Alarm sounded about lack of healthcare providers

(First of two parts)

For Dr. Bien Nillos, being healthcare provider in an environment with limited resources is a challenge.

As part of Doctors to the Barrios (DTTB) Batch 23, Nillos was assigned as municipal health officer in Candoni, Negros Occidental, from 2007 to 2009, serving around 27,000 people scattered across a wide area which only has a small dilapidated rural health unit.

Though Nillos is accompanied by a public health nurse and nine barangay midwives, enough based on the ratio (one nurse per 20,000 and one midwife per 5,000), the fact that his area is far-flung and in a very mountainous region means it is not that relevant. “I had to ask from the mayor more midwives and nurses to help run our night emergency clinic and, later, our birthing clinic, which operated 24/7. It was a tough negotiation because the town, being a fourth-class municipality, could not simply afford to hire them.”

The work was tough and sometimes frustrating, Nillos said. “Majority of the work is administrative, clinical work comes in second.” Although the Department of Health briefed them on the various health programs, he said that “as fresh graduates, we were never academically prepared to become health managers and leaders.”

Eventually, with Nillos’ urging and local government funds, Candoni’s health unit was renovated and turned into a PhilHealth-accredited birthing clinic with a TB (tuberculosis) DOTS (Direct Observed Therapy Short-term) facility.

DTTB, along with RNHeals and successor Nurse Deployment Program, is one of the DOH’s means to provide more healthworkers in poor and rural areas. Pioneered by then Health Secretary Juan Flavier in 1993, DTTB sends doctors for two years to some of the country’s poorest and most remote barrios and villages, where healthcare needs are at their direst.

Impact on drive for UHC

Last Feb. 11, health advocates led by the Philippine Society of General Internal Medicine (PSGIM) and the Philippine College of Physicians (PCP), sounded the alarm on the extreme shortage of healthcare workforce, and its impact on the country’s drive for universal healthcare.

“Doctors and healthworkers are those who drive forward the healthcare system, yet we only have an average of seven doctors to service every 10,000 Filipinos,” said Health Undersecretary Teodoro Herbosa, basing from the 2014 figure of 70,000 doctors registered with the Professional Regulation Commission. This is far from the ideal ratio of one doctor per 1,000 persons set by the World Health Organization.

However, the DOH puts it even lower to 3.5 doctors for every 10,000 persons.

Even worse, the shortage is more pronounced in rural regions. In areas served mainly by public doctors, the average doctor-to-population ratio declines to three for every 10,000.

For Ang Nars party-list Rep. Leah Paquiz, the crisis is not only on the shortage of healthworkers but also the serious inequity between the rich and the poor in accessing them. “There is a huge discrepancy in the quantity and quality of healthcare services received by the poor and the rich, which at its extreme, is world-class for millionaires while insufficient for the poor and marginalized groups,” she said.

Paquiz added that not many would be encouraged to work in poor and rural areas, since incentives are lacking. “No doctor or healthworker would go to those places, unless [service] is their passion.”

Why the shortage

Health advocates said the current crisis is a complex, systemic problem, whose driving factors include but are not limited to:

1Brain drain. Healthworkers  migrate to more developed countries like the United States as well as European and Middle Eastern countries.

2Maldistribution. The intensity of urbanization and rural-to-urban migration led to a disproportionate concentration of health professionals in urban centers such as Metro Manila.

For instance, the 2012 Health Service Delivery Profile Philippines by the WHO and the DOH said three regions—National Capital Region, Regions 3 and 4-A (which are relatively close to Metro Manila)—have a higher proportion of government healthworkers than more remote areas such as Mindanao.

3Malallocation. Lack of incentives push doctors to overspecialize and seek employment in the private sector while the public health sector remains understaffed.

Nillos said that while those under the DTTB are compensated well, some municipal health officers aren’t, forcing them to look for other sources of income. “They moonlight in other hospitals outside of their towns or  run a private practice after office hours within the town.”

4Lack of priority in the health and state of the healthcare workforce in public policy, despite the devolution of healthcare from central government to local government units (LGUs).

According to Nillos,  LGUs tend to depend on the DTTB, even if many of them have the plantilla positions for their own doctors.

Commendable program

The DTTB gave Nillos the opportunity to make the changes he wanted to see in the system. “I was not a scholar of government but I felt that my education and exposure to varied community work formed in me the passion to be more people-

oriented.”

He added that the program itself is commendable, especially if its idea of encouraging doctors to serve for “a longer and more permanent duration” is achieved.

Nillos lamented that the  DOH nowadays sees the program as “a band-aid solution,” having no concrete plans to ensure the doctors will continue to work in rural areas in the country. “It is like the DOH is resigned to the idea that the DTTB they deploy won’t stay after their two-year stint.”

Still, Nillos hopes that there will be health professionals working for public health, especially doctors. “The choice of doing public health [service] should be the norm, not an alternative.”

Meanwhile, PSGIM president Dr. Antonio Dans said: “The problems of the healthcare workforce are in need of long-term, system-wide solutions, if we are to overcome the nation’s health crisis. Not only do we need to recruit more healthworkers and retain them within our shores, but we also must better regulate the workforce.”