Rural Round-up : November 13 - Aileen Espina writes

EDITOR’S NOTE: the hometown of Aileen Espina about which she writes below, Tacloban, was damaged severely by Typhoon Haiyan on Friday November 8. The WONCA family is overjoyed to hear that Aileen is safe and has evacuated her children to Manila. Aileen has returned to Tacloban to work in the devastation. Our thoughts and prayers are with Aileen, her family and all our Filipino colleagues at this time. We will advise about ways to support our colleagues through financial assistance as they become available. The school that was visited by the WONCA Working Party on Rural Health in 2011 was devastated so rebuilding will be needed.

I am … WOMAN
I am … RURAL

MABUHAY! My name is Aileen Espina and I am a qualified family physician currently working as a hospital administrator in the largest government tertiary hospital in our region. I have a wide range of interests which include medical education and training, research and academic work but I place special emphasis on gender issues in medical practice and the development of rural practice in the country. I am currently a member of both the WONCA Working Parties on Rural Practice and Women in Family Medicine.

About the Philippines

My country, the Philippines is an archipelago composed of 7,100 islands. It has been divided into fifteen (15) geo-political regions and I live in the region known as the Eastern Visayas Region (i.e. Region 8). Our region lies on the eastern part of the country and it forms the mid-eastern fringe of the archipelago. It serves as the geographical backbone of the country linking the two major islands of Luzon and Mindanao. Due to its strategic location, the region figures prominently in Philippines history being twice the main port of entry for the western powers– first by the explorer Ferdinand Magellan, and then more recently, by General Douglas McArthur.

My region consists of six provinces, twelve congressional districts, six cities, 139 municipalities and 4390 barangays. The smallest political unit is the barangay and each barangay has a Barangay Health Station (BHS), which caters to the health needs of the population at the grassroots level. The Barangay Health Station to population ratio in our region is 1:4581 which is far below the WHO ideal ratio of 1:2000. Barangay Health Workers usually man the BHS with the Nurses and Midwives coming in only at scheduled time during a month to implement some public health programs like immunizations and family planning.

Barangay Health Stations are under the supervision and control of Rural Health Units or Health Center and at present, the Health Center to population ratio in the region is at 1:24,099. The Rural Health Units are currently undergoing reorganization through the Health Facilities Enhancement Program (HFEP) of the Department of Health. The HFEP program aims to improve the infrastructure of the units as well as building capacity and restructuring the human resources within the health workforce.

Rural physicians

It is the goal of the Health Department to provide physicians in all doctor-less municipalities through the Doctors to the Barrios Program. Presently, the region has 151 municipal health officers (MHO) with a gender split of 97 males and 54 female. Their ages vary from newly licensed physicians to those nearing the retirement age (65yrs). The young physicians usually stay in rural areas for a maximum of five years and the main reason for leaving is for professional growth. Sadly being a rural physician in my country is seen as a professional dead end, which impacts on recruitment and retention across the rural areas, which make up most of the Philippines. It was therefore important that we developed strategic plans to tackle rural physician shortages.

The University of the Philippines (UP) School for Health Sciences, which offers a ‘ladderrized’ medical curriculum has made significant gains in this direction. The school was conceptualized by its founders as the answer to the brain drain that the country was experiencing in the 1970s. It aimed to recruit students from underserved communities with the goal of producing health care workers who would go home and serve their “own”. Since the school is based in Palo, Leyte, the majority of its graduates are natives of our region and more than 95% are still serving in rural communities to date. This feat is worth studying and emulating elsewhere around the world. We do have some concern about a developing trend noted among recent graduates who are going into the so-called major specialties of Obstetrics and Gynaecology, Paediatrics, Internal Medicine and Surgery. In casual conversations with new graduates who pursued residency training in our hospital where I work as Chief of the Medical Division, they expressed their need for professional growth and recognition as one of the reasons why they decided to go into further specialist training.

The desire to pursue further training is just one of the several reasons cited by physicians in our region that “pushed” them to migrate and practice in the so-called bigger municipalities and cities. Approximately 40% of physicians in our region are practicing in the six major cities where the hospitals are located. We still have doctor-less municipalities especially the so-called GIDA (Geographically Isolated and Depressed Areas) communities. Other reasons include, the frustration in dealing with local politicians, safety issues especially in rebel infested areas and the lack of ancillary procedures, medicines and supplies which made them feel inadequate when treating their patients.

Personal issues for physicians

On a personal note, the lack of family opportunities such as schooling have led to migration into the larger communities where educational facilities are commonly located. Woman rural physicians in our region share the same burden as other women family doctors in the world – trying to attain a work-life balance. The burden of childcare and domestic responsibilities is still a major issue for most women doctors especially in rural communities in our country. It is not unusual for women doctors to be absent from work in order to take care of their family’s needs and to be present for their children in important events. Even unmarried female physicians have a “family” to take care of since it is not uncommon for them to take care of their parents and their sibling’s families because they have no “responsibilities of their own”.

Why a residency program?

Nonetheless, despite all these, I still salute our rural physicians for staying were they are and doing the work that the medical community more often than not looked down as being second class or inferior to the “super duper” specialists. Public health and rural medical practice especially have always ranked low in the medical totem pole in our country and it seems to be the way to go if you have no other options. It is sad really because it is actually where doctors are more needed.

Thus I welcome the move of the present Secretary of Health of our country to implement a residency training program in Family Medicine in all DOH hospitals with the goal of training all rural health physicians in generalist care in the rural setting. As a member of the Technical Working Group for this endeavor, it is my prayer that we can make a difference somehow in the lives of our rural health physicians and the Filipino people.

Aileen Espina.
The Philippines