In 1992, the Philippines devolved the provision of health services to the provincial, municipal, and city levels. This partition of public health across three different levels of government eventually created fragmentation in the overall management of the health system. The quality of basic health services generally deteriorated, and accessibility varied considerably across the country.

The Zuellig Family Foundation was established in 2008 with the ultimate vision to be “a catalyst for the achievement of better health outcomes for all Filipinos”. The foundation focuses on improving health outcomes through enabling stronger health leadership and governance in partnership with key stakeholders. CAPS sat down (virtually) with the foundation’s Chairperson and President, Ernesto Garilao, in October 2020 to understand the genesis and success factors of their Health and Leadership Transformation Program, as well as the intricacies of working with government to scale such a program across the Philippines.

CAPS: Ernesto, thank you for taking the time to speak with us today. Why did the Zuellig Family Foundation decide to focus on health leadership and governance? Why not just step in and deliver health services directly?

Ernesto: To help improve the health system in the Philippines, we looked at the six building blocks delineated by WHO (World Health Organization): leadership and governance, financing, access to essential medicines, health workforce, health information systems and service delivery. We agreed that essentially it is local leadership that moves the system—they enable the other building blocks.

And since our mission is to improve the health indicators of the most disadvantaged—and in the Philippines the health system is devolved to the local level—then it was logical and necessary to work with local government units. If we really want to address the poor, we had no alternative but to work with local governments, because the poor go to their health services.

You’re right that the alternative would be to set up the health services ourselves, but that would not be sustainable because we, as a foundation, cannot be in these towns forever. So our approach was to work with local government units on health leadership and governance.

CAPS: What are the advantages and disadvantages of working with local government units compared to the central government?

Ernesto: Well, there is less political change at the local level. The Minister of Health serves at the pleasure of the president. Mayors, on the other hand, serve three-year terms and can be reelected thrice, often serving for nine years which is a fairly long time. On the flip side, working with local government units is also a long-term time Investment and I would guess not too many foundations would like to make that time investment.

CAPS: So the mayors are the main beneficiaries of this program?

Ernesto: Yes, the mayors and their municipal health officers, and eventually their constituents. Our health change model trains local mayors to reform their health systems to provide better health services to their constituents, especially the disadvantaged. This, in turn, improves the health indicators for their areas, creating a win-win all around.

CAPS: How did you decide to use this health change model?

Ernesto: When I was at AIM (Asia Institute of Management), I developed the bridging leadership framework with my faculty colleagues. When I joined the Zuellig Family Foundation, we used this leadership framework in our ZFF health change model. The linchpin of this model is the personal transformation of the political leader into a bridging leader.

As an elected official, he must own—that’s the catchword here—must own the health inequities in his town. In other words, these poor indicators happened during his watch, so therefore he has to do something about them, right?

So if a mayor wants to improve his public health indicators, he must transform into a local health champion. This is important because he controls the delivery of primary health care, health policies, and the overall budget for his town. He has the power to improve his health services by prioritizing health in the budget.

Through our pilot from 2009-15, we demonstrated that in two to three years this leadership and governance intervention successfully lowered maternal deaths in these towns.

CAPS: And why specifically were you focusing on maternal health, rather than nutrition or other health indicators?

Ernesto: Because initially you need to have a focus, and in 2008 the Philippines’ high maternal mortality rate was a big issue. This doesn’t mean that these mayors are not offering other health services. In fact, our training was focused on general health. But the indicators we measured success by was maternal mortality. That’s because if we start saying that there must be improved maternal and child-care indicators and improved infectious diseases indicators and better non-communicable disease indicators, mayors will get overwhelmed and may not want to participate.

CAPS: Eventually the central government took notice of your program. What happened next?

Ernesto: Yes, the reduction of maternal mortality got the attention of the Minister of Health in 2013. And he said, “I like what you’re doing”. I’ve seen the program many times and I’ve watched the indicators go down. So he asked us to scale this program, essentially bringing it to the poorest municipalities with the worst health indicators across the country.

CAPS: Was the Zuellig Family Foundation excited about this opportunity?

Ernesto: Well, yes and no. We recognized that this is a great opportunity because as a foundation we always wanted to offer a product that could be mainstreamed by bigger institutions. We’re interested in developing a product, an approach, or a model that can be scaled up. And when you want to scale up, you’re really looking at government.

We recognized that we had a good program, and that if it could be scaled up it fulfils our mission of being a catalyst in improving health indicators of the disadvantaged. So we saw the central government’s interest as an opportunity, especially because growing any program nationwide requires champions inside the central government.

But we also recognized there were risks, and thought about how we could mitigate them.

CAPS: And what were some of these risks?

Ernesto: Well, for one, working with the central government means working with political appointees with no fixed terms. And priorities can change from one person to another. The political aspect is always a risk.

Secondly, even with the Minister of Health championing our intervention, it would be viewed as an “outsider” program, and not necessarily trusted by internal bureaucracy. They would have to be won over.

We went through this calculus, recognizing this as an opportunity but also being aware of these risks. The question was, how do we mitigate these risks? We decided that the program had to be co-owned between us and the Department of Health. So there was nothing in the program that did not have the approval or the consent of the Ministry of Health. They, too, had to be co-champions of the program.

CAPS: The remit you were given was massive, covering all municipalities. How did you manage it?

Ernesto: Yes, we were asked to scale it out across all municipalities. But we knew we did not have the capacity to do that—we are nowhere as big as government. So we decided to enlist and transfer the bridging leadership approach and training technology to regional academic universities and colleges. They in turn trained the mayors and health leaders of participating municipalities with funding from the Ministry of Health.

CAPS: What is the status of the program right now?

Ernesto: The program has been institutionalized. Some regional units in the Ministry of Health have taken ownership, and the Department of Health central office is now more active in pushing health leadership and governance at the federal level. All in all, the more important thing is that there is recognition that health leadership and governance is an important intervention in public health.

Why is this important? For one, because universal health care is now led at the provincial level, which means local leadership and governors will be a major factor. Number two, we have Covid-19. The response of local government units is a crucial factor on how well the pandemic is controlled. And we cannot talk about health in the age of pandemics without talking about leadership and governance. Health leadership and governance needs to be at the forefront, and the Zuellig Family Foundation has helped lay the foundation of this movement.

CAPS: You didn’t just plant the seed, you nurtured it into a tree! It’s really quite remarkable. What comes next?

Ernesto: We have become known for improving the health indicators of the disadvantaged in the Philippines, and we’ll continue working along these lines. Now we’re looking to focus on improving the health indicators of the disadvantaged faster.

Around 40% of towns in the Philippines have been exposed to our health change model, and in a sense that’s our catchment. And we will return to this catchment, to these towns, and continue to help them improve their local health systems and reduce malnutrition wasting and stunting, and adolescent pregnancies. It would be a waste not to build upon the social capital we have with these local governments.

We also look at ourselves as a catalyst who wants to leverage working with other partners to magnify impact. And make the impact long lasting. That has been our strategy from the very start: have an intervention that can be scaled up so the spillover effects are much, much greater. We plan to continue with this approach to serve the Philippines and its people.