Unsung heroes: barangay health workers

ALABAT ISLAND, Quezon — Doing fieldwork here in Alabat island — an hour-long boat ride away from mainland Luzon — reminds of me of a long-running observation I’ve made in various parts of the country: barangay health workers (BHWs) are the unsung heroes of our healthcare system.

Consider Matilde “Nanay Didit” Valderama, 76, who has served as a BHW for 35 years in the municipality of Perez, Quezon. Throughout this period, her daily tasks have included implementing nutrition programs, monitoring children’s weights and heights, assisting the midwife — and even accompanying researchers like me: essentially anything health-related. More than once, she had had to escort a patient to Lucena for emergency treatment.

For all these labors, Nanay Didit only gets a  monthly allowance of P1,150 from the local government, being officially classified as a “volunteer.” Usually, the allowances are at the discretion of the barangay captain, who also has the power to appoint (or fire) them.

This brings us to one of the challenges BHWs face: They are often dragged into local politics, recruited to participate in political activities (e.g., medical missions) and expected to support the party their barangay captain belongs to. If a rival candidate wins, they stand the risk of being fired altogether, their years of experience notwithstanding.

“BHWs are the frontliners,” Dr. Terence Kua, municipal health officer of Medina, Misamis Oriental, tells me. “Without them, primary care will fall apart.”

Here in Perez, midwife Grace Manaog likewise praises the BHWs in their town: When she attended an early morning childbirth, the person accompanying the expectant mother was Nanay Didit.

This appreciation, however, is rarely felt beyond the community; because of the devolution of healthcare, the Department of Health thinks of BHWs as a concern of LGUs and have offered little guidance about them. While there has been rightful attention on the lack of doctors and nurses in underserved areas, BHWs have largely been missing in the discourses and even policy briefs on health human resources.

BHWs have likewise been largely overlooked as a research topic, despite studies elsewhere that associate community health workers with better health outcomes. Why are almost all BHWs women, and how does this gendered nature shape their practice? What factors make BHWs stay on, and what challenges they face? These are questions we should explore as part of health systems research.

As the DOH rethinks human resources for health as part of Universal Health Care, we will do well to recognize the role that BHWs play — and tap into their full potential. Let me offer some recommendations:

First, we should reward BHWs for their service. Increasing and standardizing their allowances would be great, but even just giving them merit-based bonuses — like a loyalty cash award for every five years in service — would mean a lot for BHWs who feel not just underpaid but also underappreciated.

Second, we should insulate them from local politics. Mechanisms that will make it harder for barangay captains to fire BHWs who are otherwise doing well, and laws that prevent BHWs from participating in political activities, will go a long way in maintaining the stability of healthcare at the barangay level.

Third, we need to enhance their capacity by allowing them to take the lead in vital programs like  mental health screening and community-based drug rehabilitation. Alongside the possibility for BHWs to “pursue further training as midwives, pharmacists, nurse or doctors,” this initiative is actually mandated by Republic Act No. 7883, but over 20 years after this law was passed, it still requires proper implementation.

Finally, we ought to learn from the BHWs. If we think of the health system as a “vertical” system, we would look at BHWs as being at the bottom. But if we think of it as a network of care, then BHWs are actually its heart—and thus are experts in their own right.

Surely, BHWs like Nanay Didit know a thing or two about communicating with patients and winning their trust—if only we would bother to ask and listen.

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