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November 23, 2012

Doctor OF the Barrios

(UPDATE: This article appeared in the Philippine Daily Inquirer on Dec. 1, 2012. Here is the link to the online version of the commentary published by PDI. Thank you PDI for allowing my commentary to be published.)

Nothing could be more memorable than the 3 years I spent working as a Doctor to the Barrios. I was assigned to the municipality of Candoni, Negros Occidental in 2007 and together with the hardworking RHU staff and barangay health workers and their barangay captains, with the support of the Mayor and the entire municipal council, reforms have been made in order to halt what appeared to be at that time an increasing trend in maternal deaths and infant deaths. While I am no longer a Doctor to the Barrio (I currently work for a big NGO based in Manila), I still feel the same admiration for current Doctors to the Barrios as well as those who came before us. In the old days, fresh-grad doctors, like I was, would volunteer to become a Doctor to the Barrio (DTTB). In my batch, none of us were scholars but we felt the same burden of obligation to serve the countryside as felt by current PinoyMD scholars who eventually would become DTTB’s. There was a time in the history of the DTTB program that those who finish the 2-year tour of duty would also receive a Masters Degree in Public Health. During my time, it was no longer the case although lately they returned the program but not anymore as an MPH degree. There was nothing in return except perhaps the salary that you get from DOH Central Office and the other benefits you would expect as a full-time government employee. More importantly, and perhaps incomparably, the fulfilment a DTTB receives is to see better health outcomes in the community he or she serves.

I feel admiration for the old and new DTTBs for despite the hardships and challenges of the work, most DTTBs still continue to serve, sometimes exceeding what is expected of them. Perhaps from the start, most DTTBs began only as clinicians, expecting themselves to only provide quality medical services. I would like to believe that by the time these DTTBs are done with their contracts, they have been transformed to being health managers. After all, DTTBs, like any community physician, practice a different kind of specialty. DTTBs are social oncologists.

Perhaps it only follows that the DOH, cognizant of the work these DTTBs do, should ensure that the DTTB program remains vibrant, responsive and eventually a thing of the past. In a devolved health system, the sole responsibility of managing local health systems rests in the Local Government Unit, in this case the Local Chief Executive. As mandated by law, the LGU must have a Municipal Health Officer and must ensure ways to hire one. It is therefore a mandatory position. However, many LGUs still don’t have MHO’s and are therefore “doctorless” for a variety of reasons. Some LGU’s are GIDAs or Geographically Isolated and Disadvantaged Areas or hard-to-reach towns and islands which can discourage doctors from travelling there to reside, apply and work there as an MHO. Many LGU’s cannot afford to pay for the salary of an MHO so they would depend on the DOH to send them a DTTB since it is the DOH who pays for the DTTB’s salary. Many LGU’s actually refuse to hire an MHO and would also depend on the DTTB sent by DOH because by not hiring an MHO the intended salary for the plantilla position can be saved by the LGU and distributed as a year-end bonus of the rest of the LGU employees. Thus, in most cases, what happens is that some municipalities would receive DTTBs every 2 years from DOH making them more dependent on the deployment of a DTTB. This is unfortunately tolerated as well by the DOH since they continue deploying DTTBs to these areas. According to the DOH, more than 500 DTTBs have been deployed since its inception in the 1990’s. I wonder how much is the “retention rate” of the DTTB’s? How many DTTBs stay in their areas of deployment and continue to serve as municipal health officers? Some DTTBs leave the area for a variety of reasons but at least they still stayed within the field of public health, either working for DOH for the Provincial Health Office or perhaps working as an MHO in another municipality, or in my case, working for an NGO. Majority however would proceed to specialty training, run a private practice or even leave the country to find better opportunities. I have always wondered whether part of the design of the DTTB Program is the mechanism that would make these DTTB’s stay longer, if not for good, in the areas that they serve.

It has to be acknowledged that some reasons why DTTBs leave have something to do with their working conditions, benefits and security. I know of one DTTB who decided to extend his stay in the town where he was deployed but the LGU would refuse to give him the plantilla position and instead would only consider him as a contractual employee. This even after the DTTB found ways for the town to receive more than 2 million pesos worth of medical equipments from a foreign NGO he was able to link with. Last year, many DTTBs cried foul when the DOH would not release their hazard pays. A year earlier, some outgoing DTTBs, writing their rants in the official Facebook page of the group, expressed frustration and dismay when the government withheld their “separation pays”. Allegedly, according to a ruling of the COA, the rural doctors and some employees of DOH were “overcompensated” with their hazard pays. One former DTTB even said that she was made to even “refund” at least 17,000 pesos for the “overpaid” hazard pay. According to her, she did not receive a single centavo for her terminal pay, this after living and serving in a far-flung island for at least 2 years. Some DTTB’s, especially those deployed in areas like Tawi-Tawi, would manifest disappointment when throughout their 2 years none from DOH Central Office or even Regional Office (CHD) would come to visit them and monitor their working conditions.

The DTTBs do not expect any special treatment. After all, they see themselves no better than the non-DTTBs who also serve municipalities in similar situations. Perhaps, if the government is really serious in instituting health reforms, it must shift perspectives and start investing in its health workers. If our government seriously takes care of its health workers – Doctors, Nurses, Midwives – none of them will leave post and abandon their passion for service. The key to better health outcomes is designing a program that is health-worker-centric. Ensuring better working conditions, protection from partisan politics, guaranteed Magna Carta Benefits and appropriate and timely salaries are just a few ways the government can ensure a continuous stream of mainstay health workers in the countryside. The current perspective, I feel, is that the DTTB program is just seen as a stop-gap measure with no farsighted plans that are more sustained and enduring.

The government must, besides deploying DTTBs, strengthen the capacity of the LGUs to hire enough health workers. After all, it is the primary responsibility of the LGUs to provide health care services through competent health care workers. By abandoning this responsibility and depending on deployments from the Central office, it only proves two things: the idea of devolution, at least on the aspect of health human resources, has failed or the leadership and governance in our LGUs are not yet receptive to health reforms.

As a former Doctor to the Barrios whose passion for public health, despite the frustrations, has never waned, I long to see the day when there will no longer be Doctors “to” the Barrios. I long to see the day that out of the barrios health workers shall emerge to continue the legacy of service began by many trailblazers in the past.

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4 violent reactions. React Here.:

algene may cutamora said...

It's really good to know na marami pang tao na tulad mo. Keep on sharing your blessings to everyone. :)

Special Education Philippines said...

My reaction while reading this article has gone to different levels and stages. Admiration for our DTTB. Frustration for the poor treatment they are receiving after all the sacrifices they do for the local community. And lastly, dismay for the misplaced priority we Filipinos have to the concept of service. 
My disappointment is beyond words but instead of becoming jaded, I choose to keep moving forward to highlight what is good in this country. I read a poster somewhere of an African tribe where when a tribe member does something bad part of his rehabilitation is that for two days he will stand in front of a group of fellow tribesmen who will remind him of everything he has done good. 

Sometimes I think the government has grown numb and no matter how much we holler, our calls are unheard by deaf officials. And so to keep my faith in this country and its people, I created Special Education Philippines website as reminder that there is still good left and that even if its just a flicker of light amongst thousands of websites out there it's alive and will stay like that as long as somebody believes in the goodness of Filipino people. 

Jerwel De Perio said...

It's heart warming that there are still doctors who would really want to help people in a barrio. kudos!

Jeffrey Rilles said...

KUdos to all Doktor to the Barrio. U guys choose to serve our less fortunate co citizenry while u have the choice to work in comfortable and well established hospitals in the metro/cities

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