What are the changing roles of the Ministry of Health in decentralization? Perspectives from the Philippines after 25 years of devolving public health services Harvy Joy Liwanag1,2,3 and Kaspar Wyss1,2,* 1Swiss Tropical and Public Health Institute, Basel, Switzerland 2University of Basel, Basel, Switzerland 3Ateneo School of Medicine and Public Health, Ateneo de Manila University, Metro Manila, Philippines *Presenting author: kaspar.wyss@swisstph.ch Keywords: Decentralization, Governance, Health Systems Introduction Decentralization has been promoted as a strategy to bring decision-making closer to people. However, the evidence on its effectiveness in achieving this desired outcome for the health sector is mixed (1). In 1992, the Philippines introduced devolution, a form of decentralization where decision-making is transferred from central to locally-elected autonomous governments. Guided by Bossert’s concept of “decision space,” (2) we analyzed the changing roles of the Ministry of Health (MOH) in the context of devolution. Methods We purposively-selected 27 decision-makers in the Philippine governmental health system at national, regional, and local levels in various regions (Fig. 1). In-depth interviews were performed face-to-face to explore their perspectives on the impact of devolution and the interactions between the MOH and local governments in the delivery of health services. Each interview was analyzed in MAXQDA 12 through a combination of inductive and deductive approaches and following the Framework Method (3) of qualitative analysis. Figure 1. Present and past locations of work of the decision-makers in this study. Figure 2. A simplified structure of the governance of health services by the Ministry of Health in the Philippines before and after devolution. References: Liwanag HJ, Wyss K. Assessing decentralisation is a challenging but necessary task if it should continue as a reform strategy: Reflections from the systematic review by Sumah, Baatiema, and Abimbola. Health Policy. 2017 Apr;121(4):468–70. Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med. 1998 Nov;47(10):1513–27. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013 Sep 18;13:117. Results Decision-makers consider devolution to have a logical goal of shifting responsibility for local health services away from central decision-makers (Fig. 2) in theory, but resulted in more involvement from the MOH in practice. The MOH has assumed the role of augmentation as it continues to support local governments in performing its functions through: (a) technical assistance for strategic and operational planning; (b) budgetary and in-kind contributions for upgrading health facilities, ensuring medicines, equipment, and other supplies; (c) financing services through reimbursements from the national health insurance program; and (d) deployment of physicians and other health personnel to local governments that have no capacity to hire them. Conclusion Widening decision space through decentralization will not strengthen the health system without ensuring capacity and accountability. The Philippines is an example where the MOH assumes a stronger role in shepherding the health system even when decision-making has been devolved, especially when those absorbing the functions have little capacity to fulfil them. Health sector decentralization therefore requires not merely changing the structure of administration but a “whole of system” approach for it to be effective.