If the Philippines hopes to adopt the Cuban health system, the first thing it needs to address is the doctor shortage. The present doctor-population ratio of 1:33,000 is a far cry from the 1:1,000 in Cuba, majority of whom are primary care physicians.

The Philippine Medical Association said there are 130,000 licensed physicians in the country, but only 70,000 are active in the profession. A good number have actually turned to nursing and work as nurses overseas.

It is not uncommon for residents in far-flung villages of the Philippines to never have seen a doctor from birth to death. Home births are the still the norm in rural areas. And since people are used to not having a doctor in their community, consulting for an ailment is usually put off until the conditions get worse and treatment comes too late.

For now, government’s goal is to provide one doctor per barangay [village] to improve on the current situation where one doctor serves a municipality, usually made up of 20 to 30 barangays.

It is also necessary to improve on the 2,300 new doctors produced annually. Presently, there are only 30 to 40 percent of medical graduates who pass the board exams, way below the 98 percent in Cuba, according to Health Secretary Paulyn Ubial.

Meanwhile, what factors contribute to the lack of doctors to serve majority of the Philippine population?

Offsetting medical school expenses

Compensation is a big issue among doctors. And understandably so. There are only five public medical schools in the country, and tuition is merely subsidised, not fully shouldered by the government (unlike in Cuba where medical education is free). Private medical schools cost at least three times as much as government-funded institutions.

The costs of becoming a doctor are challenging enough, and wanting to earn back what was spent during years of study and training is logical. Even then, it takes quite a bit of time for a doctor to start building his career between medical school and further studies to specialise.

This is also what pushes many medical graduates to seek further training abroad and eventually practice there, leaving a dearth in medical professionals on the domestic front, particularly in the area of public health.

Commensurate salary

Salary is also a vital factor why many areas around the archipelago have no physicians to serve communities. The shortage of government doctors means those who are assigned these posts serve patients far and wide.

Dr. Kester Maniaul, a native of Cagayan de Oro in southern Philippines, recounted managing 12 villages during his 5-year stint as community doctor. While he was assisted by nurses and other community healthcare workers, Dr. Maniaul was required to regularly go around all 12 areas to attend to patients.

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It was not a total hardship for him to be assigned there because he was from the province. But for others who are tapped under the Health department’s doctor deployment programme, a rural assignment can be quite difficult, especially given the expanse of areas that need medical services.

Dr. Francis Paul Jagolino, who worked a year at a provincial hospital in Kalinga province, northern Philippines, said he was responsible for communities within a 200 kilometer radius from the health facility he was assigned to.

While most doctors don’t actually look at medicine as a career to enrich themselves, receiving a just and fair compensation commensurate to the work rendered is commonly aspired for.

Comfortable, not rich

According to Dr. Malou Palmero, a paediatric dermatologist, medical professionals also have to be practical especially when they have a family to support and children to send to school. It is not necessarily because they are looking to be rich but rather, want to live a comfortable life.

On the other hand, salaries are never enough for many Filipino doctors because the country is profit-oriented, according to Marikina City Vice Mayor Jose Fabian Cadiz, who is a doctor by profession.

He himself admitted to taking up medicine because he wanted to be rich. Skills, perseverance and hard work made him realise that dream, after he ended up establishing four clinics in the city where he is now a public official.

The Philippine health system, Dr. Cadiz pointed out, is very privatised. So the expectations are doctors should be making a lot of money. In fact, it is this mentality that pervades in provinces so people think all doctors are, or should be, wealthy.

Salary realities

Unfortunately, that is not always the case for physicians either working in public or private hospitals. Medical staff [residents] employed by hospitals are not necessarily paid big salaries. Government doctors are fighting to get more than the 30,000 peso average salary they receive.

While doctors in public hospitals may earn more than their counterparts in private health institutions, they do take on more work. On the other hand, if a physician serves as a consultant at a private hospital and holds clinic there regularly, he charges on a per patient basis and can dictate how much he earns.

The inequity in the setup is a government doctor may be paid higher than private medical staff but his salary will not increase even if he sees 50 or more patients in a day.

A medical consultant, meanwhile, can hold clinic 3 to 4 hours a day, three times a week and make so much more, especially if he is in-demand as a physician or specialist. He also has the option of holding clinic in multiple locations further widening his patient base.

Concentrated medical pool

Another reason contributing to the doctor shortage is the concentration of the medical pool. According to Dr. Rosalind Vianzon, chief of the Department of Health’s Intensified Disease Prevention and Control Division, the pool of physicians is much too concentrated in urban areas.

Most physicians want to set up practice in big cities, not knowing the need and market in the countryside who need healthcare services just as much.

In fact, former Health chief Dr. Enrique Ona refused to call it a shortage of doctors saying there was only a maldistribution. Majority of physicians, he noted, were based in the National Capital Region and preferred to go into private practice instead of community health.

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Dr. Palmero added that many doctors who have in fact taken the risk of setting up practice in the provinces are doing well and thriving. However, these are still in urban centres and not rural areas where they are most needed.

Devolved service

Another stumbling block that leads to a lack of doctors assigned in communities is the 1991 Local Government Code. It is a law that mandates the devolution of services, including health, to local government units such as provinces, cities and municipalities.

Dr. Vianzon explained that DOH programmes deploying doctors and other healthcare professionals to areas in need of them are usually short-lived - typically between two to three years.

“The supposed intention is although short-lived, whoever is deployed in those areas must eventually be absorbed by the local governments [where they serve] if they see it as a need,” she explained.

However, the problem is usually LGUs saying they can’t afford to absorb the physicians, yet. “What is puzzling,” she added, “is if they see it as a need, why they don’t do anything to take in these healthcare professionals.”

For those absorbed by LGUs, but not given permanent or plantilla positions, they sometimes choose to not continue for lack of security of tenure.

Salary cap

Finally, there is the matter of a salary cap for medical personnel under the DOH deployment programmes. For 2017, close to 7,000 doctors, nurses and dentists under the department’s grassroots manpower deployment programme dubbed Rural Health Practice Program (RHPP) will lose their jobs.

The reduction in number of personnel is because of a salary ceiling imposed on the department given the implementation of the next step of the Salary Standardization Law.

DOH augments the number of healthcare staff in impoverished towns around the country through the RHPP. But with the next round of salary increases, there is a need to let go of thousands so as not to exceed the budget for salaries of the department.

The positions to be cut account for 2 billion pesos in salaries and wages that would have to be included in the DOH budget.

Health officials and policy-makers remain hopeful the matter of doctor shortage will eventually be addressed. In the meantime, the country will have to make do with what is available and deliver health care services the best way it can. MIMS



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