Public-hospital staffing could be Universal Health Care’s biggest hurdle

By Gillian M. Cortez
Reporter

NURSES are vital for the successful implementation of universal health care (UHC). The World Health Organization (WHO) has highlighted the importance of investing in nurses to execute UHC properly. It’s a respected profession that has earned a reputation for also being largely overlooked, to the extent that many practitioners need to move overseas to earn a living.

If we accept that well-governed countries provide accessible health care to their citizens, the Philippines seems far off from that ideal. Political considerations interfere with efficient health care delivery even without UHC, and it’s an open question how the government will manage such a system — and that job includes ensuring there are enough health workers to carry it for a population of 110 million and growing.

UHC was finally signed into law on Feb. 20, 2019, giving all Filipinos automatic membership in the Philippine Health Insurance Corp. (PhilHealth). Setting aside for the moment PhilHealth’s own capacity to support UHC, which is a funding issue as well as a governance one — does the Philippines have enough health workers to pull it off?

MANPOWER OVERVIEW
Long before the Philippines conceived of UHC, it was an exporter of manpower. According to the Philippine Statistics Authority (PSA), there were 2.3 million Overseas Filipino Workers (OFWs) in 2018, with their remittances for the year valued at P235.9 billion. According to the WHO, 17,000 to 22,000 health professionals leave the Philippines each year for overseas work. Between 1993 and 2010, 29% of the departures among health professionals were nurses.

This “brain drain” has long been a feature of the employment scene, and has become more of a problem as UHC approaches.

“We have a surplus of nurses but it’s tragic because we produce so many nurses (to serve) the demand abroad… People leave because they lack fulfilment. They feel frustrated with the corruption, they feel frustrated with the equipment and services,” Medical Anthropologist Michael L. Tan told Businessworld.

According to the PSA, in 2016, graduates from higher education institutions numbered 41,805 in medical and allied programs. This total is the entire population of students in all health care fields, from undergraduate to doctoral programs. The student population in such programs, including underclassmen, was 203,561 in 2016.

A nursing graduate needs to pass the nursing board exams to be licensed by the Professional Regulation Commission (PRC). PSA said that in 2016, 13,019 out of 28,504 examinees passed the board exams. In more recent years the flow of licensure applicants has been reduced; the 2019 Board Exams, for instance, had 13,816 examinees and 7,627 passers.

Private Hospitals Association of the Philippines (PHAPi) President Rustico A. Jimenez said the K to 12 curriculum held back a few high school cohorts, a factor which should have been considered in the timing of UHC.

“The (government) should have studied it more because it implemented the K-12. It did not anticipate that we will have a shortage because of K-12,” he told BusinessWorld.

MISPLACED PRIORITIES
ThinkWell Philippines Senior Policy Advisor and Deputy Director for Health Financing Maria Eufemia C. Yap, said the lack of nurses should trigger an examination of priorities because nurses and midwives are neglected while the system values the creation of more doctors.

“It’s a radical thing to say but maybe we don’t need additional specialists; maybe we really need more generalists. Maybe our nurses and our midwives and other health workers will rethink leaving (the country) if they are not as overburdened,” she said in an interview with BusinessWorld.

Labor Secretary Silvestre H. Bello III said in June that he has discussed ways to minimize deployment of nurses overseas with the Philippine Overseas Labor Administration (POEA) because the UHC program needs nurses to stay in the Philippines.

But other countries need immigrant nurses too, particularly if their populations are aging or their own young people do not want to go into the profession. The Department of Labor and Employment (DoLE) has signed or is in the process of signing bilateral agreements for nurse deployment to Germany, Japan, and Canada. DoLE has also encouraged Filipino health workers to try their luck in the UK, which has removed its quota on overseas health professionals.

IN THE SAME BOAT
The Philippine Nurse Association (PNA) has called on the government to improve nurses’ rights in the Philippines, triggered by a massive retrenchment of contractual nurses at a Cebu hospital. Current labor standards do not fully protect workers especially in terms of security of tenure, it said, putting nurses in the same boat as workers lobbying for the Security of Tenure Bill.

“This mirrors the worsening scenario of our health care system today. Current laws and practices and even hospital policies are insufficient to protect not just the rights of our nurses but also that of our ordinary citizens whose right to quality health and even to safety (has been denied them),” PNA said in a position paper issued in August.

“Despite their significance nurses feel they are not being valued. For years, they have been clamoring as victims of unfair labor practices and been deprived of just compensation, (suffer from) undignified treatment at work, and poor working environments. Yet, reported incidents of exploitation and unfair labor practices among nurses persist and are increasing,” PNA added.

According to data from the Bureau of Local Employment (BLE), registered nurses working in the private sector receive monthly pay of P8,000-P13,500 on average.

The combination of unfair labor practices and the opportunity to work overseas for far more makes for a serious retention problem. The bottom-line question thus becomes, does the Philippines have enough nurses for UHC?

BUDGET HEARINGS
During the 2020 budget deliberations of the Department of Health (DoH), concerns were raised on how many public-sector health workers will still be at their jobs next year. With 2020 as the first year of UHC implementation, the DoH said that its ideal budget to handle all contingencies is P257 billion. As of this writing, legislators have set the department’s budget at P96 billion.

Legislators said that funding level is sufficient to retain more than 10,000 workers under the DoH’s Human Resource for Health Deployment Program (HRHDP).

Government health workers with job orders or are contractuals, numbering 7,107 nurses, 597 medical technologists, and 202 dentists, will all have jobs in 2020 at this funding level, according to the chairman of the Senate Committee on Health, Christopher Lawrence T. Go.

Pretchell P. Tolentino, head of the Learning and Development Division under the DoH’s Health Human Resources Development Bureau, said that while having more health personnel will always be beneficial, DoH currently employs enough staff to implement UHC next year. She added however, that the problem is always the annual funding level and the “plantilla” positions available — the regular staffing levels authorized and allocated for.

“We have enough actually. In terms of graduates we have enough but the issue is the distribution and the absorptive capacity. We need them but we cannot pay for them because there are not enough regular positions,” she told BusinessWorld.

FOR THE FORESEEABLE FUTURE
Mr. Jimenez of the hospitals association said private hospitals are also required to maintain staffing levels in order to keep their operating permits — for now, though there could yet be a shakeup in the future.

“We have manpower at this time because DoH won’t give you the license to operate unless you qualify for good service which is (directly affected by) the manpower at your hospital,” Mr. Jimenez said.

He added, “There is a requirement of 50 beds and a certain number of nurses. You cannot just get a permit to operate if you don’t fulfill the manpower requirement.”

Over the next 10 years or so as UHC rolls out, it is difficult to see how the personnel situation will develop for the over 1,000 hospitals in the Philippines.

Mr. Jimenez said one possible scenario that could overwhelm private-hospital capacity is if patients who could not otherwise afford private hospitals come to prefer such institutions, given their newfound financial capacity.

Meanwhile, public hospitals have their own staffing problems. According to the Philippine Nurses’ Association, the nurse-to-patient ratio in government institutions is 1:60, some distance away from the DoH’s ideal ratio of 1:12.

DISTRIBUTION
Another problem for the UHC is where health personnel are deployed. According to the PSA, in 2016, government hospitals employed 6,009 nurses, with 1,103 based in the National Capital Region (NCR). The Autonomous Region in Muslim Mindanao (ARMM), now the Bangsamoro Autonomous Region in Muslim Mindanao or BARMM) had only 96.

Metro Manila also had the most government doctors (718) while BARMM had 67.

These imbalances are meant to be addressed by the UHC Law, or Republic Act 112233, Section 23 of which requires the DoH to draft a National Health Human Resource Master Plan. Section 24 of the law also provides for a National Health Workforce Support System that will prioritize deployment of health personnel to Geographically Isolated and Disadvantaged Areas (GIDAs).

PAY ISSUES AND THE SUPREME COURT
The Supreme Court ruled in October that public-sector nurses will start at Salary Grade (SG) 15, which pays P30,000 a month, while overturning an executive order issued by President Gloria Macapagal-Arroyo, which called for public-sector nurses to start at SG 11, earning a little over P20,000 monthly.

Legislators as of this writing are still trying to find ways to allocate funds for the 2020 nurses’ wages, while the Department of Budget and Management (DBM) is studying the impact of the SC ruling.

DoLE has also intensified labor inspections after receiving reports of nurses in major hospitals working extreme overtime and not receiving appropriate wages. Mr. Bello also said that he is in talks on how to adjust nurses’ salaries, which can only come through by legislation.

INCENTIVES TO STAY
Mr. Tan said there needs to be an incentive scheme that encourages nurses to stay. “The turnover is so fast, everyone wants to work abroad. No one wants to work here. So we should find a way (to provide) incentives for people to stay.”

Ms. Yap said stakeholders must evaluate staffing to identify gaps and redistribute resources if necessary.

“(Stakeholders need to) revisit roles and decongest and deload people and to rationalize the different components of health delivery so we can really determine where the need is greatest,” she said.

It is by no means guaranteed that the UHC rollout will be seamless but whatever the outcome, it will serve as a lesson for the estimated decade-long UHC transition period. UHC is challenging enough on its own, but the question is whether the government can also resolve the pre-existing conditions like retention, labor practices, funding, and imbalances in health care training and deployment.