Nurses-Led Municipal Leadership and Governance Program: Experiences of Local Chief Executives in Central Visayas, Philippines

Abstract

Background

The strategic response of nurses in addressing health inequities in marginal sectors led to the conduct of a health leadership governance training program for local chief executives.

Objective

This study aimed to explore and provide a description of the experiences of local chief executives (LCEs) or mayors who participated in the nurse-initiated health training named Municipal Leadership and Governance Program (MLGP).

Methods

A qualitative descriptive design was used through key informant interviews of fifteen mayors or local chief executives (LCE) in the provinces of Bohol and Negros Oriental, Philippines. Data were collected from 16 to 20 November 2022 and analyzed using a thematic approach.

Results

The findings generated six themes: a) Leadership capacitation promoting transformative experience, b) Pandemic and program-induced limitations in the training implementation, c) Personal leadership motivation, d) Experiential learning promoting learning as applied in real-world situations, e) Celebrating leadership transformation, and f) 3R’s of MLGP: revisit, review, recommend.

Conclusion

The realizations of the training participants provided valuable implications for the quality of training offered by nurse leaders who advocated the MLGP implementation. It served as a proactive and responsive approach to the health leadership capacitation of mayors. It guided them in their personal realizations that inspired them to apply what they had learned and enabled them to effect experiences of personal to institutional transformation.

Background

Health inequities are part of the realities a country like the Philippines has experienced (Banaag et al., 2019). Health statistics generated as the basis for the development of the Philippine Health Agenda 2016-2022 states that every year, 2,000 mothers die due to pregnancy-related complications. Added to this is that a Filipino child born to the poorest family is three times more likely to not reach his 5th birthday compared to one born to the richest family, with three out of every ten children being stunted (Cabral, 2016). As part of the healthcare workforce in the country, the nursing discipline takes the biggest chunk of this workforce (Dahl et al., 2021; Limpin & Artiaga, 2023; National Academies of Sciences Engineering Medicine, 2021; University of the Philippines Population Institute (UPPI) & Demographic Research and Development Foundation (DRDF), 2020). Nurses are a valuable workforce in the implementation of health services in the community (Chan et al., 2021; Llop-Gironés et al., 2021; Roush, 2020). Universal Health Care is the country’s response to address the healthcare needs of the public, and nurses are major drivers in its implementation (Rumsey et al., 2022).

Innovative programs are developed to address these inequities in our locale. The decentralization of health care management and services is expected to improve the system of responding to the health needs of the people. The implementation of the Local Government Code of 1991 resulted in the devolution of health services in the Local Government Units (LGUs) (Bajar & Porsche-Ludwig, 2021; Fernandez & Ting, 2023). The Department of Health is the technical advisory body on the policy and program development related to health services. This has provided a vast opportunity for LGUs to strategically address the health needs of Filipinos and attain universal health for all. Nurses are the frontliners in community health services. The public health nurses and doctors in the rural health units are under the directives of the LCEs or mayors who serve as elected leaders in a town or local government unit.

However, the devolution of health service delivery and management requires capacitation and training, which most LCEs elected to office were unprepared for. Health leadership competency is an essential factor that LCEs should develop to address the complexity of the nature of health inequities in their municipalities. In the study of Noval and Palompon (2021), the impact of MLGP on local officials in Cebu Province includes enhanced knowledge and skills in health governance, self-awareness, adaptive leadership, and increased capacity in building resilient and engaging communities. For the Cebu province participants, MLGP has served as a key instrument in achieving health equity goals in all aspects of health governance at the local level. Hence, nurses are leading the training of LCEs to develop health governance competencies and guide them in prioritizing health in the local governments.

The Department of Health (DOH) in the Philippines and the Zuellig Family Foundation (ZFF) signed a Memorandum of Understanding (2013) to collaboratively implement the Health Leadership and Governance Program (HLGP). The HLGP is a strategy to enhance DOH’s operations and, importantly, to empower local government units to implement health programs and activities. HLGP is a collaborative effort between local health systems and public health programs that address health inequities, especially among the marginalized sector of the community, and to attain the health-related targets of the Sustainable Development Goals (SDGs). It also has the potential to become an approach to achieve the vision of the Philippine Health Agenda (PHA) – “All for Health towards Health for All.” The program endeavors to strengthen the health leadership capability of the Local Chief Executive (LCE) and other key health leaders at the municipal level and allow them to recognize their vital roles in tackling health inequities and attaining universal health care for all Filipinos.

It is along the premise of capacitating LCEs on health leadership competencies that MLGP was established. The Health Change Model recognizes that local leadership is the key to creating healthcare systems responsive to the needs of people with low incomes. Based on this approach, local leaders⎯particularly the mayors and the municipal health officers⎯undergo transformative training to help them appreciate the significance of their role in developing healthcare systems for people experiencing poverty. This enables them to understand and address the complexity of health issues in their communities. The Health Change Model has three main components: training, practicum, and coaching (Zuellig Family Foundation, 2022). The Municipal Leadership and Governance Program (MLGP) is a sub-component of HLGP. Implementing MLGP Training as a specialized service requires the knowledge and expertise of a service provider/academic partner to improve the LCEs and local health leaders into efficient and effective health advocates more responsive to health inequities. Selected regional academic partners then underwent training to build their capacity to run the training programs. Training designs, modules, and learning materials are available to academic partners (Zuellig Family Foundation, 2022).

In 2014, the first run of the MLGP was done by nurse leaders and public governance experts in two universities under the DOH in Central Visayas. The program has already graduated 45 LCEs or mayors. The full implementation of MLGP utilizes the health roadmaps with parameters on leadership and governance, health financing, health human resources, access to medicine and technology, health information systems, and health service delivery. MLGP is an eighteen month three module leadership program for mayors and municipal health officers (MHO), which is anchored on the Bridging Leadership Framework that allows individuals to experience transformative processes of ownership of health issues, engagement of stakeholders, and generation of collective responses (Institute of Medicine, 2015).

To our knowledge, no qualitative study has been done to explore the experiences of the mayors who were part of the cycle 2 MLGP run. The results of this study would provide research evidence for future studies and will be used as input in planning for the offering of succeeding cycles. This study provides valuable feedback on the nursing competencies of capacitating public health leaders so that health services and projects will be more responsive to the needs of the people. This also creates a paradigm of public health nursing advocacy that focuses on developing leadership and policy development in health.

This research aimed to explore and provide a detailed description of the experiences of local chief executives (LCEs) or mayors who participated in the nurse-led Municipal Leadership and Governance Program (MLGP). The study’s findings contribute to the capacitation of the local leaders in the community or municipality regarding health-related decision-making. This program provides local leaders with awareness of the priorities of their governance on the health of the public and how they can make a difference in the health outcomes of the people. In addressing the Sustainable Development Goal of health and well-being, health governance is needed to attain health for all. Moreover, this study will enable the nurses to disseminate the benefits of the training program not only to local leaders but also to national and global leaders governing our country to empower them in health governance and management. This can be an opportunity for any health governance to adapt or benchmark the MLGP training program that was implemented in the Philippine setting.

Methods

Study Design

This study employed a qualitative descriptive design. This design presents a comprehensive summarization of the experiences of the participants in the training program (Lambert & Lambert, 2012). The design obtained data that describes who, what, or where of the experiences from a subjective perspective (Doyle et al., 2020). This design was appropriate for this study as it allowed for a straight description and comprehensive summary of the phenomenon of interest: the experiences of mayors who participated in MLGP using the participants’ language and staying close to the data (Kim et al., 2016). The setting took place in two provinces, namely, Negros Oriental and Bohol provinces, Philippines.

Participants

Purposive sampling was used. The participants were selected using the following inclusion criteria: mayors who have successfully finished Module 1, 2, and 3 of MLGP version 2; incumbent local chief executives during the conduct of the study, regardless of age and gender, able to articulate the experience and willing to participate in the study. The study participants were enrolled in the MLGP, where the researchers facilitated and acted as resource persons. The training duration lasted for eighteen months and included didactics and practicum components. The total number of graduates of the program was 45. However, the first batch of 15 mayors was part of the MLGP version 1 training program. Hence, they were excluded. The second and third batches consisted of 30 mayors who were considered in the study. Of the 30, only fifteen gave their full consent to join the study. Some of the mayors were on official travel or were not available for the interview. Hence, fifteen mayors took part in the study. After gathering data from the fifteen participants, the researchers discussed the patterns of the responses to consider data saturation. Upon checking the data analysis, it was noted that saturation had been attained; hence, no additional informants were considered.

Data Collection

Prior to the conduct of the study, the participants were informed through a letter of the objectives of the research and who would conduct the interview. The participants were informed of the intent to gather honest information about their experiences. They were also informed of the interviewers’ backgrounds and affiliations. The interview was conducted from 16 to 20 November 2022 in the office of the informants. The interviewers traveled to their respective offices for the conduct of the interview.

The venue of the in-person interviews was the mayor’s municipality, and the interviews were conducted in a relatively private place, with the date and time mutually agreed upon by the participants and researchers. For virtual interviews, the researchers provided Zoom. The interview lasted for approximately thirty minutes to an hour.

Data were gathered utilizing the Key Informant Interview (KII) in face-to-face or in-person interviews. Three mayors were interviewed with a research assistant who acted as transcriber/recorder during the interview. Only the mayor, informant, interviewer, and research assistant were present during the interview. The interview was conducted only once per informant. Field notes were recorded by the research assistant and integrated with analyzing the data obtained.

An interview guide was used to generate data. The interview guide consisted of questions, through prompts and probes, to elicit further descriptions of their experiences when deemed needed, such as “Can you please tell me what you mean by that?” or “Please tell me more about it.” A content expert reviewed the interview guide. The researchers who acted as interviewers were trained online to conduct the interview. Simulation interviews were also conducted for each interviewer until mastery and consistency of the questioning were attained. Interviews were audio-taped with the participant’s consent. The researchers and the research assistant transcribed the recorded interviews using manual encoding.

Data Analysis

Data were analyzed using manual coding guided by the 6-step thematic analysis of Braun et al. (2016). The six steps of the analytical process are as follows: familiarization with the data, generating initial codes, generating themes, reviewing potential themes, defining and naming themes, and producing the report. There were five data coders. The authors assisted in providing descriptions in the coding matrix. The themes were derived from the data.

Trustworthiness/Rigor

The data collection was conducted by the researchers who were trained to conduct interviews. The interview was audio recorded with the consent of the informants. Additional sources of information were obtained from the monitoring reports by the Department of Health and their updated health roadmaps, which served as a means of validating the information shared during the interview. The research team conducted member checking of the data generated and themes. This was done after the themes were generated, and the findings were presented to the informants for verification and correction of the interpretation of the findings. Some modifications were made as suggested by the informants.

Ethical Consideration

The study proposal was granted an exemption by the Cebu Normal University Review Committee through CNU-REC Code 113/2022-08. Participants’ rights were assured through informed written consent, following an explanation of the purpose of the research. Respondents’ participation in this study was voluntary, and they were informed of the risks and benefits of the study and their right not to answer a question or withdraw from the study before signing their consent to participate. Anonymity was observed by having identification codes on the demographic form. Confidentiality was maintained by having the data stored in a locked cabinet at the University Government Affairs and subsequently shared with the co-investigators in Google Drive, which is password protected. The data will be destroyed one year after publication.

Results

Fifteen respondents participated in the study. All of them were the incumbent local chief executives; ten were in their third term, three were in 2nd term, and two were in their first term. Three are female LCEs, twelve are males, six are graduates of the 2nd batch MLGP, and nine are from the 3rd batch. In the interpretation of the findings, the researchers conducted group discussions. There were no differing opinions, but the discussion was focused on enhancing the themes and clarifying their relationship with the other themes.

Six themes emerged from the study: a) Leadership capacitation promoting transformative experience, b) Pandemic and program-induced limitations in implementation, c) Personal leadership motivation, d) Experiential learning promoting learning as applied in real-world situations, e) Celebrating leadership transformation, and f) 3R’s of MLGP: Revisit, Review, Recommend.

Theme 1. Leadership Capacitation Promoting Transformative Experience

This theme includes statements that refer to the overall experience of the mayors of local chief executives (LCE) who were enrolled in the MLGP training. The theme generated was supported by the following sub-themes:

Subtheme 1.1. A comprehensive tool in capacitating the mayors in their health leadership role. Based on the findings of the interview, the participants who are mayors gained insights from the training, which enabled them to grasp their roles as local chief executives in their municipalities.

“MLGP is a helpful program for the health of inexperienced LCEs” (P8)

“The MLGP helped the LCEs in understanding their role in health” (P6)

“The MLGP helped the LCE to recognize and prioritize health issues and concerns” (P5)

“Shift in leadership paradigm by owning the problem” (P10)

The inclusion of the six building blocks of healthcare delivery made the program more meaningful to the LCEs. It guided them on what priorities to focus on in governing.

Subtheme 1.2. Application of MLGP Knowledge in their practice as Mayors. The participants find the training experience of MLGP worthwhile, memorable, significant, foundational, and informative experience. Their narratives showed how they applied what they had learned from the training in their work as mayors.

“Worthwhile experience, able to share inputs and insights with other LCEs on matters of governance and leadership” (P2)

“The program gave LCEs the chance to fully integrate into the community and gain a broader understanding of their current health situation” (P7)

“Basic leadership foundation for new mayors” (P11)

The program enhances leadership awareness and competence, considering that most were elected without prior training.

Theme 2: Pandemic and Program-Induced Limitations in Implementation

The challenges encountered in completing the MLGP course were brought about by the program itself, especially with the duration where the mayors must complete the 18-month training and sustain the 4-day didactics. Participants were apprehensive because of how many days they had to be out of the office to comply with the requirements.

“The negative side for the MLGP is it took so much time for the mayors to be away from the office. Only one day to be away, so many things to do already” (P8)

“First is how to schedule the time, as LCE, we are so busy, also because I am a businessman” (P9)

It somehow affected the time management of the mayors in terms of balancing office work and completing the deliverables of the training course. It demands time to focus on the tasks given to the trainees to meet the deadline.

“In the beginning, the biggest challenge at that time was to put together all the requirements that were asked to be submitted: essays, journals, because everybody is busy” (P8)

One of the parts of the program is to look into the inequities in health in their respective community and find a solution. This output has become a challenge for some of the mayors who are not medically inclined.

“Then, with health issues, it seems I could not relate at first because I finished a different field” (P6)

MLGP compelled the mayors to put effort while learning despite their capacities and drive. Their learning preferences are greatly affected by age, confidence, and adeptness with the learning modalities utilized in the program.

“Every module has an examination. It was easy because we all helped each other. The difficulty is in individual activities” (P10)

“Because it seems I went back to being a student. I had difficulty because I am quite old. It seems I could not absorb well what was discussed” (P6)

Limitations in the conduct of the MLGP happened during the pandemic. Shifts in the learning platform affected the participants as the new online platform required adjustment.

“Limited implementation of programs due to COVID-19 pandemic restrictions… There’s a difference between online learning and face-to-face. Although I graduated in the program (MLGP), the grasp of knowledge is lesser compared to going through face-to-face training” (P1)

Theme 3: Personal Leadership Motivation

MLGP provides intrinsic motivations to the participants through personal leadership realizations and aspirations supported by the appreciation of the extrinsic motivations that enabled them to succeed in the program. The conduct of the MLGP has motivated the mayors to complete the whole program. The responses on the variety of motivations they have recognized developed the cluster theme through the five sub-themes:

Subtheme 3.1. Opportunity for leadership competence and valuing of health problems. The participants expressed their appreciation of the complexities of health problems as part of their learning with the program. This enabled them to realize the necessity of addressing health concerns in their municipality.

“With the MLGP program, I understood the complexity of the problem. The vicious cycle will persist if not mitigated… The deep dive is an eye-opener to the current realities on the ground” (P1)

Other testimonies of the participants included the sense of change they experienced in their personal ways of dealing with their office and clients.

“The mayor is aware that they are Bridging leaders and that MLGP is different from business as usual. Recognized that the mayors must be trained on leadership” (P4)

“It is self-improvement; every day we search for opportunities to improve. It is the inspiration to improve and the inspiration to serve others that propels me to continue with the course” (P7)

The experiences in the training program have allowed them to look beyond their role as elected officials.

Subtheme 3.2. Opportunities for positive transformation through innovations in health services. MLGP provided an avenue for mayors to develop self-enhancement in their leadership competences. The activities also inspired them to work for their respective municipalities.

“In the first module of MLGP training, I saw its good side because innovations were introduced to our health services based on the guidelines of MLGP. It was encouraging to continue and complete the program” (P1)

“Determined to finish/complete the training after learning about the current and preferred reality of BL (Bridging Leadership) leader” (P4)

Subtheme 3.3. Inspiration to develop personal mastery and service to others. The participants found a sense of inspiration knowing the health inequities they observed and started owning the problems themselves. This led them to create their shared vision of health.

“I am motivated to improve my knowledge of serving people. Otherwise, my role as a mayor will be defeated because the people choose me to serve them” (P3)

“The workshops that I was guided with. Improving my service to people is the main reason why I continued with the training” (P12)

Subtheme 3.4. A tool towards the attainment of an empowered and dynamic leadership. Appreciating the relevance of health leadership and governance in improving and sustaining health outcomes enables the participants to recognize their capacity to serve the community better.

“Biggest motivation is we were able to help our constituents to address the inequalities, address the problems that we were facing in our municipality that really helps guide me, the mayor, the doctor, on how to address that one without too much pressure on our part… But, more so, I want to complete it because I think this is a way for me to help my constituents to address the issues” (P8)

Subtheme 3.5. A supportive and flexible learning environment through the support of the facilitators/LGU team. The supportive atmosphere accorded by the training facilitators helped in the learning of the participants.

“The resource speakers were essential motivators. They are good, approachable, informative, facilitative, and friendly. What kept me going was the good MLGP program” (P2)

“Good facilitators, very good. They handled us well if they know that it seems that we do not understand the lecture, they will find another way; very well trained” (P11)

Theme 4: Experiential Learning Promoting Learning as Applied in Real-World Situations

The participants shared their experiences determining which sessions or concepts were most useful in managing/ strengthening their Municipal Health System. Based on their responses, two sub-themes emerged:

Subtheme 4.1. The interconnectedness of topics grounded on didactics and practical application of learning. Varied responses were acquired from the mayors included in the study. They identified the relevance of didactics to the actual practicum in the field, where they conducted their deep dive activity with their constituents.

“Entire MLGP to include didactics and practicum” (P8)

“The interconnection of topics requires the appreciation of all topics as useful. The whole program was useful, not the specific parts” (P11)

“All parts of MLGP didactic, practicum, and deep dive (were useful)” (P15)

Subtheme 4.2. Topics that provide practical ways of addressing health challenges and resulting in improved health outcomes. The participants appreciated most of the topics that they were able to use in their dealings in the operations of their offices. These topics trained them to interact and deal with people, which enabled them to create changes in their healthcare system.

“The session on stakeholder analysis and dialogue helped in mastering the skills of listening to, collaborating with, and implementing with the stakeholders” (P6)

“Collaboration and implementation with the community and stakeholders were helpful during the pandemic, particularly when drafting the COVID protocol” (P7)

“Dialogue and collaboration” (P10)

Generally, MLGP has enhanced its capability to understand the scenarios in the actual situation of its constituents in relation to health and its ability to create change through communication and people skills.

Theme 5: Celebrating Leadership Transformation

The participants attained leadership transformation and affirmation through the improvement of the health roadmap, local health outcomes, and health innovation initiatives, considering this as a continuous process. Exploring how the participants describe their accomplishments in the MLGP generated the sub-themes:

Subtheme 5.1. Awareness of the needs and contributions of stakeholders. The MLGP training promotes co-ownership through a shared vision and engaging stakeholders who can best explain the problems and allow them to be part of the solution to be developed and implemented to address their health challenges.

“I must admit that being the mayor, I am the king, and sometimes I consider my decision on my own. However, with MLGP, I need to consult and gather other stakeholders; that is my ownership. The stakeholders help lighten our burden in addressing the problem. That is the primary lesson I learned. We expanded the Municipal ELHB; we have NGO members and other sectors. It is a stepping stone where we start convening the health board and discussing problems and plan” (P1)

“I used social media so that people would be aware and people helped. When I say these are the protocols in Barangays, people follow them—all facilities have washing areas, including the market and municipality. One entry, one exit, no gatherings-people understood these protocols” (P2)

“I realized that alone I cannot handle the problem, but I am inspired because there were so many stakeholders who cooperated and helped” (P4)

Subtheme 5.2. Affirmation of good performance/ enhanced competencies due to MLGP. Open communication through dialogues and the involvement of stakeholders established a better way of addressing health concerns in their municipalities. Through this, they were guided on their priorities and projects, and their good deeds were recognized.

“I am finishing my third term, which affirms that I am doing well with what I am tasked and called to be. I have encountered many challenges, but I stood firm. I was struggling yet still working despite the many” (P2)

Subtheme 5.3. Utilizing creativity and Innovation. One of the accomplishments that mayors describe as part of their accomplishments in MLGP is developing new practices that are responsive to the needs of their health challenges.

“Utilized one of the SCAMPER techniques” (P2)

“Hiring of trained healers in RHU, considered as best practice” (P3)

Subtheme 5.4. Improved health system/health outcomes. One clear proof of the mayors’ accomplishments is the data supporting the changes in their health system and outcome. Health governance that is dynamically interacted can achieve two active health outcomes (health equity and health improvement).

“Program sustainability” (P2)

“Improved health system… Decrease infant mortality rate” (P3)

Theme 6: 3R’s of MLGP: Revisit, Review, Recommend

Revisit the learning curriculum, review the program management components, and recommend integration in the training of mayors. Opportunities for improvement of the MLGP program were suggested by the participants, which focused on the following subthemes:

Subtheme 6.1. MLGP to adopt an andragogy learning approach. Adult learners, like the study participants, prefer ways of transmitting learning. Their experiences focused on learning by experience and practical ways rather than downloading information.

“Since the course is on health, the way it should be explained should not be too technical” (P5)

“Not spoon-feed training for mayors because some were made by Development Management Officers (DMOs)” (P11)

Subtheme 6.2. Face-to-face training is preferred over online classes (consider the location/venue of the training). Learning preferences vary among learners. The MLGP participants started with face-to-face training; however, the remaining learning modules were delivered online due to the pandemic. Based on their experience, they suggested providing the training on a face-to-face platform.

“For continuity of training, in-house and face-to-face are suitable for all mayors” (P1)

“Face-to-face sessions rather than online, for better learning” (P13)

Subtheme 6.3. Constant monitoring is needed to ensure the sustainability of the MLGP program. The schedule requires a 4-day didactics and 6-month practicum for each of the 3 modules of the program. During the practicum, the mayors suggested that there should be constant monitoring to update and follow them up in the implementation of their practicum activities. It is further recommended that staff can be hired to facilitate catch-up sessions. In the program implementation, this is supposedly facilitated by the Development Management Officer (DMO). However, due to the expanded responsibilities of DMOs, they could have difficulty following up on the practicum component of the training.

“Monitor to keep the lines open because of the long months training gap” (P2)

“Hire an associate/ mid-level staff to do catch-up sessions” (P14)

Subtheme 6.4. Duration of Training. The training is usually conducted for four straight days. This is the mayor’s biggest concern due to the demands of their jobs. This schedule is too rigid for them. The suggestion also includes offering training in short periods.

“The four-day design is acceptable, but it’s too rigid for a mayor… Schedule the practicum properly so that it doesn’t conflict with any other events” (P5)

“Broken training schedule (2 days per week)…Adjustment of schedule – series of half-day sessions” (P11)

Subtheme 6.5. MLGP is recommended for new mayors. With the learning gained from the MLGP training, the participants suggested that the MLGP be offered as a mandated training for newly elected mayors.

“The MLGP is worth recommending to other LCEs, but being receptive to the program is an important consideration” (P5)

“All new mayors must undergo MLGP after being elected” (P11)

Discussion

Nurses and other healthcare leaders are significant players in enhancing healthcare governance to attain equity (Lavoie-Tremblay et al., 2024). Nursing advocacy to mold the leadership competencies of political leaders enables them to plan for their constituents’ health needs and concerns (Clarke et al., 2021). The MLGP is a nurse-led leadership training for LCE and health leaders in the Visayas community. This program implemented leadership and governance capability-building programs for health in various rural municipalities in the country. This program aims to improve health outcomes by enhancing local chief executives and health officers’ leadership and governance capabilities (USAID, 2017).

From the findings of the study, the narratives of the mayors showed how MLGP capacitated them as leaders with the transformative realizations of their own selves. The sense of accomplishment they acquired in their training was focused on their application of learning in their daily tasks as mayors. One motivating experience that the MLGP participants acquired was their appreciation of their learning on the complexities of health problems (Gremyr et al., 2020; Yang et al., 2023) and the process of living and working purposefully toward a shared vision and one’s values (Leah, 2024). The new arrangements they have implemented in their health system and the changes in the mental model paved the way for better health service delivery and acceptance of the people. As part of the Bridging Leadership framework, health leaders are guided through the co-creation phase (Sørensen et al., 2021).

Virtual learning has become a norm during the pandemic. Some may find adjusting to the new modalities difficult, but others likely adapt to this shift from traditional educational services (Hoofman & Secord, 2021). E-learning emerges as the best answer during the pandemic, as distant activities are necessary to try and stop the virus from spreading (Coman et al., 2020; Ferri et al., 2020; Sahito et al., 2022). The study further delves into the adaptability of the MLGP, particularly in light of the COVID-19 pandemic. The shift from face-to-face to virtual learning showcases the program’s resilience and responsiveness to challenging circumstances (Raghunathan et al., 2022). While acknowledging the challenges and complexities of the virtual realm, the study underscores the importance of continuing education during crises. The adoption of e-learning platforms in the MLGP exemplifies a proactive approach to maintaining educational continuity in uncertain times. However, the study also acknowledges the limitations of virtual learning, suggesting that while online platforms provide independent learning opportunities, they may not fully replace the value of traditional face-to-face interactions. The challenges faced in the transition to virtual learning have potentially affected the overall quality of the MLGP course. Nevertheless, the commitment and dedication of the trainees have driven them to persevere and extract meaningful insights from the program.

The appreciation of the program from the participants can be anchored on Dewey’s principle that education is the process of giving a person the skills necessary to take charge of their world and fulfill their obligations (Thwe & Kalman, 2024). This is a clear indication of how ideas of education and lifelong learning endure over the life of an individual’s existence. Lifelong learning transcends the limits of education and goes beyond traditional education (Benavot et al., 2022). In adult learning, one factor that motivates learners is the teacher or facilitators who capture their attention with practical information and the support they are accorded (Ismail et al., 2016; Loeng, 2020). Applying experiential learning through the interweaving of theory and practice promotes appreciation of learning as used in real-world situations (Amerstorfer & Freiin von Münster-Kistner, 2021; Urhahne & Wijnia, 2023).

According to Goh (2022), lifelong learning in the modern day, where changes can be unforeseen and frequent, as exemplified by the COVID-19 pandemic, is essential to understand how people learn at work throughout their lives. During the pandemic, a virtual platform was introduced in the MLGP. Trainers and trainees adapted the transition of learning strategies. The training course remains the same, but the process they have undergone has changed because of the application of online methods. Module trainings were done virtually; however, the practicum was done face-to-face. The duration of the training became longer than usual due to the restriction of activities.

Online learning is perfect for learning independently during the pandemic, but a valuable educational opportunity is lost (Syaharuddin et al., 2021). This has also affected the quality of the MLGP course. The challenges and complexities of the virtual world have compromised the quality of learning that the trainees gained during the training period. Despite all these, the trainees’ dedication to acquiring what they have learned from the program has motivated them to continue and complete the course.

Understanding health risks is key to making your own healthcare decisions. This enhanced their learning of health and its complexities (NIH News in Health, 2016). Moreover, MLGP enhanced its leadership competence as a local health leader as it gained more knowledge on the Bridging Leadership model. As a model, it promotes multi-stakeholder processes to address societal inequities. Its leading collaborative action is encouraged to bring about social change (Institute of Medicine, 2015).

Transformational learning is a significant input in the study as meaningful learning is attained through conscious ways of learning from experiences. It is a type of learning resulting from a shift in one’s worldview that presents the true meaning of the current realities in the healthcare system (Lin et al., 2020; Simsek, 2012). The training also enables the participants to realize their personal transformation and develop innovations in health services. The type of leadership skills developed will influence the services delivered. The health system occupies a pivotal role in the healthy status of the people because a healthy society is the only key to socio-economic development (Khan et al., 2015). The recognition of leaders was capacitated and guided in developing ways of promoting genuine community participation and empowerment through analysis and description (Mahmoodi et al., 2023; Pilar-Labarda, 2019).

If trained in self-awareness, knowledge acquisition, and skill building, learners will become more capable practitioners. The integration of theory and practice enhances the learning process (Berndtsson et al., 2020; Radovic et al., 2021; Wrenn & Wrenn, 2009). Adult learners prefer an accumulated foundation of life experiences and knowledge, including work-related activities, family responsibilities, and previous education (Broek et al., 2023). Part of their learning need is to connect learning to this knowledge/experience base. Adult learners should draw out participants’ experiences and knowledge relevant to the topic (Assefa, 2021; Peregoy et al., 2023). The MLGP’s impact extends beyond personal transformation to encompass leadership competence and health system improvements. By embracing the Bridging Leadership model, participants enhance their health-related knowledge and gain skills in collaborative action and addressing societal inequities. This comprehensive approach aligns with the intricate nature of health governance, making it crucial for local leaders to continuously understand health risks and complexities (Khan et al., 2015).

In essence, the nurse trainers who served as program implementers have accomplished the primary aim of capacitating the leadership competencies of the LCEs to create changes in their health outcomes. The program’s highlights that enabled the participants to attain higher leadership competencies in health are its curriculum content, which weaved the concepts from the global, national, and local health goals and thrusts. The learners internalized the consistency and interrelatedness of the concepts with the main framework anchored on Bridging Leadership as they shared how they maneuvered in addressing the pandemic demands for active health governance, forcing them to consider such experience as their real-life training ground as health leaders. The learning strategies relevant to the needs of adult learners whose unique personal contexts were addressed through the combination of didactics and practicum strengthened the program’s learning outcomes.

Although there was a disruption in the learning delivery that forced the training to shift from a face-to-face to an online platform, the richness of their learning from the program was still clearly manifested in their narratives of how they utilized Bridging Leadership in their daily challenges. In the end, what should be considered is the learning preference of adult learners, considering that MLGP is a training that is most valued when personal interaction and engagements are established. Evaluating the learned curriculum was realistic as the six pillars of the health care delivery system through their health roadmap served as their learning outcomes indicators in the program. Hence, the findings also showed the need to revisit the MLGP curriculum, review the learning strategies, and consider the utilization of MLGP as a mandatory requirement for new mayors to guide them in their health leadership and governance tasks.

Conclusion

The study highlights the MLGP’s success in fulfilling its core objective of enhancing leadership competencies among LCEs. The curriculum content, interwoven with global, national, and local health goals, exhibits a thoughtful and interconnected approach. The program’s adaptability to the virtual realm during the pandemic showcases its adaptability and commitment to continuing education. MLGP served as a proactive and responsive approach in the health leadership capacitation of mayors. It guided them in their personal realizations that inspired them to apply what they had learned and enabled them to effect experiences of personal to institutional transformation. Transformation can be traced back to mastery of self, shared vision, resiliency, and a solid commitment to service. The MLGP’s impact is evident in personal transformations and the enhancement of health services and governance. The findings offer valuable recommendations, including revisiting the curriculum, considering mandatory participation for new mayors, and optimizing training schedules to accommodate real-world responsibilities. In essence, the MLGP is a testament to the power of tailored leadership training in driving positive change within local health systems and communities. Its successes, adaptability, and potential improvements make it a notable initiative in health leadership development.

Some opportunities can be revisited to improve further the training programs, such as face-to-face training being preferred to online learning; duration and scheduling of the training need to be reviewed to address overlapping of duty versus training time of mayors, such as offering a shortened schedule per week among others; Improving monitoring scheme to promote more open communication, continuation of the nurse-initiated health leadership and governance program as mandatory training for newly-elected mayors/LCEs to address the health of the people better. Further, it is recommended that nurses take an active role in policy development and network with local leaders.

Declaration of Conflicting Interest

The authors declared that there are no conflicts of interest in this study.

Funding Statement

Funding The study received funding assistance from the Philippine Department of Health 7 through Silliman University in the conduct of the study.

Authors’ Contributions

Daisy Palompon: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing Original Draft, Reviewing, Editing, Visualization, Project Administration, Funding Acquisition, and Conducted the Interview. Michele Naranjo: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing Original Draft, Reviewing, Editing, Visualization, Project Administration, Funding Acquisition, and Conducted the Interview. Nelner Omus: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing Original Draft, Reviewing, Editing, Visualization, Project Administration, and Funding Acquisition. Evalyn Abalos: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing Original Draft, Reviewing, Editing, Visualization, Project Administration, and Conducted the Interview. Philip Jerome Flores: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing Original Draft, Reviewing, Editing, Visualization, Project Administration, and Conducted the Interview.

Authors’ Biographies

Prof. Daisy R. Palompon, PhD., DScN, MAN, RN is a Professor at Cebu Normal Univesity, Philippines. She has published in indexed journals and, as a professor, has gained training in advanced research methodologies, accredited with a Bridging Leader Training Certificate. She has been the vice president of research and the former Dean of the College of Nursing.

Michele Naranjo, PhD is a Professor at the Silliman University, Philippines. She has been the Director of the Silliman University Governance Program and Coordinator of the Masters in Public Health program. She received training in health governance and research. She is also accredited with a Bridging Leader Training Certificate.

Evalyn E. Abalos, PhD, MAN, RN is a Professor at the Silliman University, Philippines. She is a qualitative researcher. She was the former Dean of the College of Nursing, Silliman University, Philippines. She was appointed a member of the Technical Committee for Nursing Education, Commission on Higher Education, Philippines (2015-Jan, 2022). She is a Certified Bridging Leadership Trainer of Zuellig Family Foundation.

Nelner Omus, MD is a Section Head of the Department of Health 7, Philippines. She is trained in basic epidemiology, local health leadership, governance, and health programs in the country. She has been working as department head, leading the special health programs of the Department of Health.

Philip Jerome Flores, MSN, RN is a Standards and Academic Partnership Manager at Zuellig Family Foundation, Philippines. He is trained in bridging leadership and learning and development, specializing in health leadership and governance programs.

Data Availability

Data will be made available by the authors upon request.

Declaration of Use of AI in Scientific Writing

The study did not use AI in the development of the paper.