation and facilitate resource mobilization, presents a complex dynamic. The inclusion of CSOs, finance officers, and other sectors is widely lauded as a success, enabling a wider range of perspectives and potentially unlocking more resources for health initiatives. However, this inclusivity also introduces challenges. Participants frequently cited difficulties in achieving a quorum for meetings, managing time effectively due to diverse interests, and navigating potentially slower decision-making processes stemming from conflicting schedules and priorities among members. While inclusivity is vital for ensuring community-responsive health governance, effective LHB functionality requires strategic management of this expanded membership. This could involve implementing mechanisms such as executive committees or streamlined parliamentary procedures to balance the benefits of broad representation with the imperative for operational efficiency. 3.2 Dynamics of Leadership and Political Will The commitment and active participation of the Local Chief Executive (LCE), whether the Mayor or Governor, consistently emerged as the most critical determinant for LHB functionality [ 14 ]. Participants repeatedly emphasized this factor, with one stating, "Participation of the LCE is a key factor to determine the functionality of the LHB". When the LCE is actively engaged, LHB meetings are held regularly, resources are more readily mobilized, and resolutions are promptly acted upon. Conversely, a lack of engagement from the LCE often leads to stagnation and non-functionality of the LHB. Concerns were raised about communication gaps, such as when "the mayor does not inform the SB", hindering the board's effectiveness. Frequent LCE attendance, even through online platforms, was noted to ensure issues are addressed swiftly. A significant challenge identified is the impact of changes in LCEs, which frequently disrupt LHB continuity and shift program priorities, leading to what participants described as "political interference". A participant observed, "Leadership changes seem to disrupt LHB continuity". The symbiotic relationship, or "tandem," between the PHO/MHO and the LCE was frequently highlighted as crucial for successful health governance. The data overwhelmingly indicates that the LCE's active involvement, extending beyond mere compliance, is the single most influential factor in LHB functionality. When the LCE is deeply engaged, meetings are consistent, resources are effectively mobilized, and resolutions are translated into action. Conversely, LCE disinterest leads to the LHB's stagnation and eventual non-functionality. Several participants noted the positive impact of leadership and governance programs, such as the Municipal Leadership and Governance Program (MLGP), on LCEs' understanding and prioritization of health. These programs demonstrably enhance the capacity of local leaders to champion health initiatives. However, the frequent turnover of elected officials, typically every three years, means that this enhanced capacity requires constant retraining. This cyclical need for capacity building raises pertinent questions about its long-term sustainability and return on investment. One participant articulated this concern, stating, "Leaders are being changed and replaced at least every 3 years so you have to retrain them again. But in my opinion, is training really what we need? What is the Return of Investment?". 3.3 Resource Mobilization and Financial Management A recurring observation was that LHBs generally lack their own dedicated operational budgets, relying instead on allocations from the Provincial Health Office (PHO) budget, grants from the Department of Health (DOH), support from development partners, and tapping into the Corporate Social Responsibility (CSR) initiatives of the private sector. A participant underscored this challenge, stating that "The board doesn't have its own funds, so for your internal operational expenses, where can we secure, and where will you source the payment?" (translated from Filipino). Despite these constraints, successful strategies for resource mobilization were identified. These include pooling resources, particularly during emergencies like the COVID-19 pandemic, maximizing Philhealth reimbursements, and engaging industrial companies for direct funding or in-kind support for community outreach and facility repairs. A key enabler of efficient fund management was the inclusion of budget officers and local finance committees within the LHB, which significantly eased processes for fund realignment and augmentation. However, significant challenges persist, including overall limited budget allocations for health, Personnel Services (PS) Cap limitations that hinder the hiring of essential Human Resources for Health (HRH), and restrictive guidelines on the utilization of the Special Health Fund (SHF). A participant aptly summarized this frustration, remarking, "While healthcare has significant funds, spending them is challenging because of the numerous regulations involved" (translated from Filipino). Participants expressed frustration over what was described as the "paradox of 'money is there, but hard to spend.'" They acknowledged the availability of various funding sources for health, including DOH grants, Philhealth reimbursements, LGU funds, and private sector contributions. However, they consistently highlighted restrictive guidelines, particularly concerning the Special Health Fund (SHF) and the Personnel Services (PS) Cap, which severely limit their ability to hire necessary personnel or utilize funds flexibly. The explicit mention that including budget officers and local finance committees in the LHB directly facilitates fund realignment and augmentation reveals a clear and direct causal relationship. This structural integration effectively bypasses traditional bureaucratic hurdles, making financial processes more responsive to immediate health needs. 3.4 Meeting Effectiveness and Decision-Making Processes The frequency of LHB meetings varied among LGUs, ranging from quarterly to monthly, or convened as needed, often influenced by the requirements of the Seal of Good Local Governance (SGLG) or the commitment level of the Local Chief Executive (LCE). Common agenda items consistently included program updates, reviews of the health budget, recommendations for new policies, and discussions on how to address outbreaks or other health emergencies. Despite these efforts, significant challenges in meeting effectiveness were reported. These included difficulties in achieving a quorum, conflicting schedules with other local councils, and instances where LCEs sent representatives who lacked the authority to make binding decisions. To address these, the importance of a functional Technical Working Group (TWG) was consistently emphasized, as they are responsible for preparing the agenda and reports prior to LHB meetings, ensuring productive discussions. The decision-making process within the LHB typically involves deliberation, discussion among members, and the eventual endorsement of resolutions to the Local Council for formal approval. While the Local Government Code and Joint Administrative Order (JAO) No. 2022-0001 (LeadGov4Health) mandate monthly LHB meetings, participants frequently cited practical challenges that prevent consistent adherence to this schedule. These challenges include conflicting schedules, members holding multiple committee memberships, and the varying availability of LCEs. The observation that "it's crucial for the TWG to be active; they effectively serve as the implementing body for the LHB. The LHB members largely depend on the TWG's health reports for their information" (translated from Filipino) highlights the TWG as the crucial engine of LHB functionality. Without a proactive and well-capacitated TWG, LHB meetings risk devolving into mere reporting sessions rather than substantive forums for decision-making and policy formulation. 3.5 Community Engagement and Participation LHBs employ various methods to engage with their communities and other stakeholders. These strategies include inviting representatives from Civil Society Organizations (CSOs), Barangay Health Workers (BHWs), and barangay captains to LHB meetings. Digital platforms, such as Facebook pages and live streams, are also utilized to broaden reach and engagement. Additionally, community forums and assemblies serve as vital venues for direct interaction. Another participant expressed that "community involvement is extremely important, akin to a town hall format” (translated from Filipino). "Deep dive" activities, where Local Chief Executives (LCEs) personally visit and interact with communities, were identified as particularly effective in gathering authentic insights and directly influencing LHB decisions. Furthermore, community feedback, often relayed by BHWs or through formal complaints, has directly shaped LHB decisions. Examples include the revision of local ordinances (e.g., increasing penalties for smoking violations) or the proactive addressing of specific health needs (e.g., emergency procurement of rabies vaccines, establishment of dialysis clinics). A significant challenge, however, is the impact of political dynamics on the tenure of Barangay Health Workers (BHWs), as untimely dismissals can directly impede effective community-level data gathering and consistent program implementation. Barangay Health Workers (BHWs) are consistently identified as crucial for facilitating community input and ensuring the effective implementation of health programs 5 . They serve as frontline data gatherers and essential community liaisons. However, their vulnerability to political changes, which can lead to arbitrary dismissal or disqualification from social benefits, directly undermines this vital link in the healthcare system. This creates a direct cause-and-effect relationship: the politicization of BHWs leads to discontinuity in community health services and compromises the integrity of local health data. While formal LHB meetings may not always facilitate direct community engagement, practices such as LCE "deep dives" and town hall formats are consistently cited as highly effective mechanisms for bringing raw, unfiltered community concerns directly to the LHB. 3.6 Monitoring and Evaluation (M&E) Practices Monitoring and Evaluation (M&E) within LHBs is often a shared responsibility between the Department of Health (DOH) and local officials. This process typically utilizes existing tools such as the Field Health Service Information System (FHSIS), LGU health scorecards, and Program Implementation Reviews (PIRs). The "LGU health scorecard" and the achievement of an "improved health scorecard" are frequently cited as key indicators of LHB effectiveness. It was observed that Local Chief Executives (LCEs) respond particularly well to simplified, visual data, such as color-coded (red, yellow, and green) indicators, which clearly highlight performance status. Despite these efforts, several challenges in M&E practices were identified. These include a notable lack of standardized M&E tools specifically designed to assess LHB functionality itself, rather than just program outcomes. Furthermore, limited resources, both financial and in terms of manpower, significantly hinder the capacity for robust monitoring. Difficulties in effectively monitoring the implementation of Universal Health Care (UHC) at the local level also pose a considerable challenge. A participant articulated this need, stating, “I hope there would be a standard tool to measure the functionality of the LHB” (translated from Filipino). LCEs are also observed to respond effectively to simplified, visual data, such as color-coded scorecards that could highlight the significance of data visualization. 3.7 Training and Capacity Building Needs Past capacity-building initiatives for LHB members have included programs such as the Municipal Leadership and Governance Program (MLGP) and Provincial Leadership and Governance Program (PLGP), Bridging Leadership, Incident Command System courses, Community Mental Health Programs, and Local Investment Plan for Health (LIPH) workshops. These programs have demonstrably contributed to a greater understanding and increased commitment to health priorities among Local Chief Executives (LCEs). Despite these efforts, significant training needs persist. Participants expressed a demand for more comprehensive training in policy making, parliamentary procedures, financial management (particularly regarding Special Health Fund utilization), effective Monitoring and Evaluation (M&E) strategies, the application of "health in all policies" approaches, and cooperative governance. There is a clear call for specific LHB-focused trainings, distinct from general program-specific ones, and for continuous orientation programs for new members, given the high turnover rate of elected officials. A participant articulated this concern, stating, "Leaders are being changed and replaced at least every 3 years so you have to retrain them again. But in my opinion, is training really what we need? What is the Return of Investment?". There have been repeated requests for training in financial management, particularly concerning the Special Health Fund (SHF), and in policy making among these LHBs. Undoubtedly, without adequate skills in these domains, LHBs struggle to effectively manage available resources and translate identified health needs into actionable local legislation. 3.8 Impact of National Policies and Regulations National policies and regulations exert a profound influence on the operations of Local Health Boards [ 11 ]. Key legislative frameworks, including the Local Government Code, the Universal Health Care (UHC) Act, various DILG memoranda (such as those related to the Seal of Good Local Governance, SGLG), and specific DOH policies, all significantly shape LHB functions and activities. The UHC Act, for instance, directly led to the expansion of LHB membership and functions, emphasizing the board's crucial role in health system integration. However, the implementation of these national mandates is not without its challenges. Policy gaps, conflicting interpretations (e.g., regarding LHB membership composition), and the perceived inapplicability of some policies to diverse local contexts, particularly in Geographically Isolated and Disadvantaged Areas (GIDAs), create operational hurdles. A participant lamented, "A lot of policies are being disseminated that are impractical or irrelevant for GIDAs and certain other provinces” (translated from Filipino). Furthermore, concerns were raised regarding the monitoring and enforcement of benefits stipulated in the Magna Carta for Health Workers. While national policies, such as the Universal Health Care Act and the Seal of Good Local Governance, are instrumental in guiding Local Health Boards (LHBs) toward enhanced functionality and compliance, there's an observable tension in their application. Some stakeholders have voiced concerns that these policies aren't always readily applicable in Geographically Isolated and Disadvantaged Areas (GIDAs) and various other provinces. The Magna Carta for Health Workers is a critical policy designed to protect and uplift healthcare personnel. However, a significant concern emerged regarding its implementation. There is widespread confusion about which entity is responsible for monitoring its enforcement, coupled with a perception that its stipulated benefits are not fully realized at the local level. This directly impacts the morale, welfare, and retention of essential health human resources, which in turn has a cascading negative effect on the quality and continuity of health service delivery. 4. Analysis and Discussion LHB functionality emerges as a multifaceted construct, encompassing a dynamic interplay of leadership commitment, efficient resource management, responsive internal processes, genuine community engagement, and supportive national policy frameworks. 4.1 Leadership and Governance: The Enduring Centrality of the LCE The consistent emphasis on Local Chief Executive (LCE) engagement as the primary determinant of LHB vitality highlights a critical aspect of decentralized governance in the Philippines. This observation aligns with existing literature on decentralization, which often points to the challenges of "elite capture" at the local level [ 15 ]. In such contexts, politicians can become the central figures in decision-making, potentially overshadowing or even undermining health priorities, as documented by Liwanag and Wyss [ 11 ]. The active presence and political will of the LCE can either propel the LHB forward or render it inert, demonstrating a significant vulnerability in the system. The observed "MLGP effect," where leadership and governance programs enhance LCE understanding and commitment to health, is consistent with academic discourse on the importance of capacity-building for local governance [ 14 ]. However, the inherent challenge of frequent political turnover means that this enhanced capacity is often transient. This dynamic necessitates a continuous cycle of retraining, raising questions about the long-term sustainability of individual-focused capacity building efforts. This is consistent with previous findings in Chile where political turnovers negatively affect the quality of public services [ 16 ]. The reliance on individual political will rather than robust institutional mechanisms creates a fragile foundation for sustained LHB functionality. 4.2 Resource Dynamics: Bridging the Gap Between Allocation and Utilization The "paradox of 'money is there, but hard to spend'" reflects a broader systemic challenge in Philippine health financing within a decentralized framework. While funds may be allocated, restrictive guidelines, particularly concerning the Special Health Fund (SHF) and Personnel Services (PS) Cap, impede their efficient utilization at the local level. This situation resonates with findings from Capuno et al. [ 17 ], who discuss issues in Philippine health financing, including a low public budget share for health and challenges in fund absorption by LGUs. The inability to flexibly utilize funds, especially for critical human resources, directly impacts service delivery. The strategic inclusion of finance officers and local finance committees in the LHB emerged as a practical and effective solution to overcome these bureaucratic hurdles. This structural integration streamlines financial processes, making resource allocation more responsive to immediate health needs. This practice exemplifies principles of good financial governance, demonstrating that effective resource mobilization is not solely about securing funds but equally about optimizing their internal allocation and utilization through cross-functional collaboration within the LHB. 4.3 Responsive Processes: Efficiency and Adaptiveness of LHBs Internal processes are one of the factors that define efficiency of organizations, similar to the case of government institutions. Findings from the study highlight the challenges between mandatory meetings and practical feasibility given the heavy workload circumstances of each involved agency or stakeholder. This suggests a need for flexible meeting formats, such as convergence meetings or hybrid sessions, to improve attendance and productivity. Moreover, the critical role of the Technical Working Group (TWG) in driving LHB effectiveness cannot be overstated. The TWG functions as the indispensable technical arm, responsible for preparing agendas, conducting data analysis, and drafting policy recommendations. Their proactive work ensures that LHB meetings are substantive and evidence-based, even when LCEs have limited time. This underscores the need for strong technical support structures in decentralized health systems, which can provide continuity and informed decision-making despite political changes. To further enhance stability, institutionalizing LHB functions through local ordinances, rather than less permanent Executive Orders, can provide a more robust legal framework that withstands political shifts, a strategy supported by studies on strengthening local governance such as that by Juban et al [ 18 ]. Apart from these structures, effective monitoring and evaluation (M&E) tools that link closely with functional LHBs remain to be a significant gap. Findings from the study highlight how the current M&E frameworks primarily focus on outputs and outcomes of health programs rather than the quality of the governance processes driving them. Developing such a tool, potentially integrated into the SGLG, would provide crucial feedback for LHB self-improvement and enhance accountability. Observations from participants showed the significance of harmonization and clear communication, even in monitoring systems - which was previously identified as part of the broader challenges of fragmented data monitoring systems in decentralized health systems [ 11 ]. Ultimately, more efficient and adaptive processes make the institution more responsive to the needs to attain the set targets and goals. This would define having a higher institutional capacity which was already previously found to significantly impact positively the service delivery [ 19 ]. 4.4 Community Engagement: From Representation to Co-Ownership Barangay Health Workers (BHWs) were consistently identified as the "unsung heroes and vulnerable link" in community engagement. Their immense engagement with the community provides them a deeper understanding of actual community concerns. The findings of the study align with Ramiro et al [ 3 ] and Gonzales [ 21 ]who previously found the significance of the BHWs in functioning health boards to enhance community participation. Despite their introduction into the Philippine health system in the 1980s and later institutionalized through Republic Act 7883 [ 20 ], a few decades later, the recognition and value the health system puts into their role remains minimal. With the current programs and policies in place, BHWs remain with precarious positions being highly vulnerable to politicization and changes in leadership. This vulnerability directly undermines authentic community participation, a core objective of decentralization. Consequently, this negatively affects service delivery, similar to the case of Brazil [ 22 ]. As highlighted by Liwanag and Wyss [ 11 ], political interference can compromise community involvement and data integrity. Protecting BHWs through institutionalized roles and safeguards is therefore essential for sustainable grassroots health initiatives. The inclusion of community health workers aligns with participatory governance principles, which emphasize bottom-up planning and co-creation of health solutions, as advocated by Juban et al [ 18 ]. Moving beyond mere representation to active, empathetic listening and collaborative solution-finding fosters greater trust and ensures programs are truly responsive to local needs. 4.5 Policy Environment and Capacity Building: Towards a Responsive Framework A critical gap exists in financial management and policy development skills among LHB members. This deficiency acts as a significant barrier to LHB empowerment under UHC, hindering their ability to effectively manage resources and translate health needs into actionable local legislation. Targeted training in these areas is crucial to enable LHBs to fulfill their expanded roles. The impact of national mandates, while driving compliance, presents a "double-edged sword." While policies like UHC and SGLG push for greater functionality, their perceived inapplicability to diverse local contexts, particularly GIDAs, can lead to a focus on mere compliance rather than genuine local impact. This suggests a need for greater local autonomy and bottom-up consultations in policy formulation. Furthermore, the "unfulfilled promise of the Magna Carta for Health Workers," with concerns about its monitoring and full implementation, directly impacts the morale and retention of health personnel. This issue underscores the need for clear directives and joint enforcement by national agencies to ensure equitable treatment of health workers. The success of government programs are heavily dependent on the motivation of these offices in the implementation process. Distor and Khaltar [ 19 ] previously found the positive impact to efficiency of national support in the implementation of programs. 4.6 Synthesizing Challenges and Enabling Factors: A Framework for Functional LHBs The findings reveal that challenges to LHB functionality are interconnected, forming a complex web where one issue exacerbates another. A set of barriers were identified to be common across these LHBs. These include pervasive political interference, persistent budget constraints, difficulties in time management due to members holding multiple roles, procedural hurdles in passing resolutions, and a significant lack of continuity stemming from frequent leadership changes. Conversely, several enabling factors were identified as crucial for LHB effectiveness. These include strong commitment from the Local Chief Executive (LCE), the benefits derived from an expanded multi-sectoral membership, the presence of effective Technical Working Groups (TWGs), the provision of technical assistance from DOH and DILG, and the positive impact of leadership training programs. We propose a framework that describes these relationships as shown in Fig. 1 . Despite the attempt to simplify these into this framework, the magnitude of the way each construct affects the other cannot be quantified. For instance, political interference can directly lead to budget instability, which in turn impedes program implementation and resource mobilization, ultimately impacting overall LHB effectiveness and functionality. The lack of continuity due to LCE turnover further compounds these issues by disrupting established plans and relationships. This complex interplay among these constructs necessitates a holistic and multi-pronged approach to strengthening LHBs -- i.e. one that targets multiple points in this cycle, such as institutionalizing LHB roles to mitigate political interference, ensuring stable funding, and building robust internal processes that can withstand political shifts. We propose in this framework the significance of putting genuine community engagement at the core of a functional LHB which makes it participative and responsive to the actual needs of the community. Outside these internally relevant constructs, we also found the significance of creating an enabling policy environment that provides significant support and foundation to the functionality of LHBs. Additionally, despite the myriad internal challenges, LHBs that actively engage external stakeholders—including the DOH, DILG, non-governmental organizations (NGOs), and the private sector—and effectively leverage their support tend to exhibit higher levels of functionality. This observation suggests that external technical assistance, sustained advocacy, and consistent monitoring can serve as crucial enabling factors, providing a vital counterbalance to internal limitations such as political shifts or chronic resource constraints. This highlights the importance of DOH and DILG strengthening their joint monitoring and technical assistance roles, ensuring consistent support and guidance that transcends local political dynamics. Such sustained external engagement fosters a more resilient and functional LHB ecosystem across the country. 5. Conclusion and Recommendations The functionality of Local Health Boards in the Philippine context is a complex and dynamic interplay of various factors, extending beyond mere procedural compliance. This thematic analysis underscores that a truly functional LHB is characterized by strong and consistent political will from the Local Chief Executive, effective and flexible resource management, robust internal processes supported by a proactive Technical Working Group, genuine and institutionalized community engagement, and a national policy framework that balances standardization with local applicability. The study's empirical insights, drawn directly from the experiences of diverse local stakeholders, contribute to a nuanced understanding of decentralized health governance under the Universal Health Care Act. It highlights that while national mandates provide direction, the success of LHBs ultimately hinges on their adaptive capacity to navigate political landscapes, overcome financial constraints, and foster authentic collaboration at all levels. The interconnectedness of challenges necessitates a holistic approach, where addressing one area (e.g., political interference) can positively impact others (e.g., budget stability and program continuity). Conversely, the power of collaboration and external support from national agencies and other stakeholders serves as a crucial counterbalance, reinforcing local efforts and driving continuous improvement. Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. Written informed consent was obtained from all individual participants included in the study prior to the focus group discussions. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including individual details, images, or videos). Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the confidential nature of the focus group discussions and to protect the privacy of the participants. However, anonymized data are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research was supported by a grant from the Philippine Business for Social Progress (PBSP) through the Department of Health – Bureau of Local Health Systems Development (BLHSD). The funding body had no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript. Authors' contributions B.E.N. conceptualized and designed the study, supervised data collection, and was a major contributor in writing and revising the manuscript. M.B. was involved in the data collection process, conducted the primary thematic analysis, and contributed to the drafting of the results section. J.J.G.G. and P.C.E. assisted in the literature review, data analysis, and contributed to the writing and editing of the final manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to express their sincere gratitude to all the Provincial and Municipal Health Officers, Local Chief Executives, Local Council Bayan members, DOH and DILG representatives, and Civil Society Organization members from Laguna, Aklan, Sarangani, and Benguet who generously shared their time and invaluable insights for this study. We also thank Philippine Business for Social Progress (PBSP) and the Department of Health for their logistical support during the data collection process. Authors' information (optional) Bien Eli Nillos, MD, MHSS - is a former Municipal health officer and Doctor to the Barrio, public health practitioner for more than 15 years and an academician for more than 10 years. He earned his master’s degree in Health Social Science at De La Salle University. He is currently the Cluster head of the Cluster of Management and Public health of the MAPUA School of Medicine. He is also a Fellow of the Philippine Academic Society of Social and Community Medicine (PASCOM) Mr. Miko Balisi, MSc, MPHM, RND - is a consultant for Continuous Quality Improvement and Data Quality and Governance. He has also worked as a consultant for COVID19 Provincial Data Mapping in the Philippine Society of Public Health Physicians and was a Junior Policy Research Associate of the Department of Health. He took his master’s degree in Primary Health Care Management at Mahidol University and Masters in Public Health at UE Ramon Magsaysay Medical Memorial Center Inc. Mr. Jonathan Jaime G. Guerrero -has a master’s degree in Plant Pathology from the University of the Philippines Los Baños and is currently pursuing a dual degree in Doctor of Medicine - Master of Public Health (MD-MPH), a joint program of the University of the Philippines Manila College of Medicine and College of Public Health. Mr . Paolo C. Encarnacion is currently enrolled under the Doctor of Medicine - Master of Public Health program of the University of the Philippines Manila. He previously worked as a project manager / research assistant for projects in maternal and child health, tobacco control, and PhilHealth packages. References Atienza, M. E. (2004). Local governments and devolution in the Philippines. In N. Morada & T. Encarnacion-Tadem (Eds.), Philippine politics and governance (pp. 415–438). University of the Philippines Press. Capuno J. Tugs of war: local governments, national government. Public Policy. 2017;16:98-116. Ramiro LS, Castillo FA, Tan-Torres T, Torres CE, Tayag JG, Talampas RG, Hawken L. Community participation in local health boards in a decentralized setting: cases from the Philippines. Health policy and planning. 2001. 1:61-9. https://doi.org/10.1093/heapol/16.suppl_2.61 Grundy J, Healy V, Gorgolon L, Sandig E. Overview of devolution of health services in the Philippines. Rural and remote health. 2003 Sep;3(3):1-0. Lam HY, Zarsuelo MA, Capeding TP, Silva ME, Mendoza MA, Padilla CD. Policy analysis on province-level integration of healthcare system in light of the universal health care act. Acta Medica Philippina. 2020 Dec 26;54(6). de Claro V, Lava JB, Bondoc C, Stan L. The role of local health officers in advancing public health and primary care integration: lessons from the ongoing Universal Health Coverage reforms in the Philippines. BMJ Global Health. 2024 Jan 22;9(1). Department of Health. (2019). Implementing Rules and Regulations of Republic Act No. 11223 (Universal Health Care Act). https://doh.gov.ph/sites/default/files/health-programs/UHC-IRR-signed.pdf Department of Health (DOH). A Guide to Local Health Board Operations. Manila: DOH; 2020. Co PA, Vîlcu I, De Guzman D, Banzon E. Staying the Course: Reflections on the Progress and Challenges of the UHC Law in the Philippines. Health Systems & Reform. 2024 Dec 18;10(3):2397829. Cuenca JS. Health devolution in the Philippines: lessons and insights. PIDS discussion paper series; 2018. Liwanag HJ, Wyss K. What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines. PLoS One. 2018 Nov 5;13(11):e0206809. Abrigo MR, Tam ZC, Ortiz DA. Decentralization and health in the Philippines: A systematic review of empirical evidences. Department of the Interior and Local Government & Department of Health. (2022). Joint Administrative Order No. 2022-0001: Guidelines on the Strengthening of Local Health Boards for the Implementation of the Universal Health Care Act. Noval, C. C., & Palompon, D. R. (2024). Nurses-Led Municipal Leadership and Governance Program: Experiences of Local Chief Executives in Central Visayas, Philippines. International Journal of Nursing Science, 14(2), 112-120. doi:10.11648/j.ijn.20241402.13 Bardhan, P., & Mookherjee, D. (2010). Decentralization, corruption, and the accountability of local governments: An overview. Journal of Economic Perspectives, 24(4), 185-204. Gallegos S (2023). Political Turnover Negatively Affects the Quality of Public Services: A Replication. Journal of Economic Behavior & Organization, Vol. 212, pp. 796-818. https://doi.org/10.1016/j.jebo.2023.05.046 Capuno, J. J., Corpuz, J., & Lordemus, S. (2024). Natural disasters and local government finance: Evidence from Typhoon Haiyan. Journal of Economic Behavior & Organization, 220, 869–887. Juban NR, Salisi JA, Mier ARB, Mier-Alpaño JDB. Seal of Health Governance, Philippines. Social Innovation in Health Initiative; 2020. Distor, C. B., & Khaltar, O. (2022). What Motivates Local Governments to Be Efficient? Evidence from Philippine Cities. Sustainability, 14(15), 9426. https://doi.org/10.3390/su14159426 Congress of the Philippines: Republic Act no. 7883: An act granting benefits and incentives to accredit barangay health workers and for other purposes. In. Metro Manila: Republic of the Philippines; 1995. Gonzales, M. L. S. (2013). Community health workers in the Philippines: A study on their roles and capabilities. Institute of Philippine Culture, Ateneo de Manila University. Akhtari M, Moreira D, Trucco L (2022). "Political Turnover, Bureaucratic Turnover, and the Quality of Public Services," American Economic Review, American Economic Association, vol. 112(2), pages 442-493, February. Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. InHandbook of research methods in health social sciences 2019 (pp. 843-860). Springer, Singapore. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":98511,"visible":true,"origin":"","legend":"\u003cp\u003eConstructs supporting functionality of LHBs in the Philippines\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7169520/v1/216c4a6518ed0b51ba01b1fa.png"},{"id":98621993,"identity":"19f2b03c-ceae-42a9-9a3d-1465ca7eb46c","added_by":"auto","created_at":"2025-12-19 16:39:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1065169,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7169520/v1/d2e7b99d-4692-476a-9017-901093875fbe.pdf"},{"id":96794012,"identity":"a75d7c41-0221-43cf-bd15-cd81df5f3176","added_by":"auto","created_at":"2025-11-26 07:09:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":40565,"visible":true,"origin":"","legend":"","description":"","filename":"FGDQuestionnaireValidated.docx","url":"https://assets-eu.researchsquare.com/files/rs-7169520/v1/4bdb5681c25c49348c6e5820.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determining the Functionality of Local Health Boards in the Philippines: Perspectives from Local Government Units","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe decentralization of governance, a move towards empowering sub-national entities, has been a cornerstone of public sector reforms in many developing nations. In the Philippines, this transition was formally enshrined in the Local Government Code of 1991 (Republic Act 7160), a landmark legislative act that fundamentally reconfigured the relationship between national and local government units [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This mandate devolved significant administrative and fiscal powers, most notably in the critical domain of health services, with the objective of fostering a more localized and responsive healthcare system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A key mechanism established by this framework was the creation of local health boards (LHBs) at the provincial, city and municipal levels. Envisioned as a primary forum for localized health governance, these boards were tasked with facilitating community participation, enhancing the efficiency of health service delivery, and tailoring health programs to the specific needs of local populations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the initial mandate for LHBs was significant, their role has continued to expand, particularly with the enactment of the Universal Health Care (UHC) Act of 2019 (Republic Act 11223). This landmark legislation elevated the function of LHBs from advisory bodies to pillars of health systems integration, emphasizing their critical role in ensuring equitable access to healthcare for all Filipinos [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Functional LHBs are now recognized as indispensable for their successful implementation of UHC [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], serving as the primary local governance mechanism for strategic allocation of resources, coordination of services, and meaningful engagement with diverse communities. They are responsible for a range of critical functions, including the formulation of local health plans, management of local health funds, and oversight of health facilities [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these clear mandates, many LGUs continue to face persistent challenges in establishing and maintaining the full functionality of their LHBs. The operational effectiveness of these boards is often hampered by a confluence of factors, including limited technical expertise among board members, insufficient financial allocations for health programs, and inadequate infrastructure to support health service delivery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The uneven capacity of LGUs to perform their devolved health functions has been a long-standing issue in the Philippines, leading to disparities in health outcomes across different localities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, challenges in ensuring effective inter-sectoral collaboration and community engagement can hinder the LHBs ability to develop health programs that are truly responsive to local needs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecognizing these challenges, providing targeted technical assistance to LGUs becomes paramount for the effective operation of LHBs. This support encompasses crucial guidance on organizational setup, strategies for resource mobilization, and the practical implementation of health programs. Such technical assistance is vital in helping LGUs develop robust strategic health plans, rigorously monitor and evaluate health outcomes, and ensure consistent compliance with national health standards. This comprehensive support not only bolsters the intrinsic capacity of local health systems but also contributes directly to the overarching national goal of achieving universal health coverage in the Philippines. By proactively addressing identified gaps through dedicated assistance, LGUs can significantly enhance their health systems' capacity, elevate the quality of health service delivery, and ensure that health programs are both sustainable and genuinely responsive to community needs.\u003c/p\u003e\u003cp\u003e The primary purpose of this study is to explore and determine the constructs significant to the functionality of Local Health Boards in the Philippine context. This study aims to provide empirical insights that can inform the development of practical tools and guidance for LGUs, thereby enabling them to establish and sustain effective LHBs that can significantly enhance healthcare service delivery.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Design\u003c/h2\u003e\u003cp\u003eThis study employed a cross-sectional exploratory qualitative research design. This design was chosen to gather in-depth insights into the lived experiences, persistent challenges, and successful practices of LHB members across various localities. Ethical clearance was received from the Research Ethics Review Panel (RERP) of the De La Salle University tagged with a project code: 2025\u0026thinsp;\u0026minus;\u0026thinsp;269. The study was deemed low risk since the study does not pose more than minimal risk or harm to the participants, does not involve participants from the vulnerable groups, involves use of anonymous or anonymized laboratory/pathology samples or stored tissues or data, and is not sensitive in nature and does not generate vulnerability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study Setting and Participants\u003c/h2\u003e\u003cp\u003eFGDs were strategically conducted in selected provinces across the Philippines, specifically Laguna, Aklan, Saranggani, and Benguet. Participants in the FGDs comprised a diverse group of LHB members including Provincial Health Officers (PHOs), Municipal Health Officers (MHOs), DOH Medical Officers (DMOs), Sangguniang Bayan (SB) members, DILG representatives, and Civil Society Organization (CSO) representatives.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Collection\u003c/h2\u003e\u003cp\u003e Data were systematically collected through semi-structured Focus Group Discussions (FGDs), which were conducted in adherence to established ethical standards. Prior to participation, all individuals were provided with clear and comprehensive information about the purpose, process, and intended use of the study through an informed consent procedure. Participants voluntarily agreed to take part and were assured of their right to withdraw at any time without consequence. To protect privacy, all responses were anonymized during data handling and reporting, ensuring that no personal identifiers were linked to any of the shared insights.\u003c/p\u003e\u003cp\u003eThe questionnaire centered on the roles of the LHBs, challenges encountered, notable achievements, core functions, strategies for resource mobilization, approaches to community engagement, methods for monitoring and evaluation, identified training needs, and the influence of national policies.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data Analysis\u003c/h2\u003e\u003cp\u003eCollected data were transcribed and coded through NVivo 15. Subsequently, these were analyzed by two authors through the six phases of thematic analysis as identified by Braun and Clarke [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]: familiarization, coding, searching for themes, reviewing themes, defining and naming themes, and writing the report.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 4 FGDs were conducted consisting of 83 participants from the four study sites. The thematic analysis of the FGD transcripts revealed several key themes and sub-themes that highlight the intricate interplay of internal dynamics, external influences, and the adaptive strategies employed by LHBs. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides an overview of these identified themes and their corresponding sub-themes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKey Themes and Sub-Themes on LHB Functionality\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain Theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-Themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRoles, Responsibilities, and Evolving Structure of LHBs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShifting Paradigms from Advisory to Managerial/Policy-Making Body\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Double-Edged Sword of Expanded Membership\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDynamics of Leadership and Political Will\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLCE Engagement as the Primary Determinant of LHB Vitality\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe \"MLGP Effect\" and its Limitations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResource Mobilization and Financial Management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Paradox of \"Money is There, But Hard to Spend\"\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStrategic Inclusion of Finance Officers as a Best Practice for Resource Flow\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMeeting Effectiveness and Decision-Making Processes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Tension Between Mandated Regularity and Practical Feasibility\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Critical Role of the TWG in Driving LHB Effectiveness\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCommunity Engagement and Participation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBHWs as the Unsung Heroes and Vulnerable Link in Community Engagement\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeep Dives and Town Halls as Effective Mechanisms for Authentic Community Voice\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMonitoring and Evaluation (M\u0026amp;E) Practices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Gap Between Program-Level M\u0026amp;E and LHB Functionality Assessment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVisual Data as a Catalyst for LCE Action\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTraining and Capacity Building Needs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Sustainability Challenge of Capacity Building Amidst Political Cycles\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Critical Gap in Financial Management and Policy Development Skills\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eImpact of National Policies and Regulations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Double-Edged Sword of National Mandates: Compliance vs. Contextual Relevance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe Unfulfilled Promise of the Magna Carta for Health Workers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Evolving Structure of LHBs\u003c/h2\u003e\u003cp\u003eThe structure of the LHB has undergone significant transformation, moving beyond the initial framework outlined in the Local Government Code. This expansion has been particularly pronounced with the advent of the Universal Health Care (UHC) Act and various DILG memoranda, leading to the inclusion of a more diverse range of stakeholders [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These now encompass Civil Society Organizations (CSOs), members of local finance committees, and even barangay captains, reflecting a deliberate effort towards broader representation. A participant articulated this evolution, stating that \"The LHB transformed from a mere advisory body to the manager of the SHF\".\u003c/p\u003e\u003cp\u003eThis transformation signifies a fundamental shift in the LHB's mandate, moving beyond mere recommendations to direct operational and legislative influence. Initially, LHBs were primarily conceived as advisory bodies, offering guidance to local chief executives on health matters. However, with the implementation of UHC and specific directives from DILG, their roles have expanded to include active management of the Special Health Fund (SHF) and direct involvement in drafting and endorsing policies and resolutions. This expanded role necessitates a different set of competencies, such as expertise in financial management and policy drafting, and a clearer understanding of their legal authority. It appears that these new requirements are not yet fully internalized by all LHB members or LGUs, creating a potential gap in their operational capacity.\u003c/p\u003e\u003cp\u003eThe expansion of LHB membership, while intended to foster broader representation and facilitate resource mobilization, presents a complex dynamic. The inclusion of CSOs, finance officers, and other sectors is widely lauded as a success, enabling a wider range of perspectives and potentially unlocking more resources for health initiatives. However, this inclusivity also introduces challenges. Participants frequently cited difficulties in achieving a quorum for meetings, managing time effectively due to diverse interests, and navigating potentially slower decision-making processes stemming from conflicting schedules and priorities among members. While inclusivity is vital for ensuring community-responsive health governance, effective LHB functionality requires strategic management of this expanded membership. This could involve implementing mechanisms such as executive committees or streamlined parliamentary procedures to balance the benefits of broad representation with the imperative for operational efficiency.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Dynamics of Leadership and Political Will\u003c/h2\u003e\u003cp\u003eThe commitment and active participation of the Local Chief Executive (LCE), whether the Mayor or Governor, consistently emerged as the most critical determinant for LHB functionality [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Participants repeatedly emphasized this factor, with one stating, \"Participation of the LCE is a key factor to determine the functionality of the LHB\". When the LCE is actively engaged, LHB meetings are held regularly, resources are more readily mobilized, and resolutions are promptly acted upon. Conversely, a lack of engagement from the LCE often leads to stagnation and non-functionality of the LHB. Concerns were raised about communication gaps, such as when \"the mayor does not inform the SB\", hindering the board's effectiveness. Frequent LCE attendance, even through online platforms, was noted to ensure issues are addressed swiftly.\u003c/p\u003e\u003cp\u003eA significant challenge identified is the impact of changes in LCEs, which frequently disrupt LHB continuity and shift program priorities, leading to what participants described as \"political interference\". A participant observed, \"Leadership changes seem to disrupt LHB continuity\". The symbiotic relationship, or \"tandem,\" between the PHO/MHO and the LCE was frequently highlighted as crucial for successful health governance.\u003c/p\u003e\u003cp\u003eThe data overwhelmingly indicates that the LCE's active involvement, extending beyond mere compliance, is the single most influential factor in LHB functionality. When the LCE is deeply engaged, meetings are consistent, resources are effectively mobilized, and resolutions are translated into action. Conversely, LCE disinterest leads to the LHB's stagnation and eventual non-functionality.\u003c/p\u003e\u003cp\u003e Several participants noted the positive impact of leadership and governance programs, such as the Municipal Leadership and Governance Program (MLGP), on LCEs' understanding and prioritization of health. These programs demonstrably enhance the capacity of local leaders to champion health initiatives. However, the frequent turnover of elected officials, typically every three years, means that this enhanced capacity requires constant retraining. This cyclical need for capacity building raises pertinent questions about its long-term sustainability and return on investment. One participant articulated this concern, stating, \"Leaders are being changed and replaced at least every 3 years so you have to retrain them again. But in my opinion, is training really what we need? What is the Return of Investment?\".\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Resource Mobilization and Financial Management\u003c/h2\u003e\u003cp\u003eA recurring observation was that LHBs generally lack their own dedicated operational budgets, relying instead on allocations from the Provincial Health Office (PHO) budget, grants from the Department of Health (DOH), support from development partners, and tapping into the Corporate Social Responsibility (CSR) initiatives of the private sector. A participant underscored this challenge, stating that \"The board doesn't have its own funds, so for your internal operational expenses, where can we secure, and where will you source the payment?\" (translated from Filipino).\u003c/p\u003e\u003cp\u003eDespite these constraints, successful strategies for resource mobilization were identified. These include pooling resources, particularly during emergencies like the COVID-19 pandemic, maximizing Philhealth reimbursements, and engaging industrial companies for direct funding or in-kind support for community outreach and facility repairs. A key enabler of efficient fund management was the inclusion of budget officers and local finance committees within the LHB, which significantly eased processes for fund realignment and augmentation.\u003c/p\u003e\u003cp\u003e However, significant challenges persist, including overall limited budget allocations for health, Personnel Services (PS) Cap limitations that hinder the hiring of essential Human Resources for Health (HRH), and restrictive guidelines on the utilization of the Special Health Fund (SHF). A participant aptly summarized this frustration, remarking, \"While healthcare has significant funds, spending them is challenging because of the numerous regulations involved\" (translated from Filipino).\u003c/p\u003e\u003cp\u003eParticipants expressed frustration over what was described as the \"paradox of 'money is there, but hard to spend.'\" They acknowledged the availability of various funding sources for health, including DOH grants, Philhealth reimbursements, LGU funds, and private sector contributions. However, they consistently highlighted restrictive guidelines, particularly concerning the Special Health Fund (SHF) and the Personnel Services (PS) Cap, which severely limit their ability to hire necessary personnel or utilize funds flexibly.\u003c/p\u003e\u003cp\u003eThe explicit mention that including budget officers and local finance committees in the LHB directly facilitates fund realignment and augmentation reveals a clear and direct causal relationship. This structural integration effectively bypasses traditional bureaucratic hurdles, making financial processes more responsive to immediate health needs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Meeting Effectiveness and Decision-Making Processes\u003c/h2\u003e\u003cp\u003e The frequency of LHB meetings varied among LGUs, ranging from quarterly to monthly, or convened as needed, often influenced by the requirements of the Seal of Good Local Governance (SGLG) or the commitment level of the Local Chief Executive (LCE). Common agenda items consistently included program updates, reviews of the health budget, recommendations for new policies, and discussions on how to address outbreaks or other health emergencies.\u003c/p\u003e\u003cp\u003eDespite these efforts, significant challenges in meeting effectiveness were reported. These included difficulties in achieving a quorum, conflicting schedules with other local councils, and instances where LCEs sent representatives who lacked the authority to make binding decisions. To address these, the importance of a functional Technical Working Group (TWG) was consistently emphasized, as they are responsible for preparing the agenda and reports prior to LHB meetings, ensuring productive discussions. The decision-making process within the LHB typically involves deliberation, discussion among members, and the eventual endorsement of resolutions to the Local Council for formal approval.\u003c/p\u003e\u003cp\u003eWhile the Local Government Code and Joint Administrative Order (JAO) No. 2022-0001 (LeadGov4Health) mandate monthly LHB meetings, participants frequently cited practical challenges that prevent consistent adherence to this schedule. These challenges include conflicting schedules, members holding multiple committee memberships, and the varying availability of LCEs. The observation that \"it's crucial for the TWG to be active; they effectively serve as the implementing body for the LHB. The LHB members largely depend on the TWG's health reports for their information\" (translated from Filipino) highlights the TWG as the crucial engine of LHB functionality. Without a proactive and well-capacitated TWG, LHB meetings risk devolving into mere reporting sessions rather than substantive forums for decision-making and policy formulation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Community Engagement and Participation\u003c/h2\u003e\u003cp\u003eLHBs employ various methods to engage with their communities and other stakeholders. These strategies include inviting representatives from Civil Society Organizations (CSOs), Barangay Health Workers (BHWs), and barangay captains to LHB meetings. Digital platforms, such as Facebook pages and live streams, are also utilized to broaden reach and engagement. Additionally, community forums and assemblies serve as vital venues for direct interaction. Another participant expressed that \"community involvement is extremely important, akin to a town hall format\u0026rdquo; (translated from Filipino).\u003c/p\u003e\u003cp\u003e\"Deep dive\" activities, where Local Chief Executives (LCEs) personally visit and interact with communities, were identified as particularly effective in gathering authentic insights and directly influencing LHB decisions. Furthermore, community feedback, often relayed by BHWs or through formal complaints, has directly shaped LHB decisions. Examples include the revision of local ordinances (e.g., increasing penalties for smoking violations) or the proactive addressing of specific health needs (e.g., emergency procurement of rabies vaccines, establishment of dialysis clinics).\u003c/p\u003e\u003cp\u003eA significant challenge, however, is the impact of political dynamics on the tenure of Barangay Health Workers (BHWs), as untimely dismissals can directly impede effective community-level data gathering and consistent program implementation.\u003c/p\u003e\u003cp\u003eBarangay Health Workers (BHWs) are consistently identified as crucial for facilitating community input and ensuring the effective implementation of health programs\u003csup\u003e\u003cb\u003e5\u003c/b\u003e\u003c/sup\u003e. They serve as frontline data gatherers and essential community liaisons. However, their vulnerability to political changes, which can lead to arbitrary dismissal or disqualification from social benefits, directly undermines this vital link in the healthcare system. This creates a direct cause-and-effect relationship: the politicization of BHWs leads to discontinuity in community health services and compromises the integrity of local health data.\u003c/p\u003e\u003cp\u003eWhile formal LHB meetings may not always facilitate direct community engagement, practices such as LCE \"deep dives\" and town hall formats are consistently cited as highly effective mechanisms for bringing raw, unfiltered community concerns directly to the LHB.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Monitoring and Evaluation (M\u0026amp;E) Practices\u003c/h2\u003e\u003cp\u003eMonitoring and Evaluation (M\u0026amp;E) within LHBs is often a shared responsibility between the Department of Health (DOH) and local officials. This process typically utilizes existing tools such as the Field Health Service Information System (FHSIS), LGU health scorecards, and Program Implementation Reviews (PIRs). The \"LGU health scorecard\" and the achievement of an \"improved health scorecard\" are frequently cited as key indicators of LHB effectiveness. It was observed that Local Chief Executives (LCEs) respond particularly well to simplified, visual data, such as color-coded (red, yellow, and green) indicators, which clearly highlight performance status.\u003c/p\u003e\u003cp\u003eDespite these efforts, several challenges in M\u0026amp;E practices were identified. These include a notable lack of standardized M\u0026amp;E tools specifically designed to assess LHB functionality itself, rather than just program outcomes. Furthermore, limited resources, both financial and in terms of manpower, significantly hinder the capacity for robust monitoring. Difficulties in effectively monitoring the implementation of Universal Health Care (UHC) at the local level also pose a considerable challenge. A participant articulated this need, stating, \u0026ldquo;I hope there would be a standard tool to measure the functionality of the LHB\u0026rdquo; (translated from Filipino). LCEs are also observed to respond effectively to simplified, visual data, such as color-coded scorecards that could highlight the significance of data visualization.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.7 Training and Capacity Building Needs\u003c/h2\u003e\u003cp\u003ePast capacity-building initiatives for LHB members have included programs such as the Municipal Leadership and Governance Program (MLGP) and Provincial Leadership and Governance Program (PLGP), Bridging Leadership, Incident Command System courses, Community Mental Health Programs, and Local Investment Plan for Health (LIPH) workshops. These programs have demonstrably contributed to a greater understanding and increased commitment to health priorities among Local Chief Executives (LCEs).\u003c/p\u003e\u003cp\u003eDespite these efforts, significant training needs persist. Participants expressed a demand for more comprehensive training in policy making, parliamentary procedures, financial management (particularly regarding Special Health Fund utilization), effective Monitoring and Evaluation (M\u0026amp;E) strategies, the application of \"health in all policies\" approaches, and cooperative governance. There is a clear call for specific LHB-focused trainings, distinct from general program-specific ones, and for continuous orientation programs for new members, given the high turnover rate of elected officials. A participant articulated this concern, stating, \"Leaders are being changed and replaced at least every 3 years so you have to retrain them again. But in my opinion, is training really what we need? What is the Return of Investment?\".\u003c/p\u003e\u003cp\u003eThere have been repeated requests for training in financial management, particularly concerning the Special Health Fund (SHF), and in policy making among these LHBs. Undoubtedly, without adequate skills in these domains, LHBs struggle to effectively manage available resources and translate identified health needs into actionable local legislation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.8 Impact of National Policies and Regulations\u003c/h2\u003e\u003cp\u003eNational policies and regulations exert a profound influence on the operations of Local Health Boards [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Key legislative frameworks, including the Local Government Code, the Universal Health Care (UHC) Act, various DILG memoranda (such as those related to the Seal of Good Local Governance, SGLG), and specific DOH policies, all significantly shape LHB functions and activities. The UHC Act, for instance, directly led to the expansion of LHB membership and functions, emphasizing the board's crucial role in health system integration.\u003c/p\u003e\u003cp\u003eHowever, the implementation of these national mandates is not without its challenges. Policy gaps, conflicting interpretations (e.g., regarding LHB membership composition), and the perceived inapplicability of some policies to diverse local contexts, particularly in Geographically Isolated and Disadvantaged Areas (GIDAs), create operational hurdles. A participant lamented, \"A lot of policies are being disseminated that are impractical or irrelevant for GIDAs and certain other provinces\u0026rdquo; (translated from Filipino). Furthermore, concerns were raised regarding the monitoring and enforcement of benefits stipulated in the Magna Carta for Health Workers.\u003c/p\u003e\u003cp\u003eWhile national policies, such as the Universal Health Care Act and the Seal of Good Local Governance, are instrumental in guiding Local Health Boards (LHBs) toward enhanced functionality and compliance, there's an observable tension in their application. Some stakeholders have voiced concerns that these policies aren't always readily applicable in Geographically Isolated and Disadvantaged Areas (GIDAs) and various other provinces.\u003c/p\u003e\u003cp\u003eThe Magna Carta for Health Workers is a critical policy designed to protect and uplift healthcare personnel. However, a significant concern emerged regarding its implementation. There is widespread confusion about which entity is responsible for monitoring its enforcement, coupled with a perception that its stipulated benefits are not fully realized at the local level. This directly impacts the morale, welfare, and retention of essential health human resources, which in turn has a cascading negative effect on the quality and continuity of health service delivery.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Analysis and Discussion","content":"\u003cp\u003eLHB functionality emerges as a multifaceted construct, encompassing a dynamic interplay of leadership commitment, efficient resource management, responsive internal processes, genuine community engagement, and supportive national policy frameworks.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Leadership and Governance: The Enduring Centrality of the LCE\u003c/h2\u003e\u003cp\u003eThe consistent emphasis on Local Chief Executive (LCE) engagement as the primary determinant of LHB vitality highlights a critical aspect of decentralized governance in the Philippines. This observation aligns with existing literature on decentralization, which often points to the challenges of \"elite capture\" at the local level [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In such contexts, politicians can become the central figures in decision-making, potentially overshadowing or even undermining health priorities, as documented by Liwanag and Wyss [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The active presence and political will of the LCE can either propel the LHB forward or render it inert, demonstrating a significant vulnerability in the system.\u003c/p\u003e\u003cp\u003eThe observed \"MLGP effect,\" where leadership and governance programs enhance LCE understanding and commitment to health, is consistent with academic discourse on the importance of capacity-building for local governance [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the inherent challenge of frequent political turnover means that this enhanced capacity is often transient. This dynamic necessitates a continuous cycle of retraining, raising questions about the long-term sustainability of individual-focused capacity building efforts. This is consistent with previous findings in Chile where political turnovers negatively affect the quality of public services [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The reliance on individual political will rather than robust institutional mechanisms creates a fragile foundation for sustained LHB functionality.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Resource Dynamics: Bridging the Gap Between Allocation and Utilization\u003c/h2\u003e\u003cp\u003eThe \"paradox of 'money is there, but hard to spend'\" reflects a broader systemic challenge in Philippine health financing within a decentralized framework. While funds may be allocated, restrictive guidelines, particularly concerning the Special Health Fund (SHF) and Personnel Services (PS) Cap, impede their efficient utilization at the local level. This situation resonates with findings from Capuno et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], who discuss issues in Philippine health financing, including a low public budget share for health and challenges in fund absorption by LGUs. The inability to flexibly utilize funds, especially for critical human resources, directly impacts service delivery.\u003c/p\u003e\u003cp\u003eThe strategic inclusion of finance officers and local finance committees in the LHB emerged as a practical and effective solution to overcome these bureaucratic hurdles. This structural integration streamlines financial processes, making resource allocation more responsive to immediate health needs. This practice exemplifies principles of good financial governance, demonstrating that effective resource mobilization is not solely about securing funds but equally about optimizing their internal allocation and utilization through cross-functional collaboration within the LHB.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Responsive Processes: Efficiency and Adaptiveness of LHBs\u003c/h2\u003e\u003cp\u003eInternal processes are one of the factors that define efficiency of organizations, similar to the case of government institutions. Findings from the study highlight the challenges between mandatory meetings and practical feasibility given the heavy workload circumstances of each involved agency or stakeholder. This suggests a need for flexible meeting formats, such as convergence meetings or hybrid sessions, to improve attendance and productivity.\u003c/p\u003e\u003cp\u003eMoreover, the critical role of the Technical Working Group (TWG) in driving LHB effectiveness cannot be overstated. The TWG functions as the indispensable technical arm, responsible for preparing agendas, conducting data analysis, and drafting policy recommendations. Their proactive work ensures that LHB meetings are substantive and evidence-based, even when LCEs have limited time. This underscores the need for strong technical support structures in decentralized health systems, which can provide continuity and informed decision-making despite political changes. To further enhance stability, institutionalizing LHB functions through local ordinances, rather than less permanent Executive Orders, can provide a more robust legal framework that withstands political shifts, a strategy supported by studies on strengthening local governance such as that by Juban et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eApart from these structures, effective monitoring and evaluation (M\u0026amp;E) tools that link closely with functional LHBs remain to be a significant gap. Findings from the study highlight how the current M\u0026amp;E frameworks primarily focus on outputs and outcomes of health programs rather than the quality of the governance processes driving them. Developing such a tool, potentially integrated into the SGLG, would provide crucial feedback for LHB self-improvement and enhance accountability. Observations from participants showed the significance of harmonization and clear communication, even in monitoring systems - which was previously identified as part of the broader challenges of fragmented data monitoring systems in decentralized health systems [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUltimately, more efficient and adaptive processes make the institution more responsive to the needs to attain the set targets and goals. This would define having a higher institutional capacity which was already previously found to significantly impact positively the service delivery [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Community Engagement: From Representation to Co-Ownership\u003c/h2\u003e\u003cp\u003eBarangay Health Workers (BHWs) were consistently identified as the \"unsung heroes and vulnerable link\" in community engagement. Their immense engagement with the community provides them a deeper understanding of actual community concerns. The findings of the study align with Ramiro et al [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Gonzales [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]who previously found the significance of the BHWs in functioning health boards to enhance community participation. Despite their introduction into the Philippine health system in the 1980s and later institutionalized through Republic Act 7883 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], a few decades later, the recognition and value the health system puts into their role remains minimal. With the current programs and policies in place, BHWs remain with precarious positions being highly vulnerable to politicization and changes in leadership. This vulnerability directly undermines authentic community participation, a core objective of decentralization. Consequently, this negatively affects service delivery, similar to the case of Brazil [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. As highlighted by Liwanag and Wyss [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], political interference can compromise community involvement and data integrity. Protecting BHWs through institutionalized roles and safeguards is therefore essential for sustainable grassroots health initiatives.\u003c/p\u003e\u003cp\u003eThe inclusion of community health workers aligns with participatory governance principles, which emphasize bottom-up planning and co-creation of health solutions, as advocated by Juban et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Moving beyond mere representation to active, empathetic listening and collaborative solution-finding fosters greater trust and ensures programs are truly responsive to local needs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Policy Environment and Capacity Building: Towards a Responsive Framework\u003c/h2\u003e\u003cp\u003eA critical gap exists in financial management and policy development skills among LHB members. This deficiency acts as a significant barrier to LHB empowerment under UHC, hindering their ability to effectively manage resources and translate health needs into actionable local legislation. Targeted training in these areas is crucial to enable LHBs to fulfill their expanded roles.\u003c/p\u003e\u003cp\u003eThe impact of national mandates, while driving compliance, presents a \"double-edged sword.\" While policies like UHC and SGLG push for greater functionality, their perceived inapplicability to diverse local contexts, particularly GIDAs, can lead to a focus on mere compliance rather than genuine local impact. This suggests a need for greater local autonomy and bottom-up consultations in policy formulation. Furthermore, the \"unfulfilled promise of the Magna Carta for Health Workers,\" with concerns about its monitoring and full implementation, directly impacts the morale and retention of health personnel. This issue underscores the need for clear directives and joint enforcement by national agencies to ensure equitable treatment of health workers. The success of government programs are heavily dependent on the motivation of these offices in the implementation process. Distor and Khaltar [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] previously found the positive impact to efficiency of national support in the implementation of programs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Synthesizing Challenges and Enabling Factors: A Framework for Functional LHBs\u003c/h2\u003e\u003cp\u003eThe findings reveal that challenges to LHB functionality are interconnected, forming a complex web where one issue exacerbates another. A set of barriers were identified to be common across these LHBs. These include pervasive political interference, persistent budget constraints, difficulties in time management due to members holding multiple roles, procedural hurdles in passing resolutions, and a significant lack of continuity stemming from frequent leadership changes. Conversely, several enabling factors were identified as crucial for LHB effectiveness. These include strong commitment from the Local Chief Executive (LCE), the benefits derived from an expanded multi-sectoral membership, the presence of effective Technical Working Groups (TWGs), the provision of technical assistance from DOH and DILG, and the positive impact of leadership training programs.\u003c/p\u003e\u003cp\u003eWe propose a framework that describes these relationships as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Despite the attempt to simplify these into this framework, the magnitude of the way each construct affects the other cannot be quantified. For instance, political interference can directly lead to budget instability, which in turn impedes program implementation and resource mobilization, ultimately impacting overall LHB effectiveness and functionality. The lack of continuity due to LCE turnover further compounds these issues by disrupting established plans and relationships. This complex interplay among these constructs necessitates a holistic and multi-pronged approach to strengthening LHBs -- i.e. one that targets multiple points in this cycle, such as institutionalizing LHB roles to mitigate political interference, ensuring stable funding, and building robust internal processes that can withstand political shifts.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWe propose in this framework the significance of putting genuine community engagement at the core of a functional LHB which makes it participative and responsive to the actual needs of the community. Outside these internally relevant constructs, we also found the significance of creating an enabling policy environment that provides significant support and foundation to the functionality of LHBs.\u003c/p\u003e\u003cp\u003eAdditionally, despite the myriad internal challenges, LHBs that actively engage external stakeholders\u0026mdash;including the DOH, DILG, non-governmental organizations (NGOs), and the private sector\u0026mdash;and effectively leverage their support tend to exhibit higher levels of functionality. This observation suggests that external technical assistance, sustained advocacy, and consistent monitoring can serve as crucial enabling factors, providing a vital counterbalance to internal limitations such as political shifts or chronic resource constraints. This highlights the importance of DOH and DILG strengthening their joint monitoring and technical assistance roles, ensuring consistent support and guidance that transcends local political dynamics. Such sustained external engagement fosters a more resilient and functional LHB ecosystem across the country.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion and Recommendations","content":"\u003cp\u003eThe functionality of Local Health Boards in the Philippine context is a complex and dynamic interplay of various factors, extending beyond mere procedural compliance. This thematic analysis underscores that a truly functional LHB is characterized by strong and consistent political will from the Local Chief Executive, effective and flexible resource management, robust internal processes supported by a proactive Technical Working Group, genuine and institutionalized community engagement, and a national policy framework that balances standardization with local applicability.\u003c/p\u003e\u003cp\u003e The study's empirical insights, drawn directly from the experiences of diverse local stakeholders, contribute to a nuanced understanding of decentralized health governance under the Universal Health Care Act. It highlights that while national mandates provide direction, the success of LHBs ultimately hinges on their adaptive capacity to navigate political landscapes, overcome financial constraints, and foster authentic collaboration at all levels. The interconnectedness of challenges necessitates a holistic approach, where addressing one area (e.g., political interference) can positively impact others (e.g., budget stability and program continuity). Conversely, the power of collaboration and external support from national agencies and other stakeholders serves as a crucial counterbalance, reinforcing local efforts and driving continuous improvement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments. Written informed consent was obtained from all individual participants included in the study prior to the focus group discussions.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026apos;s data in any form (including individual details, images, or videos).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the confidential nature of the focus group discussions and to protect the privacy of the participants. However, anonymized data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by a grant from the Philippine Business for Social Progress (PBSP) \u0026nbsp;through the Department of Health \u0026ndash; Bureau of Local Health Systems Development (BLHSD). The funding body had no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eB.E.N. conceptualized and designed the study, supervised data collection, and was a major contributor in writing and revising the manuscript. M.B. was involved in the data collection process, conducted the primary thematic analysis, and contributed to the drafting of the results section. J.J.G.G. and P.C.E. assisted in the literature review, data analysis, and contributed to the writing and editing of the final manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to all the Provincial and Municipal Health Officers, Local Chief Executives, Local Council Bayan members, DOH and DILG representatives, and Civil Society Organization members from Laguna, Aklan, Sarangani, and Benguet who generously shared their time and invaluable insights for this study. We also thank Philippine Business for Social Progress (PBSP) and the Department of Health for their logistical support during the data collection process.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBien Eli Nillos, MD, MHSS\u003c/strong\u003e - is a former Municipal health officer and Doctor to the Barrio, public health practitioner for more than 15 years and an academician for more than 10 years. He earned his master\u0026rsquo;s degree in Health Social Science at De La Salle University. He is currently the Cluster head of the Cluster of Management and Public health of the MAPUA School of Medicine. He is also a Fellow of the Philippine Academic Society of Social and Community Medicine (PASCOM)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMr. Miko Balisi,\u003c/strong\u003e \u003cstrong\u003eMSc, MPHM, RND\u003c/strong\u003e - is a consultant for Continuous Quality Improvement and Data Quality and Governance. He has also worked as a consultant for COVID19 Provincial Data Mapping in the Philippine Society of Public Health Physicians and was a Junior Policy Research Associate of the Department of Health. He took his master\u0026rsquo;s degree in Primary Health Care Management at Mahidol University and Masters in Public Health at UE Ramon Magsaysay Medical Memorial Center Inc.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMr. Jonathan Jaime G. Guerrero\u003c/strong\u003e -has a master\u0026rsquo;s degree in Plant Pathology from the University of the Philippines Los Ba\u0026ntilde;os and is currently pursuing a dual degree in Doctor of Medicine - Master of Public Health (MD-MPH), a joint program of the University of the Philippines Manila College of Medicine and College of Public Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMr\u003c/strong\u003e. \u003cstrong\u003ePaolo C. Encarnacion\u0026nbsp;\u003c/strong\u003eis currently enrolled under the Doctor of Medicine - Master of Public Health program of the University of the Philippines Manila. He previously worked as a project manager / research assistant for projects in maternal and child health, tobacco control, and PhilHealth packages.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAtienza, M. E. (2004). Local governments and devolution in the Philippines. In N. Morada \u0026amp; T. Encarnacion-Tadem (Eds.), Philippine politics and governance (pp. 415\u0026ndash;438). University of the Philippines Press.\u003c/li\u003e\n\u003cli\u003eCapuno J. Tugs of war: local governments, national government. Public Policy. 2017;16:98-116.\u003c/li\u003e\n\u003cli\u003eRamiro LS, Castillo FA, Tan-Torres T, Torres CE, Tayag JG, Talampas RG, Hawken L. Community participation in local health boards in a decentralized setting: cases from the Philippines. Health policy and planning. 2001. 1:61-9. https://doi.org/10.1093/heapol/16.suppl_2.61\u003c/li\u003e\n\u003cli\u003eGrundy J, Healy V, Gorgolon L, Sandig E. Overview of devolution of health services in the Philippines. Rural and remote health. 2003 Sep;3(3):1-0.\u003c/li\u003e\n\u003cli\u003eLam HY, Zarsuelo MA, Capeding TP, Silva ME, Mendoza MA, Padilla CD. Policy analysis on province-level integration of healthcare system in light of the universal health care act. Acta Medica Philippina. 2020 Dec 26;54(6).\u003c/li\u003e\n\u003cli\u003ede Claro V, Lava JB, Bondoc C, Stan L. The role of local health officers in advancing public health and primary care integration: lessons from the ongoing Universal Health Coverage reforms in the Philippines. BMJ Global Health. 2024 Jan 22;9(1).\u003c/li\u003e\n\u003cli\u003eDepartment of Health. (2019). Implementing Rules and Regulations of Republic Act No. 11223 (Universal Health Care Act). https://doh.gov.ph/sites/default/files/health-programs/UHC-IRR-signed.pdf\u003c/li\u003e\n\u003cli\u003eDepartment of Health (DOH). A Guide to Local Health Board Operations. Manila: DOH; 2020.\u003c/li\u003e\n\u003cli\u003eCo PA, V\u0026icirc;lcu I, De Guzman D, Banzon E. Staying the Course: Reflections on the Progress and Challenges of the UHC Law in the Philippines. Health Systems \u0026amp; Reform. 2024 Dec 18;10(3):2397829.\u003c/li\u003e\n\u003cli\u003eCuenca JS. Health devolution in the Philippines: lessons and insights. PIDS discussion paper series; 2018.\u003c/li\u003e\n\u003cli\u003eLiwanag HJ, Wyss K. What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines. PLoS One. 2018 Nov 5;13(11):e0206809.\u003c/li\u003e\n\u003cli\u003eAbrigo MR, Tam ZC, Ortiz DA. Decentralization and health in the Philippines: A systematic review of empirical evidences.\u003c/li\u003e\n\u003cli\u003eDepartment of the Interior and Local Government \u0026amp; Department of Health. (2022). Joint Administrative Order No. 2022-0001: Guidelines on the Strengthening of Local Health Boards for the Implementation of the Universal Health Care Act.\u003c/li\u003e\n\u003cli\u003eNoval, C. C., \u0026amp; Palompon, D. R. (2024). Nurses-Led Municipal Leadership and Governance Program: Experiences of Local Chief Executives in Central Visayas, Philippines. International Journal of Nursing Science, 14(2), 112-120. doi:10.11648/j.ijn.20241402.13\u003c/li\u003e\n\u003cli\u003eBardhan, P., \u0026amp; Mookherjee, D. (2010). Decentralization, corruption, and the accountability of local governments: An overview. Journal of Economic Perspectives, 24(4), 185-204.\u003c/li\u003e\n\u003cli\u003eGallegos S (2023). Political Turnover Negatively Affects the Quality of Public Services: A Replication. Journal of Economic Behavior \u0026amp; Organization, Vol. 212, pp. 796-818. https://doi.org/10.1016/j.jebo.2023.05.046\u003c/li\u003e\n\u003cli\u003eCapuno, J. J., Corpuz, J., \u0026amp; Lordemus, S. (2024). Natural disasters and local government finance: Evidence from Typhoon Haiyan. Journal of Economic Behavior \u0026amp; Organization, 220, 869\u0026ndash;887.\u003c/li\u003e\n\u003cli\u003eJuban NR, Salisi JA, Mier ARB, Mier-Alpa\u0026ntilde;o JDB. Seal of Health Governance, Philippines. Social Innovation in Health Initiative; 2020.\u003c/li\u003e\n\u003cli\u003eDistor, C. B., \u0026amp; Khaltar, O. (2022). What Motivates Local Governments to Be Efficient? Evidence from Philippine Cities. Sustainability, 14(15), 9426. https://doi.org/10.3390/su14159426\u003c/li\u003e\n\u003cli\u003eCongress of the Philippines: Republic Act no. 7883: An act granting benefits and incentives to accredit barangay health workers and for other purposes. In. Metro Manila: Republic of the Philippines; 1995.\u003c/li\u003e\n\u003cli\u003eGonzales, M. L. S. (2013). Community health workers in the Philippines: A study on their roles and capabilities. Institute of Philippine Culture, Ateneo de Manila University.\u003c/li\u003e\n\u003cli\u003eAkhtari M, Moreira D, Trucco L (2022). \u0026quot;Political Turnover, Bureaucratic Turnover, and the Quality of Public Services,\u0026quot; American Economic Review, American Economic Association, vol. 112(2), pages 442-493, February.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V, Hayfield N, Terry G. Thematic analysis. InHandbook of research methods in health social sciences 2019 (pp. 843-860). Springer, Singapore.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health Governance, Local Health Boards, Health Policy, Philippines, Decentralization","lastPublishedDoi":"10.21203/rs.3.rs-7169520/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7169520/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn the Philippines, Local Health Boards (LHBs) are the cornerstone of a decentralized health system by coordinating local health priorities, budgeting, and implementation. However, their performance remains highly variable across different regions. While national policies set the groundwork for Universal Health Care (UHC), actual service delivery hinges on local functionality. This study sought to define the constructs that define functionality of local health boards in the Philippine context, drawing from the experiences and perspectives of those directly involved in local health governance.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a series of in-depth focus group discussions (FGDs) with members of LHBs across four different provinces in the Philippines. Participants included local chief executives, health officers, barangay representatives and civil society leaders. The discussions were designed to explore governance dynamics, barriers to implementation, and enabling conditions for effective board performance. Thematic analysis was employed to identify recurring patterns and insights from the narratives.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAcross all provinces, the most consistently cited determinant of a functional LHB was the active engagement and political will of the local chief executive (LCE). While national frameworks and mandates exist, their successful localization depends heavily on whether the LCE prioritizes health. Participants highlighted significant operational barriers, particularly in fund utilization, due to stringent national guidelines that limit spending flexibility. A proactive and well-resourced Technical Working Group (TWG) was identified as vital in operationalizing LHB decisions and bridging policy with practice. Additionally, community engagement efforts were found to be vulnerable to political transitions, especially when frontline workers such as Barangay Health Workers (BHWs) lack protection from changes in local leadership.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe functionality of LHBs is shaped less by formal compliance and more by the quality of local governance and institutional support. The political commitment of the LCE, when combined with a capable TWG and mechanisms to shield community health workers from political transitions, significantly enhances board performances. As the Philippines moves toward full implementation of Universal Health Care (UHC), reinforcing the governance capacity of LHBs offers a pragmatic and necessary pathway to more responsive and resilient local health systems.\u003c/p\u003e","manuscriptTitle":"Determining the Functionality of Local Health Boards in the Philippines: Perspectives from Local Government Units","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 07:09:00","doi":"10.21203/rs.3.rs-7169520/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5be55935-29d9-4a38-9e5c-0afac92126cb","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T12:08:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-26 07:09:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7169520","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7169520","identity":"rs-7169520","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}