Health politics demoralizes doctors

(Conclusion)

When barrio doctor Richard Lariosa arrived in Tagapul-an, Samar in 2002, he was surprised to learn that medicines for the town were being kept at the mayor’s office. "When you gave a prescription to a patient not of the same political color as the mayor, he’d be told by the people at the mayor’s office there was no medicine even when there was still a lot," the doctor says. "Color coding."

The mayor was later persuaded to turn over all the stocks to the rural health unit (RHU), after being assured the people would know the medicines came from him. But months before the May 2004 elections, newly delivered medicines again wound up with the mayor. He agreed to let go of half the medicines only after Lariosa paid him a visit.

The young doctor’s relationship with the mayor, however, was already quite strained. At one point, Lariosa had objected to the removal of trained health workers and their replacement by untrained supporters of the mayor and the barangay captains. The mayor was in turn displeased when Lariosa changed caterers for a health-training course because the food served by the first caterer caused the trainees to have diarrhea. Apparently, the former caterer was the mayor’s ally.

Last December, Lariosa was pulled out of Tagapul-an after the Doctors to the Barrio-Leaders for Health program, which had sent him there, concluded that the mayor was not very concerned about health. Now assigned to Uyugan, Batanes, Lariosa hopes local politics will not again become a hindrance to his work.

Corruption and official neglect are not the only problems plaguing the health system in local government units. Traditional politics is also compromising the delivery of health services to the people who need it most, and discouraging health workers who would otherwise not even mind the low pay and long hours their jobs entail.

"Confidently, we can say that partisan politics is the number one problem at the RHU," says Maritona Labajo, assistant director for field operations of the Leaders for Health program that allows barrio doctors to earn a master’s degree in community health management. She also concedes, "Politicians… are really difficult to work with. The (health) program can be sabotaged by the mere fact that the mayor does not cooperate."

This has led to disillusionment even among the most idealistic of doctors, some of whom had volunteered for the much-vaunted Doctors to the Barrio program begun more than a decade ago by then health secretary Juan Flavier. The program has already sent more than 400 physicians to about 300 doctorless fifth- and sixth-class towns, but medical practitioners are still badly needed in the countryside, even by wealthy towns.

While some of the volunteer doctors eventually stay as municipal health officers in the towns they are assigned to, several wind up swearing off working for local governments ever again. One barrio doctor assigned to a remote town in Mindanao can hardly wait until her four-year contract is up. "I can’t stand the politics," she says.

Yet Pascualito Concepcion, an Ateneo de Zamboanga alumnus assigned by the Doctors to the Barrio program to Talusan, Zamboanga Sibugay in 2002, has shown just how much a community doctor can accomplish when the local government is health-friendly.

With help from the mayor and the town council, Concepcion transformed a dusty warehouse-like building into an air-conditioned health center. He got Philhealth to accredit his rural health unit and enrolled 500 poor families in the program in 2002 alone. His RHU’s pharmacy also sells paracetamol for as low as 50 centavos per tablet; usually the cheapest a tablet of the medicine sells for is 90 centavos.

Concepcion convinced local officials to increase the RHU’s share from the development fund (from P200,000 in 2002 to P1.2 million in 2003) and even persuaded them to let it keep the Philhealth payments for the upkeep of the health center and its programs. The local government has since created more positions for the RHU and has been fully implementing the Magna Carta for Public Health Workers. The health center laboratory is comparable to a medical center lab with pap smears, blood sugar and other blood chemical testing.

Concepcion was given the Grand Distinction Award in the Department of Health’s annual recognition of outstanding doctors to the barrio. Other RHU doctors, however, are probably more jealous of his luck with his local government than of his award.

Many of the doctors interviewed for this article recounted story after story about clashing with local officials – primarily the mayor – over such seemingly trivial things as the hiring of barangay health workers and the safekeeping and distribution of medicines. These, however, have serious implications, and affect the continuity of services and effectiveness of treatment.

In most of the cases, patronage politics was involved, with the officials using employment and medical supplies as a means of garnering support for themselves and clinching votes for the next election.

Lariosa’s experience in Tagapul-an is but one illustration of this. The frustrated doctor in western Mindanao also recounts that when she was the municipal health officer of another poor town in the southern part of the region, she had displeased the mayor when she dispensed medicine to every patient needing treatment instead of just the mayor’s followers. She didn’t win points either when she refused to sign procurement forms that she deemed questionable. When she resigned sometime last year, the mayor replaced her with a favored midwife, instead of the nurse, the RHU’s second in command.

Now the doctor is in yet another impoverished town, this time under the Doctors to the Barrio program. But she says it feels like she hadn’t moved at all. The first-term mayor in her new assignment has taken to appointing unqualified people as barangay health workers, for one. For another, says the doctor, patients must have their RHU-issued prescriptions signed by the mayor’s office before the medicines are released.

"There is a common practice in many LGUs (local government units) where RHU patients get their drugs from the municipal hall rather than from the RHU," notes a study by the Department of Health (DOH) and the Management Sciences for Health (MSH), a nonprofit international organization working in public health areas.

The study describes the practice in a town in Northern Luzon: The RHU doctor prescribes the drugs, the patient goes to the social welfare office to get an approval of indigency, and then proceeds to the office of the sangguniang bayan (town council) chair on health committee where the drugs are dispensed. To assure safety and regulate the validity of drug dispensing, the patient is asked to go back to the RHU for further instructions on the intake of medicine.

The risks involved in the practice, the study says, are "when the patient does not go back to the RHU for final… approval and when the wrong, inappropriate drug is given to the patient." RHU doctors themselves say that those who happen to support the opposition also do not bother to go to the town hall for their medicine, knowing the chances of being given some are small anyway.

Many of the doctors also complain that a change in local administration means a change in health workers. Unfortunately, the newcomers are often unqualified for the job that had taken their predecessors years to learn.

A doctor in Eastern Visayas says barangay captains removed barangay health workers who didn’t belong to the same party and replaced them with untrained ones. Another tactic was hiring new workers while keeping the incumbents "floating."

When the doctor offered to train the new workers, he was spurned and even accused of meddling. "I was building a good referral system, so there should be no breaks. Barangay health workers are important," he explains. "The mayor also hired midwives as casuals."

Labajo observes that a lot of barangay health workers are "nonfunctional": They do things other than deliver health services.

Months before the 2004 elections, for instance, the mayor and political candidates of the Eastern Visayas town fielded the barangay health workers, midwives and casual employees to conduct "data gathering." They went around the island to survey who the residents were voting for. "It’s that strategic," the doctor says. "Politicians paid P500 per voter, and more for those who may not vote for them."

Labajo says even governors have recognized that barangay health workers are a political force in elections and offer to pay half their salaries or make them casuals or contractuals of the provincial government. "As casuals, they get P2,500 to P3,000 a month. That’s a lot of money in a poor town," says the doctor from Eastern Visayas.

In many places, barangay health workers don’t even report for duty but still draw their pay. "Mga ‘15-30’ sila," the Mindanao doctor says, referring to employees who don’t work but show up at the town hall or capitol every 15th and 30th of the month to claim their paycheck.

Labajo says a town with 24 barangays could have as many 184 barangay health workers. But she notes, "The number of barangay health workers doesn’t necessarily mean that you have a good ratio of barangay health workers to the population or that the barangays are being serviced."

Some mayors do not stop at hiring and firing barangay health workers at a whim. In some towns, mayors have demoted doctors who disagreed with them or had somehow displeased them and appointed nurses and midwives in their stead as officers in charge of municipal health offices.

Doctors whose relationships with their mayors become strained but continue to stay in their posts often lose effectiveness in carrying out health programs. For instance, the RHU in a Ñorthern Mindanao town hardly had any local health programs to speak of because the mayor and the RHU’s staff were not on speaking terms.

Community doctors who butt heads with local officials find to their disappointment that other government agencies can hardly come to their aid. In many towns, the local health board rarely or never meets, or is under the mayor’s control, says one doctor assigned in Mindanao. The board consists of the mayor, president of the barangay health workers, the rural health physician, and one representative each from the DOH and the sangguniang bayan.

Much as he had wanted to engage the mayor and sanggunian officials to push Tagapul-an’s health program, Lariosa had realized there was little he could do. The mayor was in town just once a month, staying for about a week; most of the time he was in Calbayog, where he also kept a house, supposedly following up with other government agencies.

Lariosa couldn’t turn to the sanggunian for support either, since it hardly ever convened sessions. "The resolutions are passed around the barangay where they happen to be for their signature," he says.

But things came to a head when the mayor’s nephew sought treatment at the RHU and found it empty. The doctor and his staff were out implementing a DOH campaign and the staff assigned to man the health center had failed to report to work. The angry mayor nailed the RHU shut. Recounts Lariosa: "The following morning I told the mayor what he did was unfair. Hindi kami naglalakwatsa (We weren’t out having fun)."

It may take some time before the DOH sends another barrio doctor to Tagapul-an. The town would first have to convince the national government that its local officials and community leaders are cooperative enough to deserve another barrio doctor.

Lariosa was actually the second barrio doctor to become a casualty of local politics in Tagapul-an. Danilo Reynes, the town’s first physician after a doctorless decade, belonged to the Doctors to the Barrio program’s first batch. He stayed there for four years, but left because incumbent officials perceived him to be allied with their political opponents.

Lariosa was not the only barrio doctor withdrawn from their places of assignment. Two doctors from the Western Samar towns of Matuguinao and Jiabong were pulled out for the same reason: The mayors refused to abide by the agreement that full support for health be given that are within their very limited resources.

A few years ago, two of seven barrio doctors assigned to a northern Mindanao province cut short their stint, saying they could not stand the treatment they were getting from their mayors. Says one of the doctors: "I left feeling really bad. I didn’t even want to be reassigned. My idealism had been shattered. I had been disillusioned. I go to another local government unit, and there would be yet another mayor who would be controlling my life."

Doctors who have lodged complaints against their mayors to their governors, the DOH, the Department of Interior and Local and Governments and the Department of Budget and Management say many of these remain unresolved.

Still, when the local government puts importance on health, success stories like that of Concepcion are possible. Robert Briones, who gave up a lucrative private practice to become a barrio doctor in the island town of Loreto in Surigao del Norte, also says he does not regret his decision, even if it has meant being away from his wife and three young children, aged six, four, and two.

"I frequently wonder… what is happening to them," he says. "But in my journey as a doctor to the barrio, a doctor in a far-flung community… one thing is apparent. This (has) made me affirm that ‘it is not the end of the journey that matters most but the journey itself is what matters in the end.’"

Even Lariosa has not junked the idea of serving communities despite his rather tumultuous experience in Tagapul-an. He admits mulling over the idea of residency training in internal medicine or surgery after finishing his contract as barrio doctor. "But I’m having second thoughts," he says. "The work of a public health practitioner is challenging."

Lariosa’s younger sister has just graduated from medical school and plans to go straight to residency training. "But I’ll try to expose her to the Doctors to the Barrio program when she visits me in Batanes in the summer," says Lariosa. "There are bits of ugliness, but I think my type of work is beautiful."