3. The Scaling-Up Process and Health MDGs in the Philippines

The Philippines is statistically on track to meet most of the 2015 MDG health targets. But while it may “win the numbers,” the unanswered need is how to broaden the MDG reach to expand access and enhance quality for more Filipinos over a wider geographical area in order to cover more impoverished areas. Conventional wisdom suggests enlarging the scale of both locally based effective pilot health projects and centrally established government health operations. That implies that centrally based, top-down governance and locally driven, bottom-up governance are considered complements rather than substitutes. But pilots seldom spread geographically, and centrally directed health programs have reached bureaucratic exhaustion. The key to unlocking this dilemma is to reinvent the scaling-up process: in the process of reaching out, centrally directed health programs should be “localized” down without loss of coherence, and local initiatives should be scaled up without loss of context. While a coherent national health framework is indispensable, health is at its core contextual—the result of localized interactions and shared experiences. A successful, context-friendly expansion seems to lie in scaling up the conditions that allowed the health initiative to do well, more than the specific elements that constitute it. In the final analysis, a reinvented scaling-up process is always a negotiated arrangement on how to maintain the appropriate balance between central authority and local autonomy. This chapter attempts to draw lessons, using a critical assessment of a number of significant cases of public sector health service delivery systems in the Philippines, regarding the links between local health contexts and a reinvented scaling-up process.