The Vacant Frontlines: A Review of the Doctors to the Barrios Program and Gaps In The Philippine Health Human Resource
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The Vacant Frontlines: A Review of the Doctors to the Barrios Program and Gaps In The Philippine Health Human Resource



This is the powerpoint presentation that accompanies a written report submitted as a requirement to my Biological and Sociological Foundations of Health course in my Masters in Health Social Science

This is the powerpoint presentation that accompanies a written report submitted as a requirement to my Biological and Sociological Foundations of Health course in my Masters in Health Social Science



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  • Health Human Resource is defined as “all people engaged in actions whose primary intent is to enhance health”, according to the World Health Organization's World Health Report 2006. This is in fact included as one of the 6 pillars in the health systems framework of the WHO. In the same report, According to the World Health Organization (WHO), it is estimated that there is around a shortage of almost 4.3 million physicians, midwives, nurses and support workers worldwide. The shortage is most severe in 57 of the poorest countries, especially in sub-Saharan Africa. The Philippines is not spared from this. According to reports, the Philippines is one of the top exporters of doctors and nurses. The situation was declared on World Health Day 2006 as a "health workforce crisis" – the result of decades of underinvestment in health worker education, training, wages, working environment and management.Shortages of skilled for health workers are also reported in many specific care areas. For example, there is an estimated shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries. Shortages of skilled birth attendants in many developing countries remain an important barrier to improving maternal health outcomes. Many countries, both developed and developing, report maldistribution of skilled health workers leading to shortages in rural and underserved areas.World Health Organization (2006). The world health report 2006: working together for health, Geneva.Scheffler RM et al. (2011). Human resources for mental health: workforce shortages in low- and middle-income countries. Geneva, World Health Organization.The effect of this “brain drain” is disastrous. Although the nature of the Filipino health-worker exodus is different from that decimating the health systems of sub-Saharan Africa, the effects are similar. It has been estimated that seven out of ten Filipinos die without receiving medical care. “Why let your health personnel leave or encourage medical tourism if seven out of ten are dying without receiving medical attention?” according to Dr. Gene Nisperos of HEAD who was interviewed for the same article.
  • In November of 2012, the Philippine Secretary of Health, Dr. Enrique Ona, made a bold statement. “No more doctorless areas by the end of the year (2012)”. According to an article published in the Philippine Daily Inquirer (November 5, 2012), Ona told reporters that “by the end of this year, all of these so-called doctor-less municipalities will be filled up. Since the program started in 1993, we’ve always had vacancies.” The Secretary shared to them the “secret” to this Herculean task: the deployment of doctors through the doctors to the barrios program.
  • Launched in 1993 by former DOH Secretary Juan Flavier, the Doctors to the Barrios program aims to fill in the gap in health human resource in far-flung areas, specifically those which require a doctor. This gap became very obvious when during the same year, the devolution of health services was implemented through the enactment of the Local Government Code. In the devolved set up, it is the primary role of the local government units to hire and pay their own health workers (municipal health officers, nurses, midwives) and the responsibility of managing the local health system would rest in the Mayor who may or may not be a health professional. One of the approaches of the Department of Health was the establishment of the Doctors to the Barrios program. “The Doctors to the Barrios (DTTB) program was initiated in response to the inability of the LGUs t hire physicians due to low pay scales, remoteness of their location or peace and order problems. Under the DTTB program, the DOH hires the doctors and deploys them to the hardship areas. The concerned LGUs in turn provide the accommodations and supplemental allowances. After their two-yea tour of duty, the deployed doctors either choose to be absorbed in the local bureaucracy or purse further studies with DOH sponsorship.” (Capuno, 2009).   The DTTB program started out as a volunteer program. Doctors who wish to serve in the far-flung and doctorless municipalities are being hired by the Department of Health and deployed to these municipalities under an arrangement that the LGU’s would take care of the deployed DTTBs and would eventually ‘absorb’ them and sustain them as their own LGU-paid doctor. Throughout the program, many variations have been made. There was even a time when the deployed DTTB’s would earn a Masters Degree upon completion of their 2-year contract. Called the Leaders for Health Program – a joint undertaking of the Department of Health (DOH), the Ateneo Graduate School of Business (AGSB), which grants participating physicians a master’s degree in community health care management at the end of the service, and Pfizer Inc., the project not only dispatches volunteer doctors to doctor-less or medically underserved areas. More significantly, it invests in the formation of future health managers by training local government and community leaders in healthcare management.  Prior to their deployment, DTTB’s are trained in the various health programs of the government, including the intricacies of local governance. Among the trainings they received for example is an orientation on Telehealth or Telemedicine. Due to the absence of doctors in rural communities, most patients have to travel long hours in order to seek medical attention from clinical specialists in provincial or city centers.  According to President Benigno S. Aquino III, as reported by DOH Secretary of Health Enrique T. Ona in his speech last March, 30 percent of Filipinos die without seeing a health professional. Telemedicine offers some relief to the country’s health challenges by connecting health workers in poor remote rural communities with specialists in the Philippine General Hospital. With the implementation of the 5-year partnership of DOH and UP under the National Telehealth Service Program  (NTSP), local health professionals from 606 poorest municipalities and regional centers will be connected to clinical specialists via telemedicine.     “Telemedicine has to be practiced professionally, grounded on a strong ethical-legal base; hence the need to train health professionals is a core component of the NTSP,” Dr. Portia Fernandez-Marcelo, NTHC director said  Currently, the DTTBs are also get training from the Development Academy of the Philippines so that they could also get a degree in Master in Public Management Major in Health Systems and Development.  University of the Philippines Manila National Telehealth Center Blog (accessed last August 22, 2013)
  • In the devolved set up, it is the primary duty of the Local Government Units (municipalities and provinces) to ensure that they have enough health workers to provide the basic health care services in their municipality. It is their primary duty to ensure that these health workers are well compensated and are working in a safe and secure environment. Unfortunately, many of the LGU’s are unable to meet the WHO and DOH standards when it comes to health worker to population ratios. According to the standards, at least 1 doctor is needed to serve 20,000 people, 1 nurse for every 20,000 and 1 midwife for every 5,000. For hard-to-reach areas such as the Geographically Isolated and Disadvantaged areas, the ratio may even be lower (1 midwife is to 2,500 to 3,000). There are many reasons why many of these LGUs cannot fill the “vacancies” in their municipalities. Among the many reasons would be the ‘exodus’ of health workers from the country. In an article published in The Lancet, A survey done by HEAD (Health Alliance for Democracy) in 2006, found that 80% of doctors working in the Filipino public sector had applied or intended to apply to work overseas and 90% of municipal health officers were set to leave to work abroad. They were planning to leave not as doctors but as nurses, because it is nurses that the major recruiting countries—the USA, the UK, Ireland, Saudi Arabia, and Singapore—are seeking and luring with promises of pay well above a Filipino public doctor's salary.Officially, the Philippines does not have a nurse shortage. “We are not as hard up as Africa…In absolute numbers we have an oversupply”, says Kenneth Ronquillo, Director of the Health Human Resources Development Bureau of the Philippines' Department of Health.The Philippine Government is even encouraging medical tourism—private sector plastic surgery, renal transplantation, dialysis, and other services more expensive or unavailable in neighboring Asian and Pacific nations.But it is their best and brightest—from specialist doctors and nurses, nursing educators, to even engineers and teachers—who are leaving to work as nurses overseas. And nurse training schools have mushroomed. In the past decade, the number of institutions offering nursing training courses has risen from 170 in the 1990s to 471 providing full nursing courses of which 45 provide abridged courses for doctors wishing to become nurses (Cheng, 2009).Cheng, M.H. (2009). The Philippines’ Health Workers Exodus. The Lancet. Vol. 373, Issue No. 9658.
  • DTTB Program regularly assigns a cohort of physicians to underserved and difficult-to-access municipalities for a period of 2 years. Initially, the deployment was twice or three times a year. During this assignment, the physicians receive good salaries and full benefits as employees of the national DOH. Later on, they have priority access to a Master’s degree or to clinical residency programs. These physicians have the role of Municipal Health Officer (MHO) which includes technical and managerial functions that cover national and local policy and program implementation, financial effectiveness, human resource for health management and development, provision of health services, information management, and infrastructure development and preservation. After completion of the two years, the DTTBs have the choice to remain in their position and to be “absorbed” as MHO of the LGU. However, LGU employees in low-income (5th and 6th class) municipalities are only entitled to part (65-70%) of what they would normally receive from a national agency under the same salary grade. Consequently, DTTBs experience a drop in their total compensation upon absorption. There is a huge challenge therefore in enticing or convincing the DTTB to stay in the area of assignment. According to a study conducted by Leonardia et. al. there are many reasons and motivations for staying and leaving. Ongoing monitoring by the DOH showed that of the 452 DTTBs who took part in the Program between 1993 and 2011, only 81 (18%) chose to remain in their rural posts and to be absorbed by their respective LGUs. According to the DTTB Alumni Database, the numbers of those choosing to be absorbed have in fact declined since 2006 (Leonardia et. al., 2012) In the study, the researchers conducted a survey using a self-administered questionnaire for all current DTTB, and oral interviews by telephone with available former DTTBs. The findings from both methods were analysed separately and later consolidated for the final interpretation. Of the 71 current DTTBs who filled out the self-administered questionnaire, 46 (65%) were female and 25 (35%) male. The mean age of the respondents was 29 years. Twenty-nine (41%) of the respondents had dependents, with an average of 2 dependents each. Eleven (15%) of them were married. Fifty-eight (82.9%) were from urban areas and 45 (63.4%) graduated from medical schools in the NCR.Leonardia, J.A., Prytherch, H., Ronquillo, K., Nodora, R., & Ruppel, A. (2012). Assessment of factors influencing the retention in the Philippine National Rural Physician Deployment Program. BMC Health Services Research.
  • Of the 452 DTTBs who had graduated from the Program, a total of 26 DTTBs took part in the interviews; 14 of whom were male and 12 were female. The mean age of the interviewees was 38 years, with a range of 28 to 64 years. Fifteen of them came from a rural background. Nine of the interviewees were employed as local government health officers, 7 worked under the DOH Central Office, 5 were hospital clinicians, 3 were private practitioners, and 2 worked in other public health agencies. Twelve of the interviewees had chosen to work as municipal health officers for an average of 6 years after completing the DTTB Program, while 6 had re-entered the Program for a further rural deployment but to a different municipality. The remaining 8 had left the rural assignment after finishing the Program (Leonardia et. al., 2012).According to the DTTBs who participated in the study, Former DTTBs derived job satisfaction from applying their training in practice, gaining experience, successfully lobbying for staff benefits and development of their respective health centres, as well as from improvement in local health indicators. Some former DTTBs perceived a decline in DOH support once they were absorbed by their LGU. More than half of them enjoyed opportunities for further education while being on the Program. However, others mentioned that training on legal issues was lacking. Others were dissatisfied with their administrative roles as MHO, had concerns that their clinical skills could become out-dated, or had left to undergo further training in clinical areas.
  • Less than half of these DTTBs agreed that there was good access to essential drugs and resources for health programs. Most disagreed about the availability of other medical supplies and equipment. Moreover, less than half perceived their LGU to be competent. In a devolved set-up, the Mayor or the Local Chief Executive is the over-all health manager. In the study, “establishing a relationship with the Mayor is therefore critical for any municipal health officer. Relations with the municipality mayor, as the MHO’s direct superior, emerged as extremely important in this regard. Former DTTBs who re-entered the Program rather than choosing to be absorbed felt that, as part of the LGU, it would be harder to critique the system and create positive change. Former DTTBs who stayed after the 2 years all stated that support from their respective LGUs was crucial to their decision to stay.” (Leonardia et. al., 2012) In the same study, many of the former DTTBs agreed that problems with living conditions influenced their decision to leave their rural post and those who stayed on reported having good accommodation. Negative issues raised in the interviews included difficulties with reaching and living in storm-prone regions and political violence during election times. One female DTTB even said in the interview that she “did not feel very safe in my area of assignment. Elections were approaching and there were reports of politically-motivated killings.”
  • Former DTTBs considered conditions to have been good but felt better compensation was justified, as they were practically on-call for 24 hours and carried a great deal of responsibility. Some of the former DTTB who were absorbed, described having received inadequate allowances and incentives from the LGU and how they engaged in private enterprise activities as a response. As such possibilities were limited in rural areas, the constrained rural economy ultimately became a reason to leave (Leonardia et. al., 2012).One controversial finding in the study is that DTTBs who joined the Program because of return service enjoyed significantly lower personal satisfaction than those who joined the Program for other reasons. Other less positive perceptions were also linked with mandatory service obligations. Currently, the DTTBs are from a pool of Pinoy.MD scholars unlike the previous batches who were only pure volunteers who were not necessarily scholars of either government or any private entity. The study revealed that Graduates of medical schools from the NCR were less satisfied with DOH support compared to those who graduated from schools in the provinces. The graduates from the NCR also found less flexibility to enjoy their personal time and were less likely to find sufficient options for leisure and entertainment. They were more likely to disagree with the statement that health programs are sufficiently resourced and significantly less satisfied with their compensation.
  • From this study, it is quite clear that for our local government units to retain or attract young doctors to serve in their areas, the LGUs must ensure that 1) there is visible support through 2) adequate and justifiable compensation, 3) a clear career track for the health professional and 4) arrangements for family and relatives. In fact, in relation to the 3rd and 4th motivations, most of the former DTTB who initially remained in their rural post after the Program eventually left. The most frequently cited reasons for this were related to family and career development. Specific family reasons included the need to spend more time with their children, to raise their children in the city or at least in their hometowns, and to be within reach of their aging parents or relatives as the doctor in the family.

The Vacant Frontlines: A Review of the Doctors to the Barrios Program and Gaps In The Philippine Health Human Resource The Vacant Frontlines: A Review of the Doctors to the Barrios Program and Gaps In The Philippine Health Human Resource Presentation Transcript

  • The Vacant Frontlines: A Review of the Doctors to the Barrios and the Gap in the Philippine Health Human Resources Reported by Bien Eli Nillos, MD
  • 84% 16% I find fulfillment in my work as DTTB Agree or Strongly Agree Disagree or Strongly Disagree 75% 25% DOH appreciates my work Agree or Strongly Agree Disagree or Strongly Disagree 58% 42% I am satisfied with the support I receive from the LGU Agree or Strongly Agree Disagree or Strongly Disagree 56% 44% I am satisfied with the support I receive from DOH CO Agree or Strongly Agree Disagree or Strongly Disagree
  • 27% 73% I have the supplies which I need to do my job well and safely Agree or Strongly Agree Disagree or Strongly Disagree 29% 71% My RHU has access to resources for health programs and projects Agree or Strongly Agree Disagree or Strongly Disagree 42% 58% My health center has good access to essential drugs and medications Agree or Strongly Agree Disagree or Strongly Disagree 39% 61% I work with a competent LGU Agree or Strongly Agree Disagree or Strongly Disagree
  • 79% 21% My salary is fair Agree or Strongly Agree Disagree or Strongly Disagree 56% 44% My representation and travel allowances are fair Agree or Strongly Agree Disagree or Strongly Disagree 53.5 23.9 18.3 8.5 4.2 2.81.4 Reasons for Joining the DTTB Return Service Opportunity to serve Interest in Public Health and Com. Med Experience and Adventure Fulfilment and Meaning in Life Master's degree and career opportunities Good salary
  • Top Factors that would make the DTTB stay 1. Local government support 2. Good salary and compensation 3. Family 4. Career advancement opportunities 5. Sustainability of health projects 6. DOH support and re-centralized health human resources 7. Needs of the poor and udnerserved 8. Ease of transportation 9. Passion for public health 10. Personal reasons Leonardia et. al. BMC Health Services Research 2012 12:411
  • “An employee's motivation is a direct result of the sum of interactions with his or her manager.” – Bob Nelson