NOTHING CAN be more memorable than the three years I spent working under the Doctor to the Barrios (DTTB) program. In 2007 I was assigned to the municipality of Candoni, Negros Occidental, and, together with the hardworking regional health unit staff and barangay health workers (along with their captains), and supported by the mayor and the municipal council, we instituted reforms to halt what appeared then as an upward trend in maternal and infant deaths.
In the old days, fresh medical graduates like myself volunteered to be deployed to the rural areas. No one in my batch was a scholar, but we felt the same obligation to serve the countryside that is felt by current Pinoy MD scholars who will eventually become rural doctors. (There was a time in the history of the DTTB program that anyone who completed the 2-year tour of duty would receive a master’s degree in public health. It was no longer the case in my time although lately they have revived the program but not anymore with the MPH degree.) There was nothing in return except perhaps the salary that one received from the Department of Health Central Office and the benefits one would expect as a full-time government employee. More importantly, and perhaps incomparably, a rural doctor experienced fulfillment in seeing better health outcomes in the community he/she served.
I feel admiration for old and new DTTBs. Despite the hardships and challenges, most continue to serve, sometimes exceeding what is expected of them. Perhaps most rural doctors begin only as clinicians, expecting themselves to only provide quality medical services. I would like to believe that by the time they are done with their contracts, they have been transformed into health managers. After all, DTTBs, like community physicians, practice a different specialty. DTTBs are social oncologists.
It only follows that the DOH, cognizant of the work these rural doctors do, should ensure that the program is vibrant and responsive—and, eventually, will become a thing of the past. In a devolved setup, the sole responsibility of managing a local health system rests on the local government unit (LGU), in this case the local chief executive. As mandated by law, the LGU must have a municipal health officer (MHO), or must hire one. But many LGUs still don’t have MHOs and are therefore “doctorless” for a variety of reasons. Some are geographically isolated and disadvantaged areas or hard-to-reach towns and islands, which can discourage doctors from travelling there to live and work as MHOs. Many cannot afford the salary of an MHO, so they depend on the health department to send them a doctor whose salary the DOH will pay. Others actually refuse to hire an MHO so that the intended salary for the plantilla position can be saved and distributed as a yearend bonus to the LGU employees.
Thus, in many cases, some municipalities receive DTTBs every two years, making them more dependent on such deployments. Unfortunately, the DOH tolerates this. According to the DOH, more than 500 rural doctors have been deployed since the program’s inception in the 1990s. I wonder: What is their “retention rate”? How many stay in their areas of deployment and continue to serve as municipal health officers?
Some DTTBs leave their areas for different reasons, but at least they stay within the field of public health, either working for the provincial health office, as an MHO in another area, or, as in my case, working for a nongovernment organization. Most, however, proceed to specialty training, run a private practice, or leave the country to find better opportunities. I have always wondered whether part of the design of the DTTB program is a mechanism that will make these doctors stay longer, if not for good, in the areas that they serve.
It has to be acknowledged that some DTTBs leave for reasons that have to do with their working conditions, benefits and security. I know of one doctor who decided to extend his stay in the town where he was deployed but the LGU refused to give him the plantilla position and instead would only consider him a contractual employee. This even after the doctor found ways for the town to receive more than P2 million worth of medical equipment from a foreign NGO he was able to link with.
Last year, many rural doctors cried foul when the DOH would not release their hazard pay. A year earlier, some outgoing DTTBs, airing their rants in the official Facebook page of the group, expressed frustration and dismay over the government’s withholding of their “separation pay.” Allegedly, according to a ruling of the Commission on Audit, the rural doctors and some DOH employees were “overcompensated” in terms of their hazard pay. One ex-DTTB said she was made to “refund” at least P17,000 of the “overpaid” hazard pay. She said she had not received a single centavo for her terminal pay, this after serving in a far-flung island for at least two years. Some rural doctors, especially those deployed in areas like Tawi-Tawi, manifested disappointment when, throughout their 2-year duty, no one from the DOH Central Office or even the regional office came to visit them and look into their working conditions.
The DTTBs do not expect special treatment. They see themselves no better than the other doctors who serve municipalities in similar situations. If the government were 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—they will not leave their posts and shed 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 a mere stopgap measure with no farsighted plans that are 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. Abandoning this responsibility and depending on deployments from the DOH Central Office only prove two things: The idea of devolution, at least on the aspect of health human resources, has failed, and leadership and governance in our LGUs are not yet receptive to health reforms.
As a former rural doctor 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 when out of the barrios, health workers will emerge to continue the legacy of service begun by many trailblazers.
Dr. Bien Eli Nillos graduated from the University of Saint La Salle in Bacolod City. He is now working as a program associate of the Zuellig Family Foundation and a part-time professor of family and community medicine at USLS. For comments, e-mail email@example.com.