Filipinas in the Global Care Industry
Nursing the World

Physicians of the people

WHEN RCHARD Lariosa passed the medical board exam in late 2001, he did one thing most new doctors would not even think of. Then 26, Lariosa passed up residency training and applied at the Department of Health (DOH) to be a barrio doctor.

Eight months later, the young doctor was on an outrigger to Tagapul-an, a fifth-class mountainous island town in Western Samar oft-buffeted by the fickle, perilous amihan and habagat, or the northeast and southwest monsoons.

“What’s he doing out there?” Lariosa’s incredulous professors at the Manila Central University asked. They had expected Lariosa, who had finished seventh in his class, to be where most doctors dream of working: in a hospital here or abroad.

But Lariosa’s heart had been set on joining the Doctors to the Barrio (DTTB) program. “Patok si Flavier then. All the stories about his barrio doctor days piqued my interest,” Lariosa says of Senator Juan Flavier, who had launched the program in 1993 when he was health secretary.

Flavier’s “Project 271,” as the DTTB program was first called, aimed to send doctors to 271 fifth- and sixth-class towns that hadn’t had a resident physician in at least 10 years. Flavier had appealed to young medical graduates, especially those from the heavily state-subsidized University of the Philippines, to serve in the countryside.

Since then, more than 400 doctors have been fielded in nearly 300 towns. The program’s success can be gauged partly from the fact that impoverished towns now need only to have been doctorless for two years to convince the national government to assign them a rural health physician. In 2003 and 2004, the DOH shortlisted 33 poor towns in need of one. This year, it is considering sending 25.

The DTTB program has undergone major changes as well. In 2002, it became two-track. Doctors can opt for the “classical” program, where they serve for two years. Or they can go for the Leaders for Health Program, like Lariosa did. This means serving three to four years while earning a master’s degree in community health management from the Ateneo de Manila University.

But interest in the program has flagged. “It’s worrisome,” acknowledges Rodel Nodora, the program’s coordinator at the DOH. He traces the dwindling number of applicants in part to the rising number of doctors who are leaving the practice to train as nurses and work overseas.

In 2002, 85 applied and 40 were accepted, half for the two-year program and the other half for the Leaders program. Last year, only 35 doctors enlisted. But the Leaders track alone had 30 openings and only 18 of the 35 applicants passed the screening. So all of them wound up in the new program. Municipal health officers got the remaining slots. “The pool from which we are getting the doctors is getting smaller,” says Maritona Labajo, assistant director for field operations of the Ateneo program.

ALTHOUGH FLAVIER’S chief target were the graduates of U.P., those from other schools have seemed more eager to serve as barrio doctors. In the program’s first year, only one UP alumnus- Henry Plaza-heeded the call, and since then only a few UP graduates have signed up. Lariosa, who did his internship at the Philippine General Hospital, says all his fellow interns at the UP have gone to the United States.

Nodora, himself an ex-barrio doctor who was assigned in 1999 to San Dionisio town, 110 kilometers northeast of Iloilo City, was from the University of the East medical school. So was his predecessor, Dorie Lynn Balanoba, who was in the first batch of 46 doctors sent to the countryside in 1993.

Balanoba graduated in 1989 but found residency training not quite her cup of tea. She was working part-time in different hospitals in Metro Manila when she saw Flavier on television appealing to doctors to serve in rural areas. She was posted in rebel-infested Jipapad, Eastern Samar’s northernmost town, and then opted to work for the DOH afterward.

Nodora, for his part, was inspired by a speech then Health Undersecretary Jaime Galvez Tan gave at his graduation. Nodora swore he would join the program after passing the medical board exam. “I know it sounds corny, but I wanted to render service,” he says.

Many of the barrio doctors are driven by their desire to help, sense of service, and spirit of nationalism. But Labajo has discovered that early exposure to the community during medical training, instead of a lopsided emphasis on clinical practice, whets a doctor’s desire to work among the needy. The UP College of Health Sciences in Palo, Leyte, for example, trains doctors in community-based healthcare. The Ateneo de Zamboanga requires medical students to render internship in the community. The Pamantasan ng Lungsod ng Manila exposes interns and residents to urban-poor neighborhoods. All of these schools have produced volunteers for the Doctors To The Barrio program.

But medical students trained mostly in sophisticated technology and equipment in a hospital setting get a rude awakening when they work in a small town or province. “They tell themselves, ‘I’m not trained for this. I won’t put to waste what I learned,”’ Labajo says.

Community work wasn’t part of Lariosa’s training at MCU. But being a born-again Christian, he was active in the Campus Crusade for Christ and joined its medical missions. He worked in the city’s slums and among tribal people in Mindanao.

When he decided to become a barrio doctor, his mother had no objections. (His father died before he finished medical school.) A native of the Malig Plain of Quirino, Isabela, Lariosa had hoped to be assigned to the isolated coastal towns of his province or to the Cordilleras. But the Leaders for Health Program was then focusing on Samar- Leyte and Surigao del Norte.

Nodora’s family, however, resisted letting him go to Iloilo. “It was nervewracking,” he recalls. “The family was taken by surprise. They had expected me to go to residency training. You know, white-collar, hospital setting.”

WHEN SHE chose to serve in Jipapad in 1993, Balanoba brought along her two-year-old son and her husband, a pastor who gave up his post in the city and continued his ministry among the rural folk.

Because nobody else at the DOH’s central or regional office had ventured there before her, Balanoba had to discover for herself what Jipapad was like. She found a poor mountainous town of 5,600 people, mostly coconut farmers. Eight barangays made up the town, four of them in far-flung areas accessible only by boat or a five-hour trek.

From Tacloban, Balanoba traveled by land for four hours to Borongan, Eastern Samar’s capital. Then came another four hours by land to Oras town, from which. Jipapad was still some eight hours away upstream by passenger pumpboat. Later, Balanoba would sometimes log 12 hours on a cargo pumpboat, along with canned goods intended for the town. The downstream trip from Jipapad to Oras lasted a quicker five hours. “You had copra and abaca as companions,” she says. There was only one trip a day.

A generator owned by an Italian priest supplied the town’s electricity from six to 10 p.m. At first, the doctor stayed at the town treasurer’s house, where drinking water was available. But when people hesitated to consult her, thinking she was allied with the politician, she moved to “neutral ground.” Drinking water then became a problem.

There was no market in Jipapad. “You’d have to be on the lookout for itinerant vendors,” says Balanoba. People didn’t farm much because, they reasoned, the place was often flooded. Landowners, in turn, didn’t let others cultivate their land because they were afraid that New People’s Army rebels would steal the produce.

Lariosa’s trip from Tacloban to Tagapul-an was a lot shorter, but still not quite pleasant. The road from Catlabogan to Calbayog is potholed while the banca ride from the Calbayog pier to the island municipality of 8,000 people takes some six hours because of numerous stops to unload goods.

Like Jipapad, Tagapul-an is mountainous, with only one barangay adjacent to the poblacion linked by cemented road. One could walk to the rest of the barangays, but it’s faster to go by banca, Yet even the most skilled boatman gets intimidated by the waves whipped up by the gusty monsoon winds. “These are not Pacific waves, you can’t ride them,” says Lariosa. “The current is uneven and multidirectional.” And, the doctor found out, one side of the island could be calm even as angry waves slammed the other.

Doctors assigned to Surigao del Norte’s many island municipalities under the Leaders for Health program have their share of horror stories to tell. “They travel by boat and run into giant waves as tall as a church,” says Labajo. “And they feel they’re about to die.”

THE WRATH of the elements is not the only threat. The river Balanoba used to travel to and from Jipapad has a history of encounters between NPA rebels and soldiers. On one occasion, a midwife was wounded when rebels attacked the soldiers who were with her on the pumpboat. Many encounters also took place on land. Balanoba counts herself lucky that she was never caught in the crossfire.

Not Phoebe de la Cruz, a doctor assigned to San Jose de Buan, an insurgent stronghold east of Calbayog in Samar. The military was accompanying de la Cruz on a medical mission when rebels attacked their convoy. The spirited doktora got off the vehicle to identify herself. The rebels then tried to take her with them but she stood her ground, insisting that she must treat the wounded.

Generally, the rebels consider the barrio doctors off limits. That’s why they and other rural health workers are often the only government presence in some towns where Muslim or communist rebels operate. Bound by their Hippocratic oath, the doctors treat the sick and wounded among the rebels, as well as provide them the medicines and supplies they need.

Some barrio doctors are not bothered by the remoteness of their assignments or the risks. The challenge, they say, is trying to change people’s ways and thinking. They have to deal with a dole-out mentality that has people expecting free medicine even when they’re well. Nodora also says, “They don’t see a doctor unless their illness is really severe. They believe that seeing a doctor and buying medicines are expensive. They don’t know that the doctor at the RHU (rural health unit) is there to help.”

Nearly all barrio doctors engage in health education soon after they arrive. In Jipapad, people descended on Balanoba as though an epidemic had broken out. It was their first time to be diagnosed. But they balked when she asked them to clean their wounds with soap and water. “They thought they’d get tetanus that way,” Balanoba says.

She found people walking barefoot, one reason for the high incidence of parasitism. Many had also turned the river into a public toilet, giving rise to hygiene problems.

Balanoba involved village officials in a house-to-house campaign to have children immunized. They launched a contest on the cleanest barangay, emphasizing that every house must have a toilet bowl. Not all residents faithfully complied, as one councilor found out. In one home, he fell off the toilet bowl that toppled as he was using it. “It turned out to be just for display,” says Balanoba.

BUT THE biggest problems the barrio doctors have to tackle are the low priority local governments give to health, the trapo politics, and the corruption that is often intertwined with it.

Labajo says local governments allocate little money for the rural health units, especially those that have been doctorless for some time. The budget for each unit could be as small as P50,000 a year. Yet the same town may have allotted P500,000 to P1 million to purchase medicines as part of the mayor’s discretionary fund.

The Jipapad that greeted Balanoba had no health center at all. The RHU used to be located at a small clinic the Italian priest had put up in the town, but was closed when the clergyman had a spat with the RHU staff. Balanoba converted an old, termite-infested multipurpose building with a leaking roof into a health center.

Lariosa’s RHU occupied a tiny, rundown room at the Sangguniang Kabataan building. The windows were falling off and the roof leaked. The first thing Lariosa did was to ask the mayor to repair the place while awaiting a P3-million new RHU the Japanese government had pledged to build. When Lariosa was pulled out of Tagapul-an late last year, the mayor had yet to act on his request, and Japan had not released the promised funds. “We tried to patch the roof, but Vulcaseal didn’t work well,” Lariosa says.

The solar-powered vaccine refrigerator at Lariosa’s RHU also kept breaking down, causing the vaccines to spoil. Exasperated, Lariosa stored them in a canteen operator’s fridge. “It wasn’t ideal because you shouldn’t be opening the ref as much as possible,” he says. “But I didn’t have a choice.”

The barrio doctors draw their pay from the national government. They enjoy a basic monthly salary of at least P20,824, as well as representation and travel allowances. Other benefits are provided under the Magna Carta for Public Health Workers: hazard pay, laundry allowance, subsistence allowance, and even remote allowance or medico-legal allowance depending on their assignment or task. In all, Labajo estimates, a barrio doctor could gross P30.000 to P32,000 a month.

The RHU staff-nurses, midwives, dentists, barangay health workers, and sanitation inspectors-are likewise entitled to these benefits. But many local governments have not fully implemented the Magna Carta, and barrio doctors often end up fighting for their staff’s benefits. In 1996, Balanoba led her RHU staff in going on a two-week sick leave to force the town treasurer to release the benefits due them.

“That’s the hardest part, dealing with local government officials,” says Lariosa. “They have a different perception about health. Primary health care, preventive health care is not addressed. The community’s needs are not addressed.”

“Politicians are really difficult to work with,” agrees Labajo. “The program can be sabotaged by the mere fact that the mayor does not cooperate.”

PASCUALITO CONCEPCION, an Ateneo de Zamboanga alumnus assigned to Talusan, Zamboanga Sibugay in 2002, has shown what a barrio doctor can do when the local government is health-friendly. For that he was given the Grand Distinction Award in the DOH’s annual recognition of outstanding doctors to the barrio.

With help from the mayor and the town council, Concepcion transformed a dusty warehouse-like RHU into an air-conditioned health center. He got Philhealth to accredit his RHU and enrolled 500 poor families in the program in 2002 alone. The RHU’s pharmacy sells paracetamol for as low as 50 centavos each.

Concepcion convinced local officials to increase the RHU’s share from the development fund (from P200,000 in 2002 to P1.2 million in 2003) and even persuaded them to let it keep the Philhealth payments for the upkeep of the health center and its programs. The local government has since created more positions for the RHU and has been fully implementing the Magna Carta for Public Health Workers.

Concepcion is the envy of barrio doctors like Lariosa, who was pulled out from Tagapul-an last December after the Leaders for Health Program concluded that his mayor wasn’t very concerned about health. Two other doctors in Samar were withdrawn for the same reason.

Lariosa’s relationship with the mayor had been strained. The doctor objected to the removal of trained health workers and their replacement by untrained supporters of the mayor. The mayor was in turn displeased when Lariosa changed caterers for a health- training course because the food served by the first caterer caused the trainees to have diarrhea. Apparently, the former caterer was the mayor’s ally.

When he arrived in Tagapul-an, Lariosa was surprised to find that the medicines for the town were being kept at the mayor’s office. “When you gave a prescription to a patient not of the same political color as the mayor, he’d be told by the people at the mayor’s office there was no medicine even when they were still a lot. Color coding,” the doctor says.

The mayor was later persuaded to turn over all the stocks to the RHU, after being assured the people would know the medicines came from him. But months before the May 2004 elections, newly delivered medicines again wound up with the mayor. He agreed to let go of half the medicines only after Lariosa had paid him a visit.

Things came to a head when the mayor’s nephew sought treatment at the RHU and found it empty. The doctor and his staff were out implementing a DOH campaign and the staff assigned to man the health center had failed to report to work. The angry mayor nailed the RHU shut. Recounts Lariosa: “The following morning I told the mayor what he did was unfair. We weren’t out having fun.”

Lariosa was the second barrio doctor to become a casualty of local politics in Tagapul-an. Danilo Reynes, the town’s first physician after a doctorless decade, belonged to the DTTB program’s first batch. He stayed there for four years, but left because incumbent officials perceived him to be allied with their political opponents.

IT MAY take some time before DOH sends another barrio doctor to Tagapul-an. The town would first have to convince the national government that its local officials and community leaders are cooperative enough to deserve another barrio doctor.

There are no hard data on where DTTB program graduates go after their barrio stints. But Nodora estimates that a third stay on as municipal health officers. This means great sacrifice, says Labajo, since their salaries and benefits could be just more than half what DOH used to give them.

Balanoba reckons another 30 percent take up residency training. Nodora himself became a resident at the state-run East Avenue Medical Center. He left after three months, frustrated by the hospital’s and his own helplessness to help indigent patients, plus the power play in the residency program.

Like some DTTB graduates, Balanoba and Nodora eventually ended up at the DOH central office. Others are now with the DOH regional office. Henry Plaza is currently DOH’s assistant regional director at Caraga.

Some barrio doctors “moonlight” after their DTTB stint. Others go into private practice. There are those who go overseas and to nursing school. Of the 25 doctors in Nodora’s batch, seven are in hospitals, three are with the DOH, five are moonlighting, four are in the US, and two are in nursing school.

Balanoba notes, however, that a handful of ex-barrio doctors who go overseas wind up in public health, still working in rural areas or hardship posts in Fiji, Indonesia, and Africa. A few join Medicins Sans Frontieres (Doctors without Borders). “Your experience as a doctor to the barrio has a lasting influence on you,” Balanoba says.

Lariosa, meanwhile, has been reassigned to Uyugan, Batanes. He has thought about residency training in internal medicine or surgery after finishing the Leaders program. “But I’m having second thoughts,” he says. “The work of a public health practitioner is challenging.”

Lariosa’s younger sister has just graduated from medical school and plans to go straight to residency training. “But I’ll try to expose her to the Doctors to the Barrio program when she visits me in Batanes in the summer,” says Lariosa. “There are bits of ugliness, but I think my type of work is beautiful.”