30 JPAIR Multidisciplinary Research Volume 47 • January 2022 The Ruthless Wealth of Health: Power Dynamics of Hospital Industry in Sulu Province JENNETH B. BALLESTEROS http://orcid.org/0000-0001-5819-0829 ballesterosjb_18@yahoo.com Sulu Sanitarium Hospital Jolo, Sulu, Philippines Originality: 98% • Grammar Check: 98% • Plagiarism: 2% ABSTRACT The people in Sulu usually go to hospitals and seek medical treatment when they are already in a severe condition that doctors can no longer cure and help. The qualitative method using focus group discussion and workshop conduct was employed, and the most appropriate sampling design is purposive. Four participants were invited and represented the actors from the regularity agent, supply side, demand side, and alternative substitute. Sixteen participants purposively drew and shared their opinions in the workshop. Findings show that the actors involved in the regulatory framework created by Republic Act of the Philippines and the policies and regulations were all done at the national level; the hospital director, administration, health provider, external suppliers together with the hospital and medical facilities, equipment, buildings, and services comprised the supply side in the hospital industry; the markets of the health services were the entire citizen of Sulu; alternative substitute like the traditional medicines and procedures like hilot were accepted by the Tausug. Lastly, all the interactions displayed by the different actors coming from the regulatory agent, supply side, demand side, and the alternative substitute described the nature and Vol. 47 · January 2022 DOI: https://doi.org/10.7719/jpair.v47i1.560 Print ISSN 2012-3981 Online ISSN 2244-0445 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. http://orcid.org mailto:ballesterosjb_18@yahoo.com http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ 31 International Peer Reviewed Journal performance of the hospital industry in Sulu. Nonetheless, producing a climate of quality health care service. Keywords — Health Science, hospital industry in Sulu province, qualitative method, purposive sampling design, Jolo, Sulu, Philippines. INTRODUCTION The empirical analysis of the economic environment has long remained the search of households and profit-making firms. The increasing importance of non-profit enterprises like hospitals as producers of services and as objects of government policy supports every individual in their medical treatment. Access to health care across countries, groups, and individuals is largely influenced by social and economic conditions and health policies. Countries and jurisdictions have different policies and plans for their societies’ personal and population- based health care goals. What applies to a certain country may not apply to other countries. In some countries, health care planning is distributed among market participants, whereas in other countries, health care planning is done more centrally among governments or other coordinating bodies. It is commonly acknowledged that healthcare delivery quality encompasses more than just effective clinical treatment. Quality is now defined to include dimensions such as clinical effectiveness, safety, and patient-centeredness (Institute of Medicine (US) Committee on Quality of Health Care in America, 2001). Patient experience and voice are increasingly being incorporated as a key component of health care consultation and planning. The assumption is that patient and public participation will improve healthcare quality and execution, satisfy population expectations and needs, and stimulate healthcare choices and shared decision-making (Boivin et al., 2010). According to World Health Organization (WHO), a well-functioning health care system requires a robust financing mechanism; a well-trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well-maintained facilities and logistics to deliver quality medicines and technologies. Global health policy encompasses the global governance structures that create policies underlying public health worldwide. In addressing global health, global health policy “implies consideration of the health needs of the people of the whole planet above the concerns of particular nations.” The Philippine Department of Health, or Kagawaran ng Kalusugan, is the executive branch of the Philippine government in charge of ensuring that all https://www.frontiersin.org/articles/10.3389/fsoc.2019.00038/full 32 JPAIR Multidisciplinary Research Volume 47 • January 2022 Filipinos have access to basic public health services by providing quality health care and regulating all health services and products. It is the government’s overall technical authority on health. It has its headquarters at the San Lazaro Compound, along Rizal Avenue in Manila. The department is led by the Secretary of Health, nominated by the President of the Philippines, and confirmed by the Commission on Appointments. The Secretary is a member of the Cabinet. Power has been defined in a variety of ways by different theoretical and philosophical views. There is no such thing as a neutral definition of power because it is always embedded in a theoretical context (Guzzini, 2005). It is not the goal of this article to provide an in-depth examination of various opinions on the meaning of power. Weber’s formulation, as stated by Rutar (2017) is an example of a classic sociological concept of power. “For him (Weber, 1978 [1922], p. 53), power is, as is well known, “the probability that one actor within a social relationship will be in a position to carry out his own will despite resistance, regardless of the basis on which this probability rests.” This can be, and usually is, further condensed. Social power is simply the ability of agent A to influence agent B in such a way (with the help of either personal or impersonal means) that agent B does something he/she otherwise would not have done or does not do something he/she otherwise would have done (cf. Dahl, 1961)” (2017, p. 153). The resulting demand for healthcare services and a relative shortage of some healthcare professionals make it difficult for hospitals and other healthcare providers to provide consistently high levels of care. Health care organizations are increasingly concerned with looking beyond financial performance measures while focusing on how to deliver higher quality care (Love et al., 2008). It is true that some improvements in care quality can be reached through investments in technology and infrastructure, but the most dramatic improvements are achieved through people. Previous studies have concluded that unsatisfied health care employees negatively affect the quality of care, adversely affecting patient satisfaction and loyalty to a hospital (Atkins et al., 1996; Al-Mailam, 2005). Thus, increasing the commitment and dedication of employees may benefit a health care organization and result in improved patient care and higher patient satisfaction. Patient feedback is commonly regarded as a crucial and essential resource in the improvement of healthcare services. However, there are still concerns about the legitimacy of different types of information that members of the public and experts bring to the table, as well as power struggles (O’Shea et http://en.wikipedia.org/wiki/Manila http://en.wikipedia.org/wiki/Secretary_of_Health_%28Philippines%29 http://en.wikipedia.org/wiki/Secretary_of_Health_%28Philippines%29 http://en.wikipedia.org/wiki/President_of_the_Philippines http://en.wikipedia.org/wiki/Commission_on_Appointments_%28Philippines%29 http://en.wikipedia.org/wiki/Cabinet_of_the_Philippines https://www.frontiersin.org/articles/10.3389/fsoc.2019.00038/full 33 International Peer Reviewed Journal al., 2019). As observed, despite many good outcomes and the reputation of the hospital due to its quality medical service rendered, people in Sulu usually go to hospitals and seek medical treatment when they are already in a severe condition and most of the time, doctors can no longer cure and help them because it is too late. Some factors affect their decisions not to seek medical help in the hospital, such as accessibility, finances, culture, etc. One of the many reasons is the lack of modern medical machines or technologies that can instead add assistance to medical practitioners or doctors. Only two (2) active government hospitals in Sulu, specifically in the town of Jolo, cater to the residents’ medical assistance. Both hospitals render only primary services that eventually limit their rendition of services. This study explores the dynamics of the health care or hospital industry in the province of Sulu, specifically the two government hospitals, IPHO and Sulu Sanitarium. Different actors compose the hospital industry, such as the regulating bodies, the supplier, internal and external actors, the customer, and the alternative substitute. This study reflects how these several actors influence the administration, management, and decision-making. It is a common observation that there is no study yet conducted bearing on the dynamics of the hospital industry in the context of Sulu province. This is the very reason why the present study is conducted. Accordingly, this study can be used to formulate measures that can improve the existing hospital climate in conducting and managing its services and, in a way, create a quality health care service for its Tausug people in Sulu. FRAMEWORK This study is based on the theoretical model: A model for Industry Analysis by Michael E. Porter (1980). Porter provided a framework that models an industry as being influenced by five forces. It is a framework for industry analysis and business strategy development. It draws upon industrial organization economics to derive five forces that determine the competitive intensity and, therefore, the attractiveness of a market. According to Porter, the five forces model should be used at the line-of- business industry level; it is not designed to be used at the industry group or industry sector level. An industry is defined at a lower, more basic level: a market where similar or closely related products and/or services are sold to buyers. Three of Porter’s five forces refer to competition from external sources. The remainders 34 JPAIR Multidisciplinary Research Volume 47 • January 2022 are internal threats. These are (1) Threat of new entrants, (2) Threat of substitute products or services, (3) Bargaining power of customers, (4) Bargaining power of suppliers, and (5) Competitive rivalry within an industry. They consist of those forces close to a company that affects its ability to serve its customers and make a profit. A change in forces normally requires a business unit to re-assess the marketplace given the overall change in industry information. This study relates to the five forces model by Michael Porter. The hospital industry consists of forces that affect the hospital’s ability to serve its customers, primarily the patients. The first is the context of the hospital industry in Sulu, which is the regulatory framework or the one that is responsible for the regulating bodies that impose policies and procedures and directs the hospital in servicing its people. It may yield possible new entrants, which depends on the cost of the entry points. Second is the supply condition of the hospital industry, wherein they have the principal responsibility for ensuring that care in their organization is safe and that those who use their services are treated as individuals with dignity and compassion. In line with it is the third force which refers to the demand condition concerned with the consumers. The supply and demand side depends on the actors who navigate the transaction in the hospital. Fourth is the availability of substitutes or the alternative medicines that can replace the services brought by the hospital, and last is the market structure, conduct, and performance of the public hospital industry in which there will be a comparison of the industry. It is perhaps not feasible to evaluate the attractiveness of an industry independent of the resources a firm brings to that industry. Thus, it is thus argued that this theory is coupled with the Resource-Based View for the firm to develop a much more sound strategy. It provides a simple perspective for accessing and analyzing the competitive strength and position of a corporation, business, or organization (Wernerfelt, 1984). 35 International Peer Reviewed Journal FRAMEWORK OBJECTIVES OF THE STUDY This study aimed to determine the power dynamics of the hospital industry in the province of Sulu. The interactions portrayed by different actors can be influenced, whether politically, socially, or perhaps, collusions between actors inside and outside the industry. The conduct, performance, regulating agent, demand, supply, and available substitutes, contribute to the totality of the public hospitals in rendering services to the Tausug people. 36 JPAIR Multidisciplinary Research Volume 47 • January 2022 METHODOLOGY Research Design This study assessed the inclusiveness of the hospital industry, particularly the two public hospitals in Sulu. The empirical data generated in this particular study is a qualitative method using focus group discussion. Primary data were gathered through interviews with the authorities of the hospitals. Desk reviews were administered in the collection of data as to the regularity agent, the suppliers, and the demand condition in the hospital. Through reviews conducted, determination of the different regulatory bodies, suppliers, demand-side, and the alternative medicines, it is considered that interactions, performance, and conduct of such hospitals in rendering services in Sulu to a large group of Tausug constitute what kind of hospital industry Sulu has. Focus Group Discussion was conducted with a representative from the hospital personnel and a participant from the patient to validate the key questions. A workshop or activity was administered to assess the structure, conduct, and performance of the hospital industry and participated by representatives from the regulatory bodies, suppliers, demand-side, and the alternative medicines or practitioners. Research Site In order to establish familiarity with the research area, perhaps we will briefly sketch the hospitals in Sulu. Province of Sulu includes nineteen municipalities, and Jolo is the capital of Sulu. The data in this particular section were derived from the report made by the officials of the Municipality Planning and Development Office of Jolo. The urban town of Jolo does not have sizeable land that can be utilized and devoted to agricultural purposes, especially rice, corn, and other crop products. This problem is attributed to the unavailability of farmlands for agricultural purposes, considering that Jolo has only about 596 hectares of dry land. Accordingly, the municipality of Jolo has an aggregate total land area of 26 hectares for commercial uses, as being the center of trade and industry and where the majority of the population comes from the municipality of Jolo. The place where the study was conducted was situated in the municipality of Jolo. The participants in the workshop or activity were those individuals residing in the province of Sulu: municipalities of Jolo, Parang, Patikul, Luuk, Maimbung, and other island municipalities that need the services of the hospitals, 37 International Peer Reviewed Journal as mentioned, and regulatory bodies: a representative from the personnel of the different hospitals, Philippine Health Insurance Corporation, Department of Social Welfare and Development, Social Security System and Local Government Unit; Supply Side, a representative from the personnel of the hospitals, external suppliers, private hospital, outside doctors, and pharmacy; Demand Side, a representative from the in-patients and out-patients and a representative from school; and for the Alternative substitute coming from the manghihilot, faith healers, herbolario and mangtatawas. The research setting consisted of a central section where many government offices, the public markets, stores, churches, mosques and private and public school buildings are located. As such, there are hosts of public and private hospitals operating in the municipality of Jolo. There are three hospitals in the town of Jolo namely, Integrated Public Hospital situated in barangay Asturias, Sulu Sanitarium located at the barangay San Raymundo and Medical Specialist Hospital, a private hospital situated at Martirez St. barangay San Raymundo. This was why the researcher purposely chose this place as the research setting of the study. Sources of Data Two types of empirical data were generated in this study. These are: (1) primary and (2) secondary data. The former set of data was elicited using interviews with authorities in the hospitals. The researcher personally collected data using interviews and guide questionnaires. The study uses guide questions in the conduct of Focus Group Discussion. Face-to-face interviews using guide questionnaires for those participants were also done. On the other hand, the latter set of data was generated from books, journals, hospital memorandum, orders, official reports, websites, and other reading materials which have a bearing on the research problem. Data Gathering This study used key or guide questions to measure the variables under this research and to be used in the Workshop or Activity. The content of the key question was based on literature reviews and focus group discussion (FGD) participated by representatives of both hospitals and individuals who utilized the services of hospitals. 38 JPAIR Multidisciplinary Research Volume 47 • January 2022 The questionnaire contained four parts. The 1st part consists of the Regulatory Bodies in terms of the institutions responsible for creating or establishing hospitals, structure, incentives, and power relationships. The 2nd part is the supply side of the hospital in terms of institution, structure, incentives, and power relationship. The 3rd part of the questionnaire comprises the demand side of the hospital in terms of: institution, structure, incentives, and power relationship. Part 4 of the questionnaire contains the availability of substitutes for institution, structure, incentives, and power relationships. Sampling Procedure Considering the nature of the research problem and factors like time element, financial consideration, and availability of research manpower, the most appropriate sampling design employed in this study is purposive. The sampling design does not provide the sampling units in the sampling universe an equal chance to be included in the sample (Blalock, Jr. 1972: 15-20). In purposive sampling, the researcher chooses his respondents and does not use random selection or chance to obtain a study sample (Nagel, 1961). In the four types of actors operating the hospital industry in the municipality of Jolo, four participants were invited and represented the actors from the regularity agent, supply side, demand side, and alternative substitute. The total number of participants purposively drawn and who shared their opinions in the workshop were sixteen participants. Procedure of the Study Pilot testing of the guide questionnaire was conducted at the Sulu Sanitarium on July 18, 2014, from 8:00 to 11:00 in the morning. There were 10 respondents, five from the Sulu Sanitarium staff and five from the patients who availed the service of OPD. Direct interviews for illiterate patients and questionnaire administration for the literate patients and staff were done to collect the data. In the conduct of the questionnaire administration, the purpose of the interview was explained to the respondents. They, too, were given assurance of their anonymity. It has to be stressed that a pretest was being conducted to pilot test the key questionnaire for its validity and reliability. To sharpen the content of the guide questionnaire in terms of the variables, a focus group discussion (FGD) was conducted last September 15, 2014. There were 10 staff participants. The purpose was to determine the reasons that hindered most of the Tausug from availing of hospital services. Guide questions were 39 International Peer Reviewed Journal prepared based on the pretest conducted for the FGD. Good communication was established, and the participants actively and confidently shared their opinions. Through this, findings were gathered from the results and then incorporated into the content of the Key questionnaire. Formal permission was sought from the director or chief of each servicing hospital, different government agencies, the private sector, and the individual who had participated in the conduct of the workshop or activity for the study. A letter of invitation was given to different organizations, specifically to Philhealth, SSS, DSWD, DILG, Rural Health Unit, Integrated Public Hospital, Sulu Sanitarium, Redcross, Jolo Emergency Rescue Network (JERN), Notre Dame of Jolo for Girls, one from a medical practitioner and a representative who practiced alternative substitute. The opportunity to conduct the workshop assured the researcher of reliable and valid data. The workshop was administered on November 21, 2014, from 8:00 am at the Notre Dame of Jolo College Graduate School Building which was selected for the setting of the activity. Dr. Darren B. Datiles was tapped to be the informative speaker to pilot the workshop. During the activity, research assistants were around to make the workshop sustainable. The workshop was participated by sixteen people coming from various public and private organizations, namely: the RHU of which they had a representative from each different municipality; Notre Dame of Jolo for Girls; Sulu Sanitarium; Redcross; one from the patient; one from medical practitioner; and one from the side of the alternative substitute particularly the manghihilot. Proceedings during the workshop were recorded with the use of a recorder. The key questionnaire was translated to the local dialect of Bahasa Sug for clarity of content. Rapport was established, and participants were allowed to speak in Bahasa Sug to have open communication and confidence in voicing out their opinions. Significant findings were elicited from the results of the workshop. Data Analysis Since the data elicited in the study are highly qualitative, a textual presentation was used. PROBLEM TOOL 1. Power Dynamics of regularity framework as to: a. Institution b. Structure c. Incentives d. Power Relationship Categorizing the responses from the participants and highlighting the most commonalities. 40 JPAIR Multidisciplinary Research Volume 47 • January 2022 2. Power Dynamics of the supply side in terms of: a. Institution b. Structure c. Incentives d. Power Relationship Categorizing the responses from the participants and highlighting the most commonalities. 3. Power Dynamics of the demand side in terms of: a. Institution b. Structure c. Incentives d. Power Relationship Categorizing the responses from the participants and highlighting the most commonalities. 4. Power Dynamics of the available service/substitutes as to: a. Institution b. Structure c. Incentives d. Power Relationship Categorizing the responses from the participants and highlighting the most commonalities. 5. Structure, conduct and performance of public hospitals Responses from the participants 6. Power Dynamics of the hospital industry in Sulu province Responses from the participants RESULTS AND DISCUSSION Power Dynamics of Regularity Framework Health care is conventionally regarded as an important determinant in promoting the general physical and mental health and well-being of people worldwide. The management and administration of health care are another sector vital to delivering health care services. In particular, the practice of health professionals and the operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for quality assurance. Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history. These compose the institution, structure, incentives, and power relationship. Institution. The financing of health care services is mostly mixed with general taxation to the state, country, or municipality, social health insurance, voluntary or private health insurance, out-of-pocket payments, and donation to health charities. In all countries and jurisdictions, there is much evidence in the politics that can influence the decision of a government, private sector business or other http://en.wikipedia.org/wiki/Health http://en.wikipedia.org/wiki/Health_administration http://en.wikipedia.org/wiki/Regulation http://en.wikipedia.org/wiki/Quality_assurance http://en.wikipedia.org/wiki/Quality_assurance http://en.wikipedia.org/wiki/Health_department http://en.wikipedia.org/wiki/Health_department http://en.wikipedia.org/wiki/Healthcare_provider_requisites 41 International Peer Reviewed Journal groups to adopt a specific health policy regarding the existence and financing aspects of the hospitals. As can be gleaned in Table 1 (Regulatory Framework of the Institution), the regulatory agency is composed of two hospitals servicing the medical needs of the people in which they are under the Department of Health National and ARMM, respectively. Social health insurance like the Philhealth, DSWD, Redcross, SSS, and local government constitute the institution under the Regularity Framework in support of the hospitals. The results showed in Appendix H that hospitals exist through government assistance, the Integrated Public Hospital (IPHO), and where they headed different municipalities’ hospitals and rural health units and under the National Government for the Sulu Sanitarium. From the views of the school, hospital exists through government officials or organization like DOH, DSWD, etc. Only the Sulu Sanitarium stated that they had not been assisted by the local officials, unlike the Rural Health Unit, wherein it received donations from the local government. Policies and regulations are made in national law. The findings revealed that the Department of Health is one of the health services that is dedicated to delivering health care services and products to the people. Sulu is under the Zamboanga Peninsula. The policies and regulations are based on guidelines, administrative orders, or circulations. Philippine Health Insurance Corporation, Department of Social Welfare and Development, Local Government Unit, and the Rural Health Unit were in deep connections to address the health Programs of the government in achieving Universal Health Care for all Filipinos and, at the same time, dedicated and empowered to serve the people in Sulu. Table 1. Regulatory Framework as to Institution Variable Responses Institution The Rural Health Unit (RHU) supervises the Integrated Public Hospital and exists with the help of the government. They receive assistance from the local government unit as donations like medical equipment; they have been given free medical missions, laboratory exams, and the rural health seminar for the mothers. According to Philippine Redcross, they exist through Republic Act 95. And for the Sulu Sanitarium, their agency exists as Leprosarium under National Government (DOH) and is categorized as a retained hospital. Later, the hospital expanded its general services and caters to all Tausug people, not just the leper patients. They had not been assisted in their services by the local officials or government. Policies and regulations are made at the National level based on the guidelines and administrative orders/circulations. 42 JPAIR Multidisciplinary Research Volume 47 • January 2022 Structure. The health care industry is typically divided into several areas. It is categorized according to hospital activities, medical and dental practice activities, and other human health activities. The human health activities involve or are under the supervision of nurses, midwives, physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential health facilities, or other allied health professions, e.g., optometry, hydrotherapy, medical massage, etc. This is where services are performed and as to the capacity of the hospital service. In Figure 2 (Regulatory Framework of the Structure in terms of the level or stage of services), the diagram shows that primary health care services are being offered by the hospitals. Primary care refers to the work of health care professionals who act as the first point of consultation for all patients within the health care system. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. They have good services delivered to the people. As stipulated in the creation of their services, hospitals, and other agencies providing and giving assistance to the health care of the population are continuously maintaining the good performance they offer. Figure 2. Regulatory Framework as to Structure (Level/Stage of Services) Incentives. Managers in all industries have made employee engagement a hot button issue because of growing evidence that engagement positively correlates with individual, group, and organizational performance in areas such as productivity, retention, turnover, customer service, and loyalty (Ketter, 2008). http://en.wikipedia.org/wiki/Allied_health_profession http://en.wikipedia.org/wiki/Allied_health_profession http://en.wikipedia.org/wiki/Health_care_provider http://en.wikipedia.org/wiki/Patients http://en.wikipedia.org/wiki/Preventive_medicine http://en.wikipedia.org/wiki/Health_education http://en.wikipedia.org/wiki/Health_education 43 International Peer Reviewed Journal The health care industry is no exception to this phenomenon in human resource management theory and practice. To have a strong engagement, benefits and recognition are at stake to give them motivation. In Table 2, the Regulatory Framework of the Incentive showed that good services would increase the number of patients visiting the hospitals. Giving rewards, sending employees to seminars and trainings and promoting qualified employees will encourage employees to work that will produce an effective and quality service. In line with the DOH Implementing Rules and Regulations of R.A. 7883, all accredited health workers shall be entitled to the following incentives and benefits in response to the services performed such as hazard allowance, subsistence allowance, training and education programs, civil service eligibility, free legal services and preferential access to loan. Table 2. Regulatory Framework as to Incentive Variable Responses Incentive In terms of medical services offered by different agencies, they have good services based on the increased number of patients visiting the hospital. Motivating employees, giving rewards, and sending them to different seminars and trainings related to their designation, especially outside town, will eventually help them be more effective in rendering services to people. On-time salary and benefits can be a motivating factor in order for them to be inspired to work efficiently. Giving promotions to qualified employees and sending them to seminars and trainings are the recognitions offered to employees. Power Relationship. Health care organizations that routinely achieve high employee satisfaction scores tend to have the following in common (1) accessible leadership, (2) frequent communication, and (3) employees are empowered to satisfy patients (Fassel, 2003). Internal marketing efforts have been shown to develop better relationships between employees and their organizations while increasing satisfaction and retention. The results, as depicted in Table 3 (Regulatory Framework as to Power Relationship), showed that all hospitals adopt open communication and have a harmonious relationship. Organizations that promote employee empowerment can help them take a more active role in daily care decisions, which are believed to enhance employee satisfaction (Berlowitz et al., 2003). When employees are more active in decision-making, not only in nursing practice and unit management but also in patient care, they feel more engaged, which leads to 44 JPAIR Multidisciplinary Research Volume 47 • January 2022 higher satisfaction and lower turnover rates (Relf, 1995). As seen in Appendix H, obstacles encountered by different institutions are ease of job-to-human dynamics, stress brought by the patient’s behavior, and the lack of medicines, equipment/facilities, and manpower. Table 3. Regulatory Framework as to Power Relationship Variable Responses Power Relationship Open communication and harmonious relationship are being adopted by the different agencies in rendering services. The policies and regulations are being implemented. The obstacles that a different institution is encountering are: RedCross – the task or job that is not difficult to human dynamics, challenge staff/ clients/boss. RHU – the behavior being manifested by the patient. Different styles of the patients were coming to seek the help of health workers even in the hospital. Sometimes they were respectful, but there were times when they were the ones who got angry, especially when they were the last to be checked up by the doctor. It is a big challenge for the health workers to handle the situation and have some patience, which contribute to some obstacles. Instead of more work accomplished, they will have to attend and settle for such a situation. Sulu Sanitarium – one of the problems that hinder most of the accomplishments of the hospital is the usual problem of lack of drugs and medicines in the pharmacy of the hospital. Aside from the fact that few budgets for the medicines are given and it is only through the revolving fund of the hospital that funded the supply of the medicines. Another reason for that problem is the lack of manpower to manage the operation of the hospital. Incomplete medical equipment or facilities of the hospital contribute to the obstacles in rendering services to people. A major factor that poses a problem to the hospital is the unfinished building. More employment and, most especially, more patients like the poor people who need a point of care can be given if only the construction of the two-story building is continued. Actions in response to the obstacles mentioned are: RedCross – they responded to the mentioned obstacles depending on the needs of the public. RHU – they will respond to the patients’ behavior by using the therapeutic communication. Sulu Sanitarium – responded to the obstacles described above by making and presenting budget proposals. Suggestions to improve the operations in the hospital are: For the RedCross, they need to increase staff, a position, and the salaries. The participants from the Sulu Sanitarium stated that manpower must be added just like the RedCross to man all the services needed by the public. More heads are better than one, and naturally, success is inevitable. Sulu Sanitarium also suggested that they must be provided infrastructure or finish their two-story building. Drugs and medicines, as well as medical equipment, must also be added to help the public. On the side of the consumer like the school, they suggested providing more hospital facilities, having fair treatment to the patients, and if possible, having a regular doctor assigned, especially during night time. 45 International Peer Reviewed Journal Power Dynamics of Supply-Side Health administration is the field of leadership, management, and administration of public health systems, health care systems, hospitals, and hospital networks. Health care administrators are considered health care professionals. They feed the medical or healthcare needs of the people. Institution. These are individuals who act as the central point of control within hospitals. These individuals may be previous or current clinicians or individuals with other backgrounds. There are two types of administrators, generalists, and specialists. Generalists are individuals responsible for managing or helping manage an entire facility. Specialists are individuals responsible for the efficient operations of a specific department, such as policy analysis, finance, accounting, budgeting, human resources, or marketing. The supply side includes outside doctors, pharmacies, dentists, and external suppliers. Table 4 (Supply Side as to Institution) portrays the awareness of the existence of hospital service by the population in Sulu. The health services depend on the type of agency and department they will cater to the public. Table 4. Supply Side as to Institution Variable Responses Institution Each servicing health care is aware of its contributory services to all Tausug that is vital to the needs of every individual. The services rendered will depend on the agency they are in, be it in a hospital, health center, school clinic, local government, or even in an office. Structure. According to Fahad Al-Mailam (2005), quality leadership in health care organizations helps foster an environment that provides quality care which is linked with patient satisfaction. Organizations that seek to improve patient satisfaction and encourage return visits or customer loyalty should focus on improving the quality of care. Therefore, facilities, machines, technologies, and services contribute to the accomplishment rendered by the health workers. As can be seen in, Table 5 (Supply Side as to Structure) provides a picture that Primary health care is the only service rendered by the hospitals and health units. Limited medical equipment and technologies are the only means for the doctor to render and treat patients and as a result, only limited treatment or health care that is usually basic is done by the doctors assigned. http://en.wikipedia.org/wiki/Public_health http://en.wikipedia.org/wiki/Health_care_systems http://en.wikipedia.org/wiki/Hospital http://en.wikipedia.org/wiki/Hospital_network http://en.wikipedia.org/wiki/Health_care_professional http://en.wikipedia.org/wiki/Health_care_professional http://en.wikipedia.org/wiki/Clinician 46 JPAIR Multidisciplinary Research Volume 47 • January 2022 Table 5. Supply Side as to Structure Variable Responses Structure Primary health care is the only service rendered by the agencies that participated in the seminar. They only cater to the immediate needs of the patient. Incentives. The concept of internal marketing in the health care sector suggests that the best way to satisfy patients is by viewing employees as internal customers and that by understanding and meeting employees’ needs, wants, expectations, and concerns, their level of satisfaction will increase, thereby leading to a better quality of care and higher patient satisfaction (Bitner et al., 1990; O’Neill, 2005; Testa et al., 1998). It is understood that employees were properly compensated, afforded trainings and seminars in improving their work performance, and were given promotions to qualify employees, as depicted in Figure 3 (Supply Side in terms of Incentives). Figure 3. Supply Side as to Incentive Power Relationship. Engagement level has a direct impact on the quality of care. If not engaged, quality can suffer. When the employee is unhappy in servicing people, patient care will suffer. A highly engaged employee cares more for the success of the organization and works harder for patients. In Figure 4 47 International Peer Reviewed Journal (Supply Side in terms of Power Relationship), the diagram depicts that the employees accept the tasks and duties even if obstacles exist like security threats, patient behavior, and conflict of interest. Once they willingly accept the tasks, it is likely to say that the employees are satisfied and vigorously work towards the goal of the institution. This, in turn, results in better and quality patient care and high patient satisfaction, which increases in patients visiting the hospital. Aside from the patient’s satisfaction, this is geared to better Financial Performance, and as a whole, everybody benefits. Figure 4. Supply Side as to Power Relationship (Relationship of Employee Engagement, Employee Satisfaction, Patient Satisfaction, and Financial Performance) Power Dynamics of Demand Side Patients in Sulu who experienced and encountered more satisfied employees are more likely to say that they would recommend the hospital to others. They are the target market of the health care services and are composed of the institution, structure, incentives, and power relationship. Institution. Health care is an extremely people-based industry. Much of the emphasis given is on the people’s side and satisfaction. They are the service users like families, friends, advocates, and institution like schools, Philhealth, and SSS who support the health needs of the people. 48 JPAIR Multidisciplinary Research Volume 47 • January 2022 Table 6, which is the Demand side concerning Institution states that the target market of the healthcare services or hospitals is the entire citizen of Sulu, considering those mother and child and the leper patient. Table 6. Demand Side as to Institution Variable Responses Institution The consumers of the services offered by the agencies or institution are the citizens of Sulu and those who are direct casualties, mother and child and the leper patient. Structure. Employee’s performance, the idea of improving organizational success by better connecting employees to customers accentuates the importance of patients and what they do personally as workers, particularly in an increasingly electronic and mechanized workplace dictates that health care will be provided without disparity as to age, gender, and level status in the society. This is portrayed in Table 7, Demand Side, in terms of structure. Table 7. Demand Side as to Structure Variable Responses Structure The market of the services rendered by the health institution is its entire citizen without regard for their tribes, religion, genderm and status in the society. The people of Sulu came to know the services of the health institution basically through their family, relatives, and friends. Some know through various activities or programs given by the hospitals or health centers and local officials. Incentives. Hospitals compete aggressively to attract patients, particularly for high revenue services. A variety of dimensions factor into the competitive landscape, including hospital location, infrastructure, technology and equipment, physician reputation, and hospital image, as well as the patients’ preferences in terms of accessibility and affordability of the service or product. As shown in Table 8, which is the Demand side in terms of Incentive, accessibility, and affordability of the product or service is the factor that patients consider in availing the health services. The drugs, medicines, and medical supplies are well monitored as to expiration. Therefore, results showed that repeat visits by patients could be expected, patients will spread more positive word of mouth (word of mouth is a primary driver in patient health care decisions), and financial performance of high satisfaction units will be better. 49 International Peer Reviewed Journal Table 8. Demand Side as to Incentive Variable Responses Incentive Accessibility is the very reason most Tausug avail and continue to patronize the services of the health institution. Only those who live in rural areas have difficulty engaging the services. The services also are affordable or at government price. They even offer free laboratory examinations and free medicines. They offer discounted prices, especially for those poor people who need a point of care. The drugs and medicines, as well as the medical, dental, and laboratory supplies, have been properly checked and monitored as to expiration to benefit and satisfy the receiving patient. Power Relationship. Some patients rate the quality of the care they received as higher. From this, it can be concluded that the patient, either consciously or not, infers that the care received is better merely because of the environment created by having more satisfied employees. Since the analyses dealt with average responses within and outside hospitals, differences in actual performance in delivering health care (e.g., doctors and nurses administering procedures and the support group, which are the administration and finance department rendering their jobs respectively) are averaged out. In table 9, Demand Side as to power relationship dealt with the performance and treatment of the employees in rendering service and displays a harmonious relationship between the patient and worker. Table 9. Demand Side in terms of Power Relationship Variable Responses Power Relationship The health institution is of help to every citizen in cases of emergency wherein they offer immediate relief, provide health insurance like PhilHealth members and serve the health needs such as medicines, laboratory, dental, x-ray, etc. As to health providers, it improves their skills and their communications and interactions with the patients. The interactions between patient-worker are better. The health provider treats them with respect and dignity the patients. Improvement for better performance is also needed. 50 JPAIR Multidisciplinary Research Volume 47 • January 2022 Power Dynamics of Alternative Substitute Alternative Substitute is those procedures and medicines available as an alternative to the health care services and products. Institution/Structure. The creation of the Philippine Institute of Traditional and Alternative Health Care, which is tasked with promoting and advocating the use of traditional and alternative health care modalities through scientific research and product development, greatly helps every culture in the world. Traditional medicine still enjoys a large patronization, especially in rural areas where advanced science and modern information have progressed. Table 10 on Alternative Substitutes in terms of Institution and Structure shows that it had been practiced in the early years, and alternative medicines were launched in 1992 and signed into law R.A. 8423. It further shows that acceptance of alternative medicines is seen and experienced by the people. Table 10. Alternative Substitute as to Institution and Structure Variable Responses Institution Traditional medicine has been practiced since ancient times in every culture and is influenced greatly by religion, mysticism, and superstition, especially in rural areas in Sulu. They first patronize the presence of alternative substitutes like hilot, tawas, albularyo/herbolario and faith healers that, in their thinking, will help them instead of consulting the doctors and hospitals. Structure Alternative medicines started in ancient times. Former Secretary Juan M. Flavier of the Department of Health launched the traditional medicine program in 1992 and later signed Republic Act 8423 by former Pres. Fidel V. Ramos to promote effective and safe use of traditional medicines. It is known now as the Philippine Institute of Traditional and Alternative Health Care (PITAHC). For the one practicing hilot, it all started when one approached and asked help for her, and she adopted the procedure of hilot until the patient was relieved. Incentives. Alternative procedures and medicines pose advantages to people. As can be gleaned in Table 11, Alternative Substitutes as to Incentives showed that the benefits are espoused to them, such as giving relief, offering an inexpensive cost, and being accessible to their immediate needs. 51 International Peer Reviewed Journal Table 11. Alternative Substitute to Incentive Variable Responses Incentive The alternative procedure or medicines were helpful for those who patronized and accepted the practice. It relives them; it is less expensive for services and fees and accessible for them to visit. For herbal medicines and soap, only a minimal amount can be discounted. For herbal medicines and soap, only minimal amount and can be discounted. Power Relationship. In alternative substitute, culture and tribes sometimes influenced the indulgence of procedures by the people. In Table 12 (Alternative Substitute as to Power Relationship), the practitioners had no problems while practicing the alternative procedures. Just as no contracts had been made, the patient took the risk regarding the results, and no prescribed fees were imposed regarding the services performed. Shortage of supplies in line with the alternative medicines like herbal soap and herbal medicines had been encountered. Thus, no negative impacts or criticism had been heard. Table 12. Alternative Substitute as to Power Relationship Variable Responses Power Relationship As for the one practicing the alternative procedure, she had not encountered any obstacles during the time she practiced it. Shortage of supplies was the only problem encountered by the hospital concerning herbal medicines and soaps. Structure, Conduct, and Performance of Public Hospitals Organizational processes are influenced by the mutual harmonization of parts of the system and by how power is structured and used. In organizations, the distribution of power is characterized by stability. This stability results from a commitment to decisions concerning the realization of the business strategy, the structuring of the organization, and the distribution of power that emerged from the past (Pfeffer, 1981). In organizations, there is a balance of power between the interests of individuals and of the interdependent groups. Sometimes these interests are at odds, resulting in conflicting objectives, power games, and controversies in decision-making (Hickson et al., 1971; Pfeffer, 1992). The tension between the interest of individuals and groups is viewed as inevitable and as a normal part of the way of getting things done. 52 JPAIR Multidisciplinary Research Volume 47 • January 2022 Structure. All interest groups or employees play roles in the day-to-day operations and change process based on their position in the organization, departmental power sources, and interests. Chief Executive Officers, top managers, consultants, work councils, employees, and other interest groups make up the hospital industry. Conduct. This portrays the ethical aspects of health care workers and providers in giving health care to people. They follow the standard ethical norms and conduct of a public servant. Performance. Each employee and health provider in the hospital industry delineates their duties and responsibilities, thereby creating good and quality healthcare in their performance. Power Dynamics of the Hospital Industry The power process is characterized by negotiation and the exchange of resources. Some departments in the hospital have more power than others. The departmental power bases are related to what the work unit does, but the power of different departments varies among organizations and can change over time (Perrow, 1970; Pfeffer, 1992). Three underlying dimensions that determine departmental power bases. The first dimension is the ability to cope with the uncertainty that influences the day-to-day operation of an organization. Departments that can cope effectively with uncertainty can increase their performance, power ability, and position in negotiation processes. The second dimension is the substitutability of the department’s functions and activities of the organization. Departments can prevent substitution and acquire control over scarce resources by shielding from others how the work is actually performed. The third dimension is centrality. Centrality refers to the power of a department that derives from the dependency of other departments and their significant role in the flow of work. The other departments are in grace with the department that does the significant role (Hickson et al., 1971). Conflict management and negotiation do occur in the hospital. All interest groups play roles in the process based on their position in the organization, departmental power sources, and own interests. In the process, different coalitions will focus on securing their interests, objectives, and power positions (Kanter, 1993). Resistance to change is seen as a result of the exercise of power and can be understood as a struggle to achieve power or to escape from it. The managers or the director focus on preventing conflict in the process by regulating the participation of the groups involved, by top-down decision-making and implementation, or by negotiating the objectives of the process and the way it is 53 International Peer Reviewed Journal organized and managed. At times, directors create conflict between the employees because they believe they are still the ones to be followed and have the authority to rule. The results of the study, as shown in Figure 5 (Power Dynamics of the hospital industry in Sulu) depict the structure, conduct, and performance of different actors in the regularity framework, supply side, demand side and the alternative substitute. Those actors interact in terms of the institution and structure they belong, the incentives and benefits they will get, and the power relationship they share. The hospital industry in Sulu sets an atmosphere of good service to the people. Even though obstacles have been encountered at times, employees are still motivated to render quality service to all. Figure 5. Power Dynamics of Hospital Industry in Sulu CONCLUSIONS These generalizations are derived henceforth: the conduct and performance of the Sulu hospital industry are described as to 1. The regulatory framework in terms of institution wherein all agencies exist through the Republic Act of the Philippines. An Institution like hospitals, the technical team of DOH, Philhealth, DSWD, local government, RHU, and Redcross determined the easiness of entrants in the industry. The regulatory framework stressed that primary health care services were the only service offered by the hospital and health centers. In the aspect of incentives, giving rewards, promotions, and sending employees to seminars and trainings strengthened the capabilities of every employee. Furthermore, collaboration and cooperation among the top and lower management of the health services were seen in the hospital; 2. Supply-side in 54 JPAIR Multidisciplinary Research Volume 47 • January 2022 terms of institution, where different actors who served the Tausug people, such as the doctors, director, administration, different services of the hospital, external suppliers, and dentist, determined all the interactions they would portray to the consumers of the service. Alongside the skilled workers, without such service, technologies, medical equipment, and machines, naught will be processed and utilized. Benefits and recognition had been given to employees to further inspire them to work; 3. The demand side constituted the institution, structure, incentives, and power relationship. The entire citizens were the health service market without regard for religion, tribes, gender, and status in the society. It had been stressed that the factors that gave the consumer to avail and patronized the hospital services were the accessibility and affordability of the product and services. The servicing agency practiced open communication and openness to suggestions; and 4. Alternative substitutes composed of the institution, structure, incentives, and power relationship. Traditional medicines were one of the alternative substitutes that most of the population availed, wherein they had no side-effect and were less expensive, although a shortage of supplies happened. The Tausug people practiced alternative procedures like hilot, tawas, albularyo, and faith healer. No required fees are imposed and they are accessible also because anytime they are available. This is seen that accessibility and affordability are the factors that favor the decision of a client in acquiring health services, even how the regulating and supply-side acts effectively. RECOMMENDATIONS The study yielded relevant inputs for improving the conduct and performance of the hospital industry and more programs implementing Health Programs of the DOH. The following recommendations are made toward this goal: policy, program action, and research. Policy a. Strengthen the monitoring of the Health Programs of the DOH. The DOH should develop a monitoring and evaluation scheme to strengthen the capacities of the health facilities and equipment and the infrastructure to provide quality health care services. b. Strengthen the linkages among the hospital personnel, LGUs, NGOs, and other stakeholders advocating for health through resource generation and allocation for health care services to be provided for the Tausug without 55 International Peer Reviewed Journal user’s fee or “donation” from the patient. c. Based on the study conducted, it was found that security threat hinders the employees from rendering quality service. The management must strengthen the cooperation among the LGUs, police force, and Armed Forces of the Philippines (AFP) [as necessary] in improving security measures to safeguard the safety of health workers in implementing their duties and functions. d. Require LGUs and other stakeholders to actively support and partner with health workers in information dissemination and program/s implementation. Program Action a. With the increased number of patients that the hospital caters to, the study reveals that more manpower is needed. b. Conduct seminar workshops on skills and proper dealing with patients. c. Maintain discounts and more affordable prices for the services rendered while maintaining quality service. d. Strengthens and develops the harmonious relationship between patient- worker. e. Maintain open communication by instrumenting a suggestion box or having a drop box to have patient feedback and suggestions. Research Agenda a. Review program inputs and evaluate monitoring scheme of DOH to increase service of health providers focusing on key variables for intervention in making a better hospital industry in Sulu. b. Conduct studies to assess the capacities of hospitals and health centers of Sulu to provide quality health care for All Programs. c. Conduct studies to assess the capacities and readiness of LGUs, police force, AFP, and other stakeholders to partner and actively support the hospitals and health center of Sulu in information dissemination and program/s implementation. d. Conduct studies to evaluate the willingness in the partnership of the police force and AFP in the security of the personnel in securing the advocacy of the DOH. e. Conduct studies to assess the continuous sustenance of health financing and responsive programs by the practice of good governance. 56 JPAIR Multidisciplinary Research Volume 47 • January 2022 ACKNOWLEDGEMENTS It has been an exceptional journey in my life that I have never dreamed of and that is writing a dissertation. It is one of the most challenging parts of the journey. However, this undertaking is made possible through the guidance and assistance of many persons I am deeply indebted to. Firstly, to my adviser Dr. Rec Eguia for sharing his vast expertise and valuable time. His sharp insights and countless experience significantly guide the direction of the study. Sherlito C. Sable, Marcelo M. Angelia and Carmencita B. Aquino, for their expert, and excellent ideas. Their suggestions are priceless. Dr. Atasharr S. Paradji, Dean of the Graduate School, for her constant pieces of advice, which undoubtedly strengthened my determination to finish the study. To Dr. Darren B. Datiles for gracing the workshop with his informative insights. Grateful appreciation to my officemates, especially Mrs. Catherine N. Lee, for their support and supplying me with the data needed for the study. Special recognitions to different participants from RHU, LGUs, Notre Dame of Jolo for Girls, Philippine RedCross, and Sulu Sanitarium for sharing their valuable time and opinions to enhance the study. I also appreciate the presence of my classmates Sakura Abduraji, Femushreena Ahalul, Salvador Zacarias, Raymond Delos Reyes, and Edgar Acevedo. They are the ones who pushed me to do better, and their gestures portray a clear definition of friendship. They inject in my mind that I am strong and can surpass difficulties amidst unexpected situations as we journey to completion. Such experiences make this degree so meaningful. I would be the most ungrateful person if I passed without recognizing the people behind my success: my mother and Uncle Ken for their moral support, and my lovely sisters, Lelhen, Tootz, Meckz, and Innang for understanding and helping me during the trying times. Above all, to Almighty Allah, from whom everything started, armed me with blessings and made this endeavor possible. LITERATURE CITED Al-Mailam, F. F. (2005). The effect of nursing care on overall patient satisfaction and its predictive value on return-to-provider behavior: a survey study. Quality Management in Healthcare, 14(2), 116-120. 57 International Peer Reviewed Journal Atkins, P. M., Marshall, B. S., & Javalgi, R. G. (1996). Happy employees lead to loyal patients. Marketing Health Services, 16(4), 14. Berlowitz, D. R., Young, G. J., Hickey, E. C., Saliba, D., Mittman, B. S., Czarnowski, E., ... & Moskowitz, M. A. (2003). Quality improvement implementation in the nursing home. Health services research, 38(1p1), 65- 83. 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