ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE

Master of Arts in Nursing

Filipino Nurses and COVID-19 Vaccine Decision but for this case, I decided to use Markkula
Acquisition Center Framework . This is a simple ethical
decision-making framework developed by a group of
Answering the question whether to allow or not the philosophers at the Markkula Center for Ethics at
use of nurses as a bargaining chip for the acquisition Santa Clara University. It distills various philosophical
of COVID-19 vaccines requires an in-depth study of approaches towards ethics in simple questions and
its ethical aspect but before we proceed with it, we answering these helps approaching a difficult
must first look past how the situation is framed, take situation from various perspectives. While the
it down to its bare essence and gather all the relevant framework cannot solve certain thorny issues, it is
facts and look at it with objectivity. The phrase "using quite successful at elucidating ethical
nurses as a bargaining chip" triggers an emotional problems (Schwarz, 2005)
response, the feeling of anger is more pronounced
compared with other feelings associated with that 1. RECOGNIZING AN ETHICAL ISSUE
statement. Some might argue in favor of the The issue that needs to be solved on this case is to
independence of language and emotional response determine whether it is ethical or unethical to allow
but neurophysiologic research has proven that the use of the Lifting of Nurse Deployment Cap as a
language and emotion processing affect each condition of the agreement for the acquisition of the
other (Weis & Herbert, 2017) and it has the capacity much-needed COVID-19 Vaccines.
to cloud one's objectivity. Setting aside our initial
emotional response and looking with objectivity, let us 2. GETTING THE FACTS
analyze the statement. Establishing the facts will help us scrutinize every
• Is it really the nurses that they are going to detail of the issue and look at it closely under different
use as a bargaining chip? ethical principles. Here are the facts that I considered
• Why Filipino nurses? for this issue:
• What do Filipino Nurses have? a. Nurses: It has the potential to open more
• Does the statement fully convey its intent? opportunities for nurses to work
• Was it written in a way that sensationalized overseas and enjoy better career upward
the issue? mobility and improvement of financial
• Would your initial reaction be different if the capacity. The cap on deployment of
statement was written in another way? nurses will remain without this
After trying my best to set aside my initial emotional agreement
response and innate biases, I was able to strip down b. The Public: There will be another
the statement into a version I believe accurately source of vaccine for the public which will
describes its intent: "Lifting nurse deployment cap increase their health security and
as a condition for COVID-19 Vaccine Acquisition positively affect the country's economy.
Agreement." Analyzing the statement allowed me to Without this agreement the government
realize that it is not us nurses but it's what we can do, will have to make use of the negotiation
our expertise, the quality of care we deliver, and our for the vaccine acquisition with
value as individuals and as a professional will be the manufacturers and wait for the supply
condition on the acquisition of the vaccines. from COVAX, the global initiative aimed
at equitable access to COVID-19
Deciding on whether to allow this or not requires good vaccines which the Philippines is a
ethical decision-making utilizing ethical principles and member. Both options present possible
approaches. We all know that there are a lot of Ethical delays due to limited supplies as
Principles and Approaches and we cannot determine manufacturers struggle to fulfill pre-
if something is ethical or not based solely on a single orders Further delays on vaccine rollout
ethical principle or approach. This also presents may cause on further economic
another challenge for the reason that there are big problems and increases the risk of
possibilities of having some ethical principles infection.
contradict one another. This is where an Ethical c. Destination Country: They will have
Decision-Making Framework comes would be useful. access to highly qualified and globally
Ethical Decision-Making Framework is a decision- competitive nurses which will increase
making model that utilizes a series of steps that their healthcare delivery capacity.
requires individuals to assess the conflicting situation;
consider various dispositional factors, such as 3. EVALUATE ALTERNATIVE OPTIONS
benevolence, justice, and honor; complete a In evaluating the above facts and weighing the effects
comprehensive review of the alternatives; make a of different alternative course of action, I utilized the
judgment; and document and justify the final Five Ethical Approaches which includes Utilitarian,
decision (Johnson, et al., 2017) Rights, Justice, Common Good and Virtue Approach.
There are multiple Ethical Decision-Making In Utilitarian approach, I looked for what will create
Framework we can use to come up with an Ethical the greatest balance of good over harm as this
approach conforms to our belief that our actions will
1
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

always produce some good and some bad, and that References:
the right decision will be one that produces the most 1. Hunt, S. D., & Laverie, D. A. (2004).
good or the least harm. Using the Rights Approach, I Experiential Learning and the Hunt-Vitell
looked at the rights of those involved and see which Theory of Ethics: Teaching Marketing Ethics
decision will protect their ethical rights. This by Integrating Theory and Practice.
approached also allowed me to look on the common Marketing Education Review, 14(3), 1–
argument on the issue which is reducing nurses to a 14. https://doi.org/10.1080/10528008.2004.1
mere commodity and ensure that my decision will 1488874 (Links to an external site.)
emphasize the dignity of nurses and all those 2. International Council of Nurses. (2012). The
involved. Another consideration is the fairness of the ICN Code of Ethics for
options and which options will serve more instead of Nurses. https://www.icn.ch/sites/default/files/
just a select few. The last consideration I used is to inline-
determine which decision will reflect the principles of files/2012_ICN_Codeofethicsfornurses_%20
a kind of person I want to be. eng.pdfJohnson, (Links to an external site.)
3. R. L., Liu, J., & Burgess, Y. (2017). A model
4. MAKE A DECISION AND TEST IT for making decisions about ethical dilemmas
I have decided to allow the use of the lifting of in student assessment. Journal of Moral
nurse deployment cap as a condition of the Education, 46(2), 212–
agreement on COVID-19 Vaccine Acquisition. I 229. https://doi.org/10.1080/03057240.2017.
believe that this provides the more good and less 1313725 (Links to an external site.)
harm to people and nurses. More opportunities for 4. Manuel, V., Dennis, M., Michael J., M.,
nurses to work overseas will be available and a Thomas, S., Margaret R., M., David, D.,
solution to limited supply of vaccine for the country Claire, A., & Kirk O., H. (2009). Markkula
will be secured. This also allows nurses to share with Center Framework. Markkula Center for
society the responsibility for initiating and supporting Applied Ethics at Santa Clara
action to meet the health and social needs of the University. https://www.scu.edu/media/ethic
public, in particular those of vulnerable populations s-center/ethical-decision-making/A-
(ICN,2012). At the same time, it allows the Framework-for-Ethical-Decision-
government to institute measures that will result in Making.pdfT (Links to an external site.)
humane working conditions, better career prospects 5. The Philippine Nursing Act of 2002 (RA
and a dignified existence of nurses essentially 9173),
fulfilling their responsibility toward nurses as stated (2002). https://www.officialgazette.gov.ph/20
on the Declaration of Policy of the Philippine Nursing 02/10/21/republic-act-no-9173/ (Links to an
Act of 2002 (RA 9173) external site.)
6. Schwarz, T. S. J. (2005). Teaching ethics
5. ACT AND REFLECT ON THE OUTCOME and computer forensics. Proceedings of the
My decision to allow the use of the Lifting of Nurse 2nd Annual Conference on Information
Deployment Cap as a condition of COVID-19 Vaccine Security Curriculum Development -
Acquisition comes with the recommendation that the InfoSecCD
government also create measures that will let nurses ’05. https://doi.org/10.1145/1107622.110763
choose to stay and serve them in the Philippines. 7 (Links to an external site.)
Though allowing nurses to work overseas provides 7. Trevino, L. K. (1986). Ethical Decision
opportunities for nurses, the government should not Making in Organizations: A Person-Situation
rely on it as the only way to fulfill their responsibility Interactionist Model. Academy of
of providing humane working conditions and better Management Review, 11(3), p601-
career prospects for nurses. The government should 617. https://doi.org/10.5465/AMR.1986.4306
also make established measures that these are also 235 (Links to an external site.)
available for nurses working in the Philippines - this 8. Weis, P. P., & Herbert, C. (2017). Bodily
will also pave the way for them to fulfil their Reactions to Emotional Words Referring to
responsibility of guaranteed delivery of quality basic Own versus Other People’s Emotions.
health services to the public. Frontiers in Psychology,
I understand that the more noble a decision we have 8. https://doi.org/10.3389/fpsyg.2017.01277
to make, the more people we need to hear to enable.
This enable us to be widen our view on the issue and
have the needed sensitivity to the ethical implications
of our decisions. Though I stand by me analysis and
my decision, I strongly recommend having a healthy
discussion on my decision.

2
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

RA 7614 & RA 9173 and Its Implications to the guidelines and regulations for nurses to carry out their
Scopes of Nursing Practice roles.

For more than a decade, the Republic Act 7164 also The most noteworthy change in the Philippine
known as the “Philippine Nursing Act of 1991” Nursing Act is the requirement that the Board must
regulated the practice of nursing in the Philippines. represent the three areas of nursing, namely: Nursing
Within that time-frame, the country and the nursing Education, Nursing Service, and Community Health
profession has undergone a significant development, Nursing. This ensured that Nursing Schools abide at
social change, and technological advancements. least by the minimum standards that must be followed
These made it clear that there is a need to review and to ensure that students have relevant education and
amend the law to reflect policies that will address the have enough theoretical knowledge to transition
changing needs of the profession as well as those the effectively and efficiently to a clinical setting. It also
profession servers. required professional nurses to engage in activities
that will further enhance their professional knowledge
On the 21st of October 2002 then president, Gloria and skills. A great emphasis was also put on the roles
Macapagal Arroyo signed into a law the Republic Act of nurses in community health settings.
9713 also known as the “Philippine Nursing Act of
2002”, repealing the Philippine Nursing Act of 1991 In analyzing the Philippine Nursing Act of 2002, it is
(RA 7164) and all other laws, decrees, orders, important not to dwell only on the positive changes in
circulars, issuances, rules and regulations and parts brought. To further develop the nursing profession,
thereof which are inconsistent with the Philipiine we must also take a look on the issues that arise from
Nursing Act of 2002. it and identify room for improvement. Main points
during the congress and senate debate for what
The main difference between the Philippine Nursing would be the Philippine Nursing Act of 2002 paints a
Act of 2002 to its predecessor is that its common force that guided the final details of the law
contents “guarantees the delivery of basic health – improving the nursing profession to keep Filipino
services” to the public and require for a “more nurses globally competitive and to contribute to the
responsive nursing profession” by ensuring country’s growth.
relevant nursing education and humane working
conditions for nurses. It’s quite hard not to correlate the government aim to
“provide better career prospects” to opportunities to
The Philippine Nursing Act of 2002 (RA 9713) work abroad. Based on publicly available records of
focuses more on how to improve the nursing the Philippine Overseas Employment Administration
profession and ensure the global competitiveness of (POEA), 13,536 newly-hired Filipino nurses were
Filipino Nurses. The law clearly stipulates that deployed overseas on 2001, though a decline from
member of the Board of Nursing must have a the succeeding years until 2005 was observed, the
Master’s Degree in Nursing, Education or other Allied Philippines has a record of sending not less than
Medical Profession, I believe, helps the Board to 7,000 nurses yearly and this increased to not lower
understand and discover more ways for nurses to than 9,000 nurses yearly from 2006-2010.
harmoniously and effectively work with the other
members of the health care team. The rise in numbers of Filipino nurses who got to work
in developed countries and enjoy far greater
The requirement that the last 5 years of the 10-year remuneration compared to the ones received by
continuous practice must be in the Philippines nurses in the Philippines has increased the number
ensures that the decisions the Board will make of enrollments in Nursing Schools across the country.
pertaining to nurses and the nursing profession is This presented another problem, which was finding a
based on the actual problems and issues that nurses faculty to teach new nursing students. It has become
experience in the domestic setting. This will pave the extremely difficult for nursing schools to find
way to nursing policies addressing grassroot issues seasoned and highly experienced faculty as the
of the profession. majority of them have opted to work overseas.

On Article VI of the Philippine Nursing Act of 2002 Perhaps the biggest failure on the implementation of
which stipulates the scopes of nursing practice, the the Philippine Nursing Act of 2002 that affected a
phrase “and when recovery is not possible, towards a great number of professional nurses was the
peaceful death” was added. This phrase is not implementation of the minimum base pay for nurses
included in the Philippine Nursing Act of 1991. This working in the public health institutions who,
highlights one of the most important collaborative according to the law, should receive a salary not
roles of nurses, ensuring a peaceful death when lower than salary grade 15. It would have given P
restoration of health is no longer possible. This is also 32,053 to P34,801 as a basic salary for nurses
enshrined on the preamble of the Code of Ethics for working in state-run health institutions. However, it
Registered Nurses and its inclusion on RA 9713 took almost two decades before Budget Circular No.
provided the way for the creation of concrete 2020-4 was issues, which finally implemented
3
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

Section 32 of Republic Act 9173 or the Philippine receiving less than the nurses if the proposed law is
Nursing Act of 2002. passed.

The Proposed Philippine Nursing Act of 2016 – Another factor that contributed to its rejection is the
Its Provisions and Factors that Lead to its perceived possibility of an increase in health care
Rejection costs in the country and private hospitals downsizing
their manpower to comply with the salary required by
Nurses were expecting that the Senate Bill the proposed law.
270/House Bill 6411 also known as the
Comprehensive Nursing Law of 2016 will be passed References:
into a law because its provisions align with the
government’s vision for the future of the country’s
health care system with nurses serving as one of its
backbones.

What’s actually harder to accept is that the proposed

nursing law was viewed by the majority of the public
as a law to increase the salary of nurses. It’s hard to
tell if this misconception was caused by how the
media framed the news about it or due to the public
not taking time to really look into and see all of its
provisions.

The proposes nursing law would have guaranteed

delivery of basic health care services to the public by
ensuring an adequate number of nurses in the
country. I know that there is an argument that the
country already has a surplus of nurses. What they
failed to understand is that the law will essentially
require the state to provide funding for enough
plantilla positions for nurses ensuring appropriate
nurse-patient ratio in the country.

It also has provisions requiring nurses to undergo

educational activities or trainings that will further
enhance their professional nursing skills and expand
specializations allowing nurses to take on more roles
in the health care delivery system. It also provides
more enforcing powers to the Board of Nursing in
making decisions and policies relevant to the nursing
profession.

Despite all carefully crafted provisions of the

proposed law, it was not enough to convince the then
president to sign in into a law. The main reason cited
by the president on his decision to veto the proposed
law is that “it will have dire financial consequences”
and that the salary increase included in the proposed
law will distort the existing wage level in the health
sector.

The Philippine Nursing Act of 2002 specifically states

that “the minimum base pay for nurses working in the
public health institutions shall not be lower than salary
Grade15 under the Republic Act No. 6578.” At that
time, nurses’ compensation is on Salary Grade 11
and the CNA states that it must be in Salary Grade
15, the same level where it should be based on
RA9173. However, the president stated that the
government simply cannot accept four-grade
increase, from Salary Grade 11 to 15, because
optometrists, dentists, and doctors would end up
4
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

The Philippine Nursing Act of 2002: Where are workflows of nurses. Though most first nation
we now? countries have started adapting these
advancements, this presents a challenge for Filipino
The Philippine Nursing Act of 2012 (R.A.9173) nurses as most of these new technologies are not
regulates the nursing practice in the Philippines. It widely available in the country. As a nurse, it is
clearly outlines the professional requirements for prudent to allocate time to study these technological
Practicing Filipino Nurses in the country. R.A.9173 advancements and how they may affect the way we
mandated the creation of a Professional Regulatory practice. Though it may not be available for now in
Board of Nursing (PRBON) and specified the the country, it may give us an insight into how we can
requirements for its Chairperson and Members of the improve the systems we currently use.
Board which has been fully implemented. The law
also provided PRBON the authority to monitor and Implementation of Evidenced-Based Practice
enforce quality standards of nursing practice in the As nurses, we always encounter problems and
Philippines and exercise powers necessary to ensure patient needs that require effective clinical decision-
the maintenance of efficient, ethical, and technical, making to render the best possible individualized
moral and professional standards in the practice of care. This is best achieved by implementing
nursing. With this authority, the PRBON promulgated evidence-based practice as it allows us to provide
the Philippine Professional Nursing Practice care that is constantly reviewed and updated to meet
Standards (PPNPS) on Resolution No. 22, Series of our clients’ ever-changing health needs. As a nurse,
2017. On this resolution, the PRBON outlined the 14 it will serve us better to participate in research
Responsibilities of Nurses on three different roles conducted in our field. This will also ensure that the
such as Client Care, Leadership & Management, and problems being researched are the ones that we
Role in Research. actually experienced in the field making the study
more relevant and our practice up to date
The professional requirements for Filipino nurses
have been fully implemented and this was ensured by Shortage of Nurses
the Professional Regulatory Board of Nursing as its In early April 2020, the Philippines estimated that it
main governing body. Though Filipino Nurses go needed an additional 300,000 healthcare workers to
above and beyond to comply with what is required address the COVID-19 pandemic. Now that we are
and expected from them as professionals, there now in the 2nd quarter of 2021 and with the constantly
seems to be a disconnect between the responsibility increasing number of COVID cases in the country,
of nurses and the state’s responsibility towards there is a clear disconnect between the number of
nurses. On R.A. 9173’s Declaration of Policy (Article nurses who are currently employed to address the
II), it was declared that the state is responsible for the pandemic and the number of patients they need to
protection and improvement of the nursing profession care for. I understand that there are really not enough
and it is also the state’s responsibility to provide the employed nurses right now, but I would argue that it
Filipino people quality basic health services through is not really the number of nurses that are lacking but
an adequate nursing personnel system throughout work opportunity that provides a balance between the
the country. However, there are still some sections of risks that come with the job and protection as well as
the R.A. 9173 that are not yet fully implemented, and reasonable remuneration. I do not have the exact
it can be easily observed that these sections involve figures but there is a large number of nurses who
what nurses are entitled to for serving the country. choose to leave the profession simply because it is
Recently, nearly 18 years from then-president Gloria impossible for them to support themselves and their
Macapagal-Arroyo signed R.A. 9173 into law, the families with the remuneration they receive. I am one
Supreme Court ruled in favor of nurses working in of those nurses who temporarily left the profession so
government health institutions stating that they must I can pursue my dreams of getting a master’s degree
receive the salary stipulated on R.A. 9173. However, in Nursing knowing that it would be extremely difficult
this ruling is still not yet fully implemented. This also for me to do this with the remuneration I receive. I
resulted in some senior nurses being demoted so totally agree with Yasmin Ortega, a sociologist when
their salary can remain in Salary Grade 15. she recommended that one of the best ways to
address the nursing shortage in the country is that the
Bridging Current Trends in Nursing Practice Philippine government should focus on trying to get
the nurses who have left the profession to come back
Advancements in Communication and by enticing them with a regular salary, benefits,
Technology proper protection, and hazard pay. Nurses should not
There has been a huge development in have to choose between serving the country or their
communication and technology incorporated in own families
nursing practice. With the increased need to consult
with medical professionals without having physical Burnout
contact during the pandemic, these advancements in The Philippines’ recommended ratio of nurses to
Health IT leaped to even greater speed. The patients is 1:12, but the actual ratio of nurses to
advancement in technology has transformed the patients varies from 1:50 to 1:80, depending on the
5
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

region of the country. While the nursing workforce

continues to deplete, the workloads of those nurses
remaining in service continue to increase. This,
together with the fear of getting infected due to
insufficient protection leads to burnout of nurses
making them more susceptible to infection – this is
evidenced by statistics that 13% of the country’s
COVID cases are healthcare workers. To combat
this, the government and all related agencies must
ensure that nurses are adequately protected and
there are enough nurses to cater to the needs of the
increasing number of patients. Services catering to
the health needs of nurses should also be available
and easily accessible.

Implementation of CPD Units for License Renewal

While I totally agree that Continuing Education is a
must to ensure that we as nurses are able to carry out
our responsibility to our clients to provide care that is
continually reviewed and updated, I strongly believe
that continuing education activities must be available
and easily accessible to nurses. Though we cannot
deny the fact that organizing these learning activities
includes costs, this must be augmented by either the
employer or the government, so the nurses do not
have to shoulder all the costs. After all the state must
also carry out its responsibility towards Filipino
Nurses and the Nursing Profession stated on R.A.
9173’s Declaration of Policy which is to institute
measures that will result in relevant nursing
education, humane working conditions, better career
prospects, and a dignified existence for our nurses. It
is my hope that Filipino Nurses do not have to wait
another 18 years for this like what happened with
Section 32 of the same law.

6
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

Thailand’s Nursing Legislations and it’s Bid to a law. The law mandated the creation of Nursing and
Become an International Medical Hub in Asia Midwifery Council however, I believed that the
composition of the council and the requirements may
Important: Ideas and opinions expressed on this not be enough to identify the needs of the nurses and
paper are entirely for the sake of academic midwives in the country, I would argue that the people
discussion on the topic and in no way meant to and the profession will benefit more on having higher
offend/disrespect the monarchy, the state, the qualifications for the council members.
nation’s religion and any institution/individuals
mentioned in this paper. Do not reproduce in any form I would also recommend creating separate laws that
without the written consent of the author. will govern the practice of nursing and midwifery in
the country to clearly outline the scopes of practice of
As with all other parts of the world, my full-time work both professions. The existing law failed to identify
was also affected by the pandemic. The operation of the core competencies of each profession which may
the company was reduced, and this resulted in me lead to overlapping scopes of practice, creating role
having a lot of free time on my hand. It was when I confusion, thereby reducing the effectiveness of the
decided to work as a Medical Coordinator for a healthcare delivery system in the country. Since
private hospital here in Phuket, Thailand. As one of Nursing & Midwifery Education in the country is
the first private hospitals in Thailand operating for designed to support the National Health Programs, it
more than 49 years offering full complement of will be more beneficial to have two separate laws to
diagnosis, treatment, and rehabilitation services and govern profession making their roles clearer.
designated as a tertiary care facility with dedicated
facilities for cardiology and cancer, this hospital has I totally understand that these stems from having
easily become the hospital-of-choice. As a tourist cultural preservation at the center of care dimension
island, most of the patients at this hospital are and I have the utmost appreciation on this as this has
foreigners, either tourists who decided to wait out the allowed the profession in Thailand to adapt to the
pandemic here and retired and/or working changing times and health needs of the people by
expatriates. remaining true to their national identity.

While the hospital is well equipped and staffed to One of the practices that I do not agree with is the
cater to the health needs of the patient’s, one dual pricing practice in healthcare costs. I often
important thing that has become a challenge is observed that different price for services between
communication. As most of the patients are foreigners and locals. It appears that foreigners pay
foreigners with some even unable to speak in English higher price compared with the locals. I often ask
has presented communication difficulties between about this, but I cannot get a clear explanation. I must
nurses, patients, and their significant others. This admit that my Thai language skills is extremely
stems from having the official language of instruction limited, and it is the official language used in most
in the local language, Thai. Nursing & Midwifery documentations, there is a high possibility that
students are learning the profession in Thai. Though something just got lost in translation. I really did not
there are now private educational institutions that complain about this, I more of just asked why? It is
offers the program in English, commonly known something I hope I can understand more in the future.
locally as “International Programs”, it involves hefty
tuition fees compared to the regular program
conducted in local language. To sum up, Thailand has a very efficient Health Care
Delivery System, and they are well equipped to
Most private health institutions in the country address the healthcare needs of Thai Citizens.
recognizes the need for nurses who can However, some changes are needed to ensure that
communicate in English and understands that this they are able to stay like this for the coming years and
must be included in nursing education or even better to be able to meet their aspirations of becoming an
if included on lower education level. They address International Medical Hub in Asia.
this need by hiring Medical Coordinators who are
essentially healthcare professionals from other
countries who facilitates treatment process between
the attending physician, client, and other members of
the healthcare team.

I strongly believe that the Thailand Nursing &

Midwifery Act B.E. 2528 that governs the practice of
nursing and midwifery in the country needs to be
revised and updated to address the current
healthcare needs of the people. It is evident that the
health needs today have changed since 1985 when
the Thailand Nursing & Midwifery Act was passed into
7
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

The 1991 Local Government Code & It’s Effects How does the Local Government Code affect nurses
on Health Care Delivery System and the nursing profession? I understand that the
relationship between the two is not easy to spot
The enactment of the 1991 Local Government Code because our initial thoughts would be that this law
(R.A. 7160) mandated the delegation of health outlines how the local government units functions. I
services from the National Government to the Local myself am not certain I would have spotted it if the
Government Units (LGUs). The reasoning behind this pandemic did not happen. The pandemic has shed
is to provide LGUs with autonomy, enabling them, to light on how different local government units’
attain their fullest development as self-reliant preparedness to respond to healthcare emergencies.
communities and make them more effective partners There were local government units whose healthcare
in the attainment of national health goals. The system, though with some difficulties, was able to
Department of Health (DOH), which serves as the handle the pandemic better than some local
sole provider of health-related services, was government units. One indicator of a good healthcare
transformed into a technical authority providing system is the nurse-patient ratio as this reflects the
technical support and assistance to local health units. healthcare system’s capability to handle the
healthcare needs of the people effectively with
The DOH maintained its role as the steward of enough nurses to render the needed care. The
national policies, plans, standards, and regulations Philippines has an average nurse-patient ratio of one
on health while their local counterpart, the LGUs were (1) nurse to every five (5) thousand people. Some
given the responsibility of being managers and LGU’s has prioritized their healthcare system when
providers of direct health services at the local level. allocating their fiscal resources from the national
To fund the new responsibilities of the LGUs, fiscal government while others did not, which resulted in a
transfers from the National Government to the LGUs shortage of nurses in some areas like in Itogon,
were increased. Though the act also provided that Benguet where the current nurse-patient ratio is one
LGUs the power and authority to charge some “user (1) nurse for every twenty (20) thousand people. A
fees” for some services provided in the healthcare stark difference compared to Pasig City who
sector, these only generated a small portion of the allocated almost 2.5 Billion to their healthcare system
funding for their health expenditures, and the fiscal in 2020 allowing them to have a better health care
transfers from the National Government became the delivery system evidenced by their nurse-patient ratio
major source of funding. One thing to note here is that of one (1) nurse for every one thousand-eight
most of these fiscal transfers, also known as Internal hundred (1,800) people, which is almost three (3)
Revenue Allotments (IRA) are unconditional times higher than the national average.
transfers, which means that the purpose of the
transfer is not specified by the national government. The pandemic revealed the varying healthcare needs
Local governments, therefore, have discretion in of individual local government units and the need for
allocating their fiscal resources among the sectors. unified defense against the virus. The national
LGUs have the freedom to decide by themselves government addressed this by allotting funds meant
where to use the funding they received, based on to augment the salary of healthcare workers working
what they believe is more beneficial to their at the frontlines in the form of hazard pay. However,
constituents. this was not fully realized due to a lack of funding. The
Department of Health maintains that this was caused
Despite more than two decades of decentralized by the decentralization of healthcare since they have
operations in the Philippines, there has been no clear no control over how the LGUs will spend their budget.
evidence in the peer-reviewed literature on whether As of November 2020, 16,746 healthcare workers are
or not and to what degree the decentralization has yet to receive their hazard pay. There are reports that
influenced the country’s healthcare delivery system. some have received theirs, but it is way less than the
Nevertheless, a lot has changed in the healthcare amount promised by the national government.
needs of the Filipinos from the enactment of the 1991
Local Government Code. The available literature on decentralization posits that
local government units, at certain conditions, may be
efficient in allocating resources to meet the needs of
the people within their jurisdiction due to their close
proximity to the people compared to the national
government (Oates,1999). Decentralization may also
promote competition (Shleifer, 1985), and innovation
(cf. Rose-Ackerman, 1980) among local
governments, which would ideally benefit local
constituencies. While the arguments in favor of
decentralization are compelling, the real-life
advantages it brings to the country’s healthcare
Click here to enlarge image delivery system remain to be seen.

8
 ETHICAL & LEGAL DIMENSIONS OF HEALTHCARE
Master of Arts in Nursing

The 1991 Local Government Code (R.A. 7160), has • R.A.7160 The Local Government Code of
brought clarity on how the government units should 1991, (1991).
function, giving each unit its own responsibilities and https://www.officialgazette.gov.ph/download
roles in the attainment of national health goals and s/1991/10oct/19911010-RA-7160-CCA.pdf
policies. However, certain provisions of the act must • Rose-Ackerman, S. (1980). Risk-Taking and
be ratified to ensure that the country’s healthcare Reelection: Does Federalism Promote
delivery system remains a priority for all government Innovation? The Journal of Legal Studies,
units. After all, it is the state’s responsibility to 9(3), 593–616.
guarantee the delivery of basic health services to the https://doi.org/10.1086/467654
Filipino people by ensuring adequate nursing • Shleifer, A. (1985). A Theory of Yardstick
personnel throughout the country. This will be easier Competition. The RAND Journal of
to achieve with enough funding. I hereby suggest the Economics, 16(3), 319.
following resolution: https://doi.org/10.2307/2555560
1. The provincial, city and municipal health
board must include a representative of each
member of the healthcare professionals
employed in both public & private health
institutions within their jurisdiction to ensure
that the needs of every profession related to
the provision of healthcare are heard by the
board and appropriate actions are carried
out.
2. Representatives of every professional
involved in the provision of healthcare must
be actively involved in the creation of budget
proposals in accordance with standards and
criteria set by the Department of Health,
annual budgetary allocations for the
operation and maintenance of health facilities
and services within the municipality, city or
province.
3. The final budget proposal for the healthcare
of the municipality, city, or province must
include a specified amount to be set aside for
public health emergencies.
4. The approved healthcare budget for
healthcare by a municipality, city, or province
must be deducted from the municipality, city,
or province Internal Revenue Allotments
(IRA) transfer from the national government
and should not be redirected or used to any
other projects or expenditures of the
municipality, city or province other than
healthcare expenditures of the local
government unit.

References:
• Department of Health. (2020, September 1).
Healthcare Workers Granted Critical Support
by Bayanihan 1: More Human Resources,
Increased Allowances, and Protective
Equipment.Doh.gov.ph.https://doh.gov.ph/pr
ess-release/HEALTHCARE-WORKERS-
GRANTEDCRITICAL-SUPPORT-BY-
BAYANIHAN-1-MORE-HUMAN-
RESOURCESINCREASED-
ALLOWANCES-AND-PROTECTIVE-
EQUIPMENT
• Oates, W. E. (1999). An Essay on Fiscal
Federalism. Journal of Economic Literature,
37(3), 1120– 1149. JSTOR.
https://www.jstor.org/stable/2564874?seq=1
9