DEVELOPM ENT SUSTAINABILITY THROUGH

COM M UNITY PARTICIPATION

Development Sustainability
Through Community
Participation
Mixed Results from the Philippine
Health Sector

JO A Q U IN L. G ONZALEZ HI, Ph.D.

Lecturer, Public Policy and Administration
Department o f Political Science
National University o f Singapore

Published in conjunction with the

CEN TRE FOR ADVANCED STUDIES
Faculty of Arts and Social Sciences
National U niversity of Singapore
First published 1998 by Ashgate Publishing

Reissued 2018 by Routledge

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
711 Third Avenue, New York, NYI 0017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright © Joaquin L. Gonzalez III 1998

All rights reserved. No part of this book may be reprinted or reproduced or

utilised in any form or by any electronic, mechanical, or other means, now
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any information storage or retrieval system, without permission in writing
from the publishers.

Notice:
Product or corporate names may be trademarks or registered trademarks, and
are used only for identification and explanation without intent to infringe.

Publisher's Note
The publisher has gone to great lengths to ensure the quality of this reprint
but points out that some imperfections in the original copies may be
apparent.

Disclaimer
The publisher has made every effort to trace copyright holders and welcomes
correspondence from those they have been unable to contact.

A Library of Congress record exists under LC control number: 97077887

ISBN 13: 978-1-138-61652-3 (hbk)

ISBN 13: 978-1-138-61654-7 (pbk)
ISBN 13: 978-0-429-46193-4 (ebk)
Contents

Figures and Tables vi

Acknowledgements vii

Introduction 1

1 Operationalizing Community Participation and

Project Sustainability 9

2 Does Community Participation Really Matter to

Development Sustainability?: Competing Views
and Evidences 36

3 Community Participation, Development Sustainability,

and the Decentralization of Health Care Delivery
in the Philippines 61

4 The Cases of Four Philippine Health Care Projects 95

Conclusions 131

Bibliography 142
Appendix l 168
Appendix 2 172
Appendix 2 181
Index 186

v
Figures and Tables

Figure 1: Community participation and project sustainability,

1981-90 4
Figure 2: Community participation and project sustainability:
Affirmative view 37
Table 1: Internal and external determinants of project sustainability 43
Table 2: Pessimists and theirdeterminants 48

vi
Acknowledgements

Numerous individuals and groups made the researching and writing for this
book, which started as my doctoral dissertation, possible. Sincere gratitude
goes to my guru, Dr. James B. Mayfield, who gave his unending support and
encouragement, from the start, the completion and revisions of this project. I
would also like to thank my other mentors at the University of Utah who
showered me with constructive ideas and thoughts: Drs. Daniel McCool,
Howard Lehman, Yangi Tong and Stephen Reynolds. After graduate school,
valuable intellectual guidance and stimuli were provided by Ed Campos,
Manny Jimenez, John Page, Lyn Squire, Bhuvan Bhatnagar, Aubrey
Williams, Julie Viloria, David Steedman and David Williams during my two-
year stint at the World Bank in Washington, DC. My sincere appreciation to
many friends and colleagues at the National University of Singapore, Centre
for Advanced Studies, Institute of Southeast Asian Studies, Philippine
Embassies in Singapore and the United States of America, the University of
the Philippines, De La Salle University and the Philippine Department of
Health. Special mention goes to Assoc. Profs. Jon and Stella Quah, Assoc.
Prof. Leo Suryadinata, Assoc. Prof. Lee Boon Hiok, Dr. Ho Khai Leong, Dr.
Shamsul Haque, Dr. Gambhir Bhatta, Dr. Peggy Teo, Mr. Ronald Holmes,
Mr. Rizal Buendia, Mr. Benito Bengzon, Dr. Trinidad Osteria, Dr.
Exaltación Lamberte, Dr. Ledivina Carino, Dr. Amelia Varela and Dr.
Victoria Bautista. This study would not have taken off the ground without the
generous financial and technical support of FHP Health Care (Utah) and the
Policy Research and Operations Policy Departments of the World Bank.
Moreover, I am indebted to two anonymous referees who gave helpful
comments and excellent suggestions. Thanks to Edith Gonzalez and Susan
Lopez-Nemey for providing editorial assistance. Acknowledgements also go
to the Gonzalez and Borbon families for being there during the emotional
“ups” and “downs” inherent to long-term endeavors such as this book. Above
all, I am grateful to my wife Edith Borbon Gonzalez and my daughter Elise
Borbon Gonzalez for their patience, understanding and inspiration.

Joaquin L. Gonzalez III

Singapore

Vll
Introduction

Questions about the relationship between participation and social and

human development have been around since the ancient Greeks.

J. Cohen and N. Uphoff, 1980

Cornell University

More research is needed on the importance of community participation to

the sustainability of health care systems. Specifically, different models of
participation need to be identified, and the more successful experiences
need to be documented.

J. Rice, 1990
United States Agency for International Development
and World Vision Relief

Yet, despite the widely shared view that participation improves project
performance, clear and convincing evidence on the link between
participation and project outcomes is surprisingly scarce. Advocates of
participation have relied primarily on case studies to document the link
between participation and performance. But these are easily dismissed by
skeptics because of the small number of cases and the informal testing of
the findings.

J. Page, 1998
The World Bank

Many social scientists all over Asia and the world are caught up in what seems
like a never ending search for ways and means around obstacles that hinder
project and program success in developing countries. One of the “miracle cures”
that they have been prescribing since the mid-1970s is the use of increased
community participation. In broad tenus, community participation implies
increasing stakeholder or client involvement in almost all aspects of a project cycle1

1
2 Development sustainability through community participation
from the planning and design to the actual implementation and monitoring. With
the help of academics and nongovernmental organizations (NGOs), community
participation became the virtual panacea of the 1980s. Consequently, the 1990s
witnessed bilateral and multilateral development agencies like the Asian
Development Bank (ADB), the International Bank for Reconstruction and
Development (IBRD/World Bank), the United States Agency for International
Development (USAID), which traditionally emphasized the economic, financial,
and technical aspects of development projects, slowly began to place more serious
concern for a programs social and civic dimensions primarily to increase the
likelihood of development sustainability—the continuation of the benefits and
activities of a development project beyond donor funding or supervision (See, for
instance: UNDP, 1993; World Bank, 1995). At the local government level of
developing countries, increased stakeholder participation was encouraged,
empowering the community to take responsibility for maintaining a project’s
output(s) with less or even no central government support. Some specific
examples of these socioeconomic development outputs are: better quality
educational opportunities, preventive health care habits, or environmental
conservation and preservation consciousness.
As a result, concern for community participation intensified in both
development research and practice in Asia and the rest of the developing regions in
the world. It became imperative for development projects in the 1980s and the
1990s to have a community participation component to ensure sustainability (See
Bamberger, 1986; Briscoe and de Ferranti, 1988; Bhatnagar and Williams, 1992).
Overwhelming empirical support for this panacea poured in from both researchers
and practitioners of social development. The latest international conferences to
throw in its endorsement was the 1994 World Bank Workshop on Participatory
Development in Washington, DC and the 1995 Social Development Summit in
Copenhagen. These conferences and many more have spawned a multitude of
published and unpublished papers on issues surrounding community participation.
To empirically verify this growing prescription, a computer-aided data
mining1 approach w'as utilized in this study to search through the following CD-
ROMs to develop a database of records on these two interesting development
concepts. In this era of databases compiled in high-volume hard drives, floppy
diskettes and electronic tapes, CD-ROMs, on-line networks and systems, and
recently Web-sites, information now abounds on almost any topic or area a
research scholar can conceptualize. However, this phenomenal growth of high­
speed access to large-scale information has its pros and cons. For instance, a big
advantage of computerization and access to databases is that it gives one an
abundant amount of information to gather, process and analyze, making his or her
research very exhaustive. But, the amount of information that databases yield can
 Introduction 3

be quite overwhelming and unbounded. Given time and resource constraints, a

serious challenge facing researchers who wish to take advantage of this type of
high-level computer technology is how to reduce the size of the information output
from a database search and at the same time be able to maximize the search
results. After all, development administration is multidisciplinary in nature, which
essentially means influence from a variety of established academic fields and sub­
fields like sociology, political science, management, engineering, health,
agriculture, public administration, and others. Consequently, this means sorting
through a huge amount of literature in a number of electronically accessible
databases.
The On-line Library Catalogs accessed represented libraries from the east
coast, west coast, and midwest or intermountain west of the United States. They
were selected for their geographic representation as well as specialized collections.
These library databases were: the University of Utah On-line library system
(UNIS), the University of California and California State Universities
(MELVYL), the Colorado Association of Research Libraries (CARL) and the
Harvard University On-line Information System (HOLLIS). Bilateral and
multilateral development institutions diat were accessed included: the United
States Agency for International Development (via the USAID Database), the
World Bank (via the Bank Reports Bibliography in All-In-One), the United
Nations Development Programme, the Organisation for Economic Co-operation
and Development (OECD) and the Ford Foundation.
Requests for information from the different agencies that specialized in
carrying out development administration activities yielded substantive quantitative
information only from the USAID and World Bank. An examination of the
available library information (e.g. annual reports and publications catalogues) and
communications provided by various offices at the OECD, UNDP, and Ford
Foundation indicated that these institutions have carried out few direct field
projects and activities pertaining to project sustainability.
The CD-ROM databases included in the study were: Social Planning,
Policy and Development Abstracts (SOPODA), Sociological Abstracts (SA), and
Social Science Index (SSI). These databases index and abstract more than 2000
journals and serials on social and health development and other related areas. The
search located 591 studies (e.g. published articles, books, government documents,
etc.) that dealt with community participation and project sustainability. Figure 1
confirms the growth in concern for these two important development concepts,
from only 87 studies and evaluations in 1981-85 to a huge 504 studies in 1986-90.
After the search, an in-depth content analysis was used on a more limited 45
documents that represented the trend from the larger data set. These 45 studies
4 Development sustainability through community participation
provided a diverse sample of health and health care-related development projects
from Asia, Africa, and Latin America.

1990

Figure 1. Community participation and project sustainability, 1981-90

 Introduction 5

Main Objective and Organization of the Book

Contrary to widespread expectation, there were also development scholars and

practitioners who expressed their doubts about the “miraculous abilities” of this
panacea. These studies on development projects from Asia, Sub-Saharan Africa,
and Latin America claim that this view is an exaggeration. Hence, they seem to
portray the affirmative perspective, i.e. community participation is the much
needed factor for success, as a myth. The main objective of this book is to explore
these competing views in the following chapters.
Chapter 1 is devoted to an examination of the various definitions of
both community participation (CP) and project sustainability, the two
concepts found to be the ongoing obsession of social science researchers
dealing with development studies. A review of the vast and multidisciplinary
development literature revealed three general ways of conceptualizing
community participation: ( 1) expounding through the means-and-ends
approach; (2) using a laundry-list of definitions; and (3) categorizing through
an institutional/contextual framework. Similarly, sustainability as a measure
of development project effectiveness or success can be defined and
operationalized in many different ways, depending on a number of factors.
Chapter 2 is a discussion of the two groups of views—affirmative
and negative—on whether or not community participation is really essential to
development sustainability based on the database search which came up with
45 core studies. It elaborates on the arguments and evidence from a subset of
scholars and practitioners who seem to strongly support the conventional thinking
about community participation and development sustainability. The chapter also
exposes the two sub-groups of negative views that provide evidence that
community participation is not always a key factor needed to ensure development
success. While discussing both perspectives, die chapter also highlights some of
the internal and external factors that have been identified by scholars and
practitioners to be equally important to project sustainability.
Chapter 3 discusses the influence of the evolving development
administration emphases—centralization and decentralization—to health care
service delivery in the Philippines. Millions of dollars in technical, financial,
and managerial aid from international organizations (e.g., United States
Agency for International Development, International Bank for Reconstruction
and Development, World Health Organization, United Nations Development
Programme, Canadian International Development Agency) have been poured
into the Philippines to promote these development-inducing administrative
arrangements. In die second section of diis Chapter, the discussion focuses on the
experiences of 38 local level development projects and programs that have resulted
6 Development sustainability through community participation

after the shift to a more decentralized health care delivery system. It evaluates
these project and programs to determine the significance of community
participation to their success.
Chapter 4 is an in-depth evaluation of four cases: (1) Matabungkay
Population Project, (2) Hanunuo Mangyan Community Health Project, (3)
Mindanao Schistosomiasis Control Project, and (4) Nueva Ecija Primary
Health Care Project. These four cases were taken from the 38 health care
projects described in the previous section and are highlighted in this chapter.
These development project experiences are examined to determine the degree
of community participation, institutional arrangements, project
characteristics, and contextual factors that contributed to their sustainability
or nonsustainability. The first two provided support to the affirmative view
that community participation is a strong determinant of project sustainability
while the last two reinforce the dissenting perspective about community
participation’s significance to the development effectiveness.
Based on the empirical evidence presented in the previous chapters,
the book concludes with a verdict on whether community participation really
matters to development sustainability. It also reveals some conceptual and
policy constraints on which present and future public health care managers
and provider should reflect on.

Research Approach and Data Sources

Thirty-eight Philippine health care project studies identified from CD-ROM

databases described earlier and actual health care projects from Carino and
Associates’ (1982) “A Compendium of Existing Mechanisms for Meeting
Health and Related Needs in the Philippines” are evaluated in this study. The
researcher had to rely on the databases and the Carino and Associates listing
as sources for a representative sample since neither governmental nor
nongovernmental agencies have comprehensive listings covering all health
care projects in the Philippines. The sample size represents 84.4 per cent of
all Philippine health care projects found in the four health and health-allied
databases. It also represents 95.0 per cent of the projects listed in the Carino
and Associates study.
The quality of the sample represents a mix of characteristics from
health care projects all over the Philippines. The information regarding rural
development participation and sustainability was collected from both “not
sustained” and “sustained” projects. The projects were derived mostly from
the 1970s and 1980s so that both short-term and long-term sustainability
 Introduction 1
could be tested. In addition, the 38 Philippine projects represent the following
descriptive characteristics: ( 1) three major geographic island regions of the
Philippines (Luzon, Visayas, and Mindanao); (2) three general proponent
types (nongovernmental, governmental, and joint sponsorship); and (3) two
major project types (integrated and sector specific).
These 38 projects represent evaluations and actual studies initiated by
the Philippine Department of Health (DOH), Philippine Council for Health
Research and Development (PCHRD), Philippine Institute for Development
Studies (PIDS), National Economic and Development Authority (NEDA),
United States Agency for International Development (USAID), Canadian
International Development Agency (CIDA), International Development
Research Center of Canada (IDRC), De La Salle University Research Center
(DLSU-RC), University of the Philippines’ Colleges of Public
Administration, Nursing, Medicine, Social and Community Development, and
Public Health, and other local and foreign scholars and institutions.
Open-ended questions and a semi-structured questionnaire form were
used as the primary instruments to guide collection of detailed information on
each projects especially the ones to be used as case studies. Each evaluation
form sought to extract the following information from the 38 projects: ( 1)
project type, proponent and beneficiaries, and geographic location; (2) goals
and objectives of the project; (3) involvement, interaction, and collaboration
between staff and the community in planning, implementation, and the
sustainability processes of the health care project; (4) project outputs in terms
o f human resources, physical constructions, and institution building; (5)
project outcomes (the health benefits gained by the community); (6) status of
outputs and outcomes after the project terminated; (7) long-term and
unintended consequences of the project; (8) number of years used as a start­
up period; (9) number of years the project outcomes and outputs continued
after the start-up period; and ( 10) other internal and external variables.
Many limitations were encountered in the study. The suitability of the
questions and indicators used in the evaluation guide was determined by the
amount of information available from previous studies. Some projects had
information on specific indicators like records of attendance during planning
and implementation activities, minutes of planning and implementation
meetings, and results of votes on suggestions during planning and
implementation activities. Reasons for the unavailability of these specific
types of data were mainly attributed to inconsistent record keeping procedures
or absence of records. Open-ended questions were used so that each
evaluation would concentrate on extracting participant, observer, and
evaluator descriptions, which were categorized according to their
8 Development sustainability through community participation

participation characteristics. As opposed to using highly specific indicators of

community participation and development sustainability in each health care
project, these qualitative categorizations were used to build an objective
picture of the possible causal relationships that might exist between the two
concepts under study.

Note

*Data mining is a systematic computer-aided technique more commonly utilized in

Decision Science and Information Technology to uncover potentially significant
patterns and trends from large databases.
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