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Need to increase supply of medical workers and build telemedicine infrastructure to prepare for future public health crises

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By Geoffrey Ducanes and Sarah Lynne Daway-Ducanes

THE COVID-19 pandemic covering most of the world has put a spotlight on medical workers, and has rekindled an appreciation for their importance and even heroism during times of public health crises.

In the Philippines, more than 252 healthcare workers — 152 doctors and 63 nurses — have been infected by the virus that results in COVID-19 as of April 8, according to the Department of Health (DoH), while the Private Hospitals Association of the Philippines reported the disease has already killed 21 doctors as of April 7. And despite an absence of an official count of nurse deaths due to COVID-19, sporadic reports suggest it is also on the rise.

Although losing any life to COVID-19 is tragic, losing medical workers is doubly tragic because of their role in saving lives during this pandemic, and because they are already in scarce supply in the country.

MEDICAL WORKER SHORTAGE
Even before the current pandemic, the Philippines was already facing a serious shortage of medical workers. Based on the most recent data from the DoH, there were 40,775 medical doctors (in the health sector) in the country in 2017, which translates to a medical doctor-to-population ratio of 0.4:1,000. The generally accepted standard is one doctor for every 1,000 population, which means the country was 63,710 doctors short, given its 2017 population of 104 million.

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According to the DoH, the Philippines had 90,308 practicing nurses and 43,044 practicing midwives in public and private health facilities in 2017, equivalent to a nurses and midwives-to-population ratio of 1.3:1,000. There is no clear recommended standard for the number of nurses and midwives, but the average for low middle income countries, to which the Philippines belongs, is 1.7:1,000, according to the World Health Organization (WHO). Even by this modest standard, the country was short by 44,273 nurses and midwives in 2017.

SHORTAGE MORE SEVERE OUTSIDE METRO MANILA
It is extremely important that the country’s COVID-19 infection be contained within Metro Manila and Luzon as the shortage in medical workers is generally more severe in the Visayas and Mindanao.

In fact, Metro Manila, the location of more than 70% of the country’s COVID-19 cases as of April 14, had a healthy 1.1 medical doctors per 1,000 population ratio. The rest of Luzon, meanwhile, only had 0.32 doctor per 1,000, and Visayas and Mindanao, had even less at 0.30 and 0.24 doctor per 1,000, respectively. ARMM only had 0.1 doctor per 1,000 population. The picture for nurses and midwives is similar: Metro Manila had 1.6 per 1,000, the Visayas had 1.3 per 1,000, and other Luzon and Visayas both had 1.2 per 1,000.

These numbers, combined with the generally inferior medical facilities and equipment in the rural areas, suggest the spread of COVID-19 in the Visayas and Mindanao could be potentially catastrophic.

OUTLOOK ON MEDICAL WORKER SUPPLY
The country’s medical worker shortage is not expected to be filled anytime soon, especially the shortage in medical doctors. A 2019 study by the University of the Philippines (UP) Center for Integrative Studies (UP Center for Integrative Studies Discussion Paper 2019-02 ‘Eliminating the deficit in medical doctors Strategies and costs’ authored by Clarissa David, Geoffrey Ducanes, Jose Luis Vargas Bacigalupo, Shaira Melissa Tengco, and Karol Mark Yee. https://cids.up.edu.ph/publications/discussion-papers/2019-series/2019-02/) estimated that more than 16,000 students should enter medical school every year (of whom 90% should graduate, 68% pass the board exam, and all passers practice in the country) for the next five years if the country is to achieve the one doctor per 1,000 population ratio in 10 years’ time. But this enrollment figure is four-times the current level of annual entry in medical schools. Even if the doctor-deficit is to be filled in 15 years’ time, new enrollment every year should total about 7,000 a year for the next 10 years, which is still much higher than the current level.

These scenarios do not even account for the expected radical decline in medical school enrollment in school-years 2020-2021 and 2021-2022 due to the K to 12 transition. It is also still a question as to whether this pandemic will inspire young people to take up medicine (or nursing), or scare them from doing so.

At the same time, it is expected that demand for Filipino medical workers abroad will surge as other countries move to bolster their health systems to prepare for future pandemics. Already, in the US alone, as of 2015, there were about 10,000 doctors and more than 140,000 nurses who were originally from the Philippines, according to the Migration Policy Institute in Washington D.C., which used the 2015 US Census data.

TWO-PRONGED STRATEGY
Solving the medical worker shortage likely requires a two-pronged strategy: 1.) increasing the supply of medical workers, especially doctors; and 2.) investing heavily in telemedicine to dampen the demand for medical workers.

INCREASING THE SUPPLY OF MEDICAL DOCTORS
As of 2018, there were 44 recognized medical schools in the country, of which 14 are in Metro Manila, 13 in other parts of Luzon, 12 in the Visayas, and five in Mindanao. Of the 44 medical schools, nine are public and 35 are private schools. From school-years 2012-2013 to 2015-2016, enrollment for all year levels averaged 18,300, although the trend was increasing. In the school-year 2015-2016, 92% of the enrollees and 86% of medical school graduates came from private schools.

Increasing the supply of medical workers would involve the strategic expansion of medical schools, both public and private, and a large-scale government scholarship program with a return service requirement. Although there is in place a scholarship program for medical students in state universities and colleges (Commission on Higher Education and Department of Budget and Management Joint Memorandum Circular No. 2018-1), which covers only tuition, this should be expanded to also include private schools, and should prioritize students from rural areas with more severe doctor shortages. The financial barriers to poor but capable students should also be lowered by including a reasonable living allowance and non-tuition medical school expenses, such as for textbooks and uniforms, and should extend until the board examinations.

INVESTING HEAVILY IN TELEMEDICINE
Telemedicine is the provision of medical services without physical interaction between health care professionals — and in some warranted instances, artificial intelligence (AI) — and patients. Telemedicine provides a more timely and less costly access to medical care for patients, who are unable to physically go to a healthcare facility, but require either routine and non-urgent or even urgent medical care. In the long run, investing heavily in telemedicine technology could help address the shortage of healthcare professionals in the Philippines and the under-provision of even basic health care services in far-flung areas.

The current pandemic presents an unprecedented opportunity for the rapid adoption of telemedicine technology. Indeed, other countries affected by COVID-19, notably, the US, European Union countries, and other countries in Asia, have relaxed laws and regulations to allow the faster adoption of telemedicine. In the Philippines, the Department of Health and the National Privacy Commission have jointly developed a framework that would boost the use of telemedicine to help combat COVID-19, also providing free telemedicine hotlines to “decongest our hospitals and minimize risks posed by unnecessary patient traffic.”(https://www.doh.gov.ph/doh-press-release/DOH-BOOST-TELEMEDICINE-SERVICES-FOR-NCR-SERVICE-TO-EXPAND-TO-OTHER-REGIONS-SOON) The University of the Philippines (UP) and Department of Science and Technology-developed RxBox, a portable multi-component telemedicine device, now also plays a big role in enabling telehealth services — especially in the now heavily embattled UP Philippine General Hospital — amidst the COVID-19 outbreak. (https://rxbox.chits.ph/what_is_rxbox/; http://www.pchrd.dost.gov.ph/index.php/news/6527-pgh-to-use-dost-s-rxbox-for-covid-19-in-patient-monitoring)

Developing telemedicine in the Philippines would involve investing in both fixed and human capital. Fixed capital investments involve the procurement and production of more telemedicine-related devices, ensuring stable and accessible internet connection, and developing and/or adopting telemedicine software, and even AI. (https://blog.evisit.com/what-are-the-basic-technical-requirements-for-telehealth. See, for instance, https://aip.scitation.org/doi/pdf/10.1063/1.5023979 on the viability of using AI in providing telemedicine services.) Human capital investments, in turn, involve the training of health care professionals and the mass education of the population. Moving forward even further, making provisions for investments in telesurgery (i.e., surgical procedure done remotely with robotic technology over wireless networking) infrastructure would also help address the relative shortage of surgeons in remote areas.(https://assets.cureus.com/uploads/review_article/pdf/12751/1550698319-20190220-655-3jlaza.pdf) These are some considerations that prospective bills on creating an eHealth system in the Philippines will also have to weigh up. (https://www.philstar.com/headlines/2020/01/13/1984345/house-vows-improve-universal-health-care; https://newsinfo.inquirer.net/1255555/angara-to-file-bill-creating-ph-ehealth-system-for-telemedicine)

Increasing the supply of medical workers and investing in the telemedicine infrastructure are costly but necessary undertakings to improve public health and better-prepare the country for the next public health crisis.

 

Geoffrey Ducanes is with the Ateneo de Manila University Department of Economics and Sarah Lynne Daway-Ducanes is with the University of the Philippines School of Economics

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