Monday, February 10, 2014

UHC 22: Shortage of Doctors in the Philippines

A friend, Dr. Tony Leachon of UP College of Medicine, also practicing at Manila Doctors Hospital, posted this article in his fb wall last week, and it attracted lots of healthy and useful comments from his fellow physicians. I believe more people should be able to read this useful exchange. This is long, 4,600+ 7,300+ words, 10 16 pages, enjoy.
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Tony Leachon
PMA warns of worsening shortage of doctors. http://www.abs-cbnnews.com/nation/01/30/14/pma-warns-worsening-shortage-doctors

Emmanuel 3D- Dispersal, Diffusion, Dedication

Daniel Most patients in the provinces can't afford doctors. The government thought universal healthcare through the PHIC will solve it. It just solved half the problem.

PHIC doesn't even pay for OPD consults. What, wait for these patients to be sick enough to be admitted for insurance to start paying for it? By then the healthcare cost could already skyrocket.

Ted The ratio should be 1 physician per 1000 persons. If we are 95million and we have 130,000 licensed isnt 1.3 doctors per 9,500 population? We definitely need more doctors! I believe PPP will be a major solution as many of the doctors are in the private sectir.

Iris Hopefully UPCM Return Service will help and that these new MDs will be encouraged to stay.

Minerva  This issue definitely needs a comprehensive analysis that considers demographics, changing practice patterns and healthcare access. Most existing estimates of the shortage of physicians are based on simple ratios. These estimates do not consider the impact of such ratios on patients’ ability to get timely access to care and do not quantify the impact of changing patient demographics on the demand side and alternative methods of delivering care on the supply side. We are at the threshold of collaborative practice which could be expanded to include the use of healthcare teams of physicians, nurses, midwives. Telehealth is another option to address timely access to care in remote areas. Improving allocations for physicians in government, both national and local as well as improvement in facilities through local government emphasis on health agenda is a must while we review the Local Government Code.

As an educator engaged in organized medicine, I believe we should also shift some of our focus in teaching medicine and include health informatics, leadership and management of change, medical socio-anthropology and immersion in public health issues in research, in elective rotations and as part of case scenarios in medical subjects so that medical students will have a grasp of the real world that they will face after medical school.

Ted  If each private doctor accepted or was assigned few poor families in consult and treatment under their care and Philhealth paid for their servicrs, would that lessen the problem?

Daniel  PHIC calls it capitation but its only paid to the RHU doctors, which in most cases, the poor patients won't even find in their clinics.

Adrian It might be time to consider Dr Domingo's proposal for a national matching system. That will ensure a career for doctors, while addressing distribution issues.

Minerva PHIC should in fact pay for the whole continuum of care: preventive, promotive and rehabilitative. A tall order but something that definitely needs to be considered. PHIC gets an infusion of money from the SIN Tax, from people whose mindsets we probably cannot change...so we have to think of ways (policy changes) to channel it to compensate physicians who provide coordination of care, health maintenance and disease prevention programs so as to reduce the burden especially of lifestyle diseases. Let us have less sick people with health maintenance in mind. Let us be CREATIVE and not REACTIVE!

Tony  Thanks for your views. I think we need 5 strategies 1. Comprehensive Healthcare workforce plan - evaluation of maldistribution , salaries , training , competencies , and mobilization of local medical organizations 2. Process - maximization of Phil health benefits , use if sin tax funds , absorption of non doh public hospitals eg AFP med center , VMMC , PGH etc; 3. Infrastructures - national template for the build up of hospitals with a checklist of equipment matched with the level of training of the local primary care physicians. 4. Improvement of health literacy of the patients 5. Systemic environmental health approach with involvement of different government agencies ( dilg , DepEd , CHED , DA , dost NNC etc and private sector.) - once the strategic plan is in place - communication plan, we need to put the right people for the right job , resources , balanced scorecard and monitoring of the execution and implementation of the goals.

Daniel But let's be realistic about the PHIC Premiums? 200 a month? What can the patients expect with that? They're getting us all on the cheap. Do you see lawyers lining up to form their own LMOs (Legal Maintenance Organizations)? Nah.

Iris  I really think it's time for telemedicine. Whatever happened to the telehealth bill?http://www.govhealthit.com/.../congress-introduces-bill...
Description: https://z-n.ak.fbcdn.net/external.ak/safe_image.php?d=AQA4ZRA0HjQQg49B&w=154&h=154&url=http%3A%2F%2Fwww.govhealthit.com%2Fsites%2Fgovhealthit.com%2Fthemes%2Fmedtech%2Fimages%2Fgovernment-health-it-himss-media.png
Reps. Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio) introduced a bill Dec. 1...See More

Rodel  There are a lot of doctors, even specialists who try working in resource-limited settings like in this province, but the local climate does not value the contribution of the health care worker much, which is why they leave. I think it starts with...

removing local politics from the equation. This would encourage those committed to health to stay without the need to kiss ass. Plus some politicians use the PhilHealth enrolment to their advantage so it is never maximized. Telehealth is a good way...

...to bridge the gap but again even the little investment is seen as a burden by non-health minded LGUs (which is most). Agree with deployment of MDs, with possible retention as well as a true rural public health elective in med school.

Minerva  Yes, Telemedicine should be included in our healthcare agenda to bridge the geographical divide. Each doctor has in his hand, an android or iPhone or an iPad that can serve as a tele-clinic to provide specialty consults to remote areas. But then again we need primary care physicians, nurses and midwives to man our remote areas and bring their cases to the attention of the specialists. Let us push the boundaries of healthcare.

Let us also bring Patient Education on Preventive Health as part of our Medical Missions! When we are requested to go on Medical Missions let us bring with us, aside from our stethoscopes...our bullhorns to teach patients the value of disease prevention and proper nutrition.

Daniel Things that attract doctors to practice in the provinces: peace and order, access to good educational institutions, relatively stress-free lifestyle, nurturing practice environment, self-fulfillment,attractive remuneration packages. Other reasons?

Adrian  Medical missions are just a stop gap measure.

Tony  Ted it's time to gather a group of people who are willing to help you and doh to solve this huge problem. You don't have much time. There are individual differences of course - let's go beyond the differences , chaos and clutter and work for a better PH healthcare.

Minerva Yes, I agree! Surely Medical Missions are just stop gap measures but changing mindsets through patient education has long term impact. We just use Medical Missions to gather patients to come and congregate then we teach them while they are waiting for their turn.

Ted  I agree. our method and routes maybe different but I suppose we all want better healthcare for our countrymen. Sure, Im with you as when you also supported us during the Sin taxes. Now the money is getting "locked" in PHIC. this must not happen. Those benefits must be given to the patients and the doctors who serve them!

Daniel  Let's form a Political Action Group to lobby the decision-makers on the importance of health care reform integrating all program that will advance all healthcare agenda.

USec Ted, why is it that its always a lawyer who runs PHIC? Would lawyers like it if a doctor run an organization devoted for legal concerns.

Rodel  Agree with a multisectoral health-focused group with representatives from the top level to the grassroots workers. It really is time to start focusing on health-delivery agendas in this country.

Rodel  Even Telemedicine can be used for primary health care, for like us, despite being a city, we have bgys about 5.5h away from a health center. Telemedicine could help in that regard as well even with primary health care delivery of the MHOs.

Minerva  Listen, Learn and Legislate...that should be the way to go for our policymakers! This is meaningful conversation...this is what I mean by UNITY OF PURPOSE...policymakers listening to the grassroots.

Tony  Usec , Allow me to dream with you - what's the doh visual showcase for the coming SONA , something that the people will be happy about w 2 years and 5 months to go. ? We all worked for the sin tax law and we dreamt that it would be earmarked for health. But can the leadership of doh expedite the changes ASAP ? We were able to pass the sin tax law in a record one year time after languishing in congress for 16 years ! Nothing is impossible with teamwork , courage and love of country. Thanks for listening. 

Naomi  Has DOH convened a meeting with schools, LGUs, and Philhealth? The problem needs a permanent working group with concrete goals, eg all barangays will have one GP, one IM , one pedia and one OB at least by dec 2016 (just an example) , funded by LGU, covered by PHIC, linked with a referral system and mentoring of consultant partner to the university hospital and DOH hospital for specialty consult etc. Then the project can be tracked quarterly till attainment of goal, continuously enhanced, maybe we can even get corporations to adopt and sponsor the needs.

Val  Tony Leachon, yes doc, we made a study. but not purely on HR. The problem is we do not have actual data on private physicians. Data from PMA is erratic, while DOH only collects public health workers. Again, we can address skewed distribution of physicians by stirring the demand (by insurance) and the supply side of physicians will kick in. I am so pro-free market. haha

Tony  how about the WHO ? What s your view on this ? Do you have local and global studies on this topic ? Thanks.

Naomi  This needs a practical pragmatic action oriented leadership by DOH and LGUs. Hope not too much analysis paralysis...doesnt take a lot to identify zero headcount. Focus on the zero headcount (zero gp zero pedia zero ob etc) municipalities as first priority and go from there

Maria May I know the basis for the statement of PMA that there is worsening shortage of doctors?


Doctors are in short supply.

Maria This is old news..... What needs to be done is for DOH, LGUs and medical societies to sit down and make a plan to address the problem. PMA should not be blurting out problems where they do not offer solutions.

Minerva  Yes we have to sit down together...let us engage DOH, LGUs and the Medical Societies in crafting new and creative solutions to this old issue. All of us physicians in the PMA should put our act together. We have to show the community-at-large that we are large enough to lobby on issues that affect the medical community. All of us engaged in this conversation have contributed much in terms of solutions since this morning...let us make all our dreams come true!

Tony Here are some facts

PRC : The press release lacks accuracy as far as statistics are concerned. As of March 15, 2013, there were 70,418 physicians in the list of active professionals. These have been renewing their PRC ID's. How many more have not been renewing their ID's? We do not know.

Circa 2010-2011, there were only 22,000 physicians accredited by Philhealth, with almost equal distribution between GP's and specialists, and with a tier 2 which had GP's with training performing specialty procedures.

 The government or even PMA lacks data on the human resources.

The PMA said during the previous years that they had 70,000 members, 2/3 of whom are GP's and 1/3 are specialists. They should know the geographic distribution of both GP's and specialists. However, during discussion with DOH officials , no one actually knows which provinces lack specialists. The DOH has a list of towns without doctors (meaning municipal health officers belonging to the government service). So many Health Secretaries have passed without any one coming up with a serious effort to address the problem. What we have are the Doctors to the Barrios program which is very difficult to sustain. UP is the only med school with a return service program which is not adequate to meet national needs. The regionalization of medical schools may have solved problems in some regions but overall, has not really answered the needs of the country.

I passed the medical board exam in 1986. DoH sec Bengzon started the devolution during that time. I was a Cory fan.

Blaming devolution as the cause, in addition to the shift of physicians to nursing, may not be accurate because right now we have doubled the number of takers of the NMAT from 5-6,000 to 12-13,000, mainly due to the shift of nursing graduates to medicine.

DOH-HHRDB, under Dr. Kenneth Ronquillo - good friend and patient of mine , is the unit in charge of studying the health manpower situation in the country, including projections on how many are needed. They used a WHO model before, then changed to an ILO model. They should be consulted regarding this problem. They have set up a very wide network and have conducted conferences at the DOH and at hotels with the participation of a lot of government agencies. I have attended one or two sessions of them in the past. 

UNDP used to publish the comparative number of physicians based on 100,000 population, and there were also other studies based on 10,000 or 1,000 population. These data covered all countries.

The PRC and the Board of Medicine have the following data:
1. Number of medical schools: 38
2. Number of graduates: 4,500
3. Number of takers of licensure exams: 4,000-4,500
4. Percentage passing: 62-66%
5. Number of successful examinees per year: 2,500

Based on recent PRC data -
Of the 38 medical schools, 21 are satisfactorily performing based on passing percentage of graduates. Seventeen are poorly performing. Some schools were recommended to be phased out but not a single medical school has been closed (except for Muslim Christian CM in Antipolo).

Should the CHED allow more medical schools to be opened? The PRC BOM does not agree that this should be done. The CHED should first deal with the quality of the medical schools and the quality of graduates. Poorly performing schools should be helped but if there really is no effort from their part to improve, then they should be phased out. Only then can the CHED allow more medical schools to open. Monitoring the schools is a big problem. Closing down the substandard ones is a bigger problem. 

The problem of quality assurance should be taken very seriously. Since external accreditation was made voluntary, only the excellent schools have volunteered to apply for external accreditation. There is also a policy of the accrediting body, PAASCU, that schools have to attain a passing percentage equal to or higher than the national passing average before they can apply for external accreditation. Right now, the gap between the actual passing percentage and the national passing percentage has been widening, making it impossible for the poorly performing to attain external accreditation. 

Tony During the term of Pcp president Eugene Ramos he created more chapters - to me , the problem of maldistribution is the more pressing problem. We may be able to produce the needed number, but if these physicians shy away from many areas of the country for reasons of their own, then even if the control of local government hospitals is reverted back to DOH, the problem will persist.

In 1987 I was at Mdh as a resident physician and up to the time that we were residents already, the DOH was in control of all health facilities of the government, but even during those times, we had been dealing with the same problems. 

Doc  Get the money flowing to our health workers. Make the compensation enticing and see most of the brain drain will be solve. It all boils down to how much are we paying our doctors and nurses.

Mark  Filipino citizen medical graduates should work for the Philippine govt for a certain period of time, e.g., 5-10 yrs, before allowing them to migrate to another country. Or the Philippine government can sponsor scholarships for med school and after graduation, the graduate should work for the govt for a certain period of time to payback the cost of education.

Maria  There should be a more planned effective mechanism to distribute doctors/specialists to various parts of the country. Right now, there is this policy that specialty hospitals must prioritize acceptance of doctors coming from hospitals where no specialist exists. However, this is being abused by those who wants to be accepted into training without going to the usual process even if the supposed hospital sponsor has existing specialists in their place and even from within their institution.

France No amount of policy change will motivate any doctor specialist or not, to practice in the municipal level if the salary they get dont even cover for the fuel they will consume in
Doing there job. Doctors are mortals too, if u have 5 mouths to feed, will 30-35k basic salary for an MO3 enough. Or for an MS1 or 2. Tssk...

Tony  Agree with Doc  France. The govt should take the lead in providing solutions to this chronic problem. But we will trigger an advocacy to find solutions.

Question : what are the priorities of the Philippine government for 2014 =>

P84.36B (DOH) of P2.265T (2014 National Budget) = 3.79%
[http://www.dbm.gov.ph/wp.../uploads/GAA/GAA2014/DOH/DOH.pdf]

General Public Services are expenditures for general administration (such as fiscal management, foreign affairs, lawmaking, etc.) and public order and safety.
http://data.gov.ph/infographics/budget ]

16.0% goes to General Public Services
[http://www.gov.ph/.../2014-National-Budget-Briefer-VerB...]

Minerva Our problems revolve around system and we ought to have people sitting down together (perhaps a group like what we have now) to look at the root causes...We ask ourselves the following questions: How do we mould the minds and hearts of our medical graduates? How do we instill in them the Love of the Supreme Being, Love of Country, Love of Fellowmen and Love of Profession? How do we teach them to advocate for Health and Wellness versus just Cure of the Sick, for Professionalism versus Politics in the Profession?

Rosel  Somewhere in the assessment, the fragmentation of the health care system as caused by the Devolution Law , authored by Senator A. Pimentel, has to be discussed.

Tony  Sin tax funds will augment the doh budget - and the reallocated PDAF !

Rosel Taking the cue from Ted, I agree that vigilance and advocacy is needed in this area of Sin Tax Implementation because there is a possibility that most of the money might be locked up in Philhealth. If Philhealth is run by lawyers and bankers, the priority will be to increasingly augment the asset base, If it were run by the likes of Dodo Banzon, a different battle plan would be in place in the service of universal health care. It is a matter of policy direction and orientation of the Fund actually.

Maria  Sin tax funds is meant to augment DOH funds for programs. I don't believe that it should be poured in to pay for personnel. We should advocate for more budget for health in the LGUs and this should cover for health personnel. LGU chief executives must realized that health should be a priority

Edge  Hi Tony, sorry for joining this discussion late in the hour. My take on this is that we need to examine the situation from an evidence-based and strategic standpoint. Dr Marilyn Lorenzo's research on HRH in the Philippines in 2008 points to a growing need not just for doctors but for other types of health workers as well:


However, at the time of the said research, these were the available positions:


Now considering the cost of training health workers, and hence projecting the investments needed to produce the required number of health workers, a broad national strategy has to be crafted in order to match the need for HRH vs the available HRH supply vs the positions available in both public and private sectors, rural and urban settings vs the investments needed by both government and private sectors to address the HRH gap.


For me, evidence should drive the strategy, not emotions or mere subjective opinions so that we would be able to arrive at the sanest, most feasible policy interventions that will benefit the country, and not just appease specific group or individual vested interests..

Let us all remember, too, that the issue is complex and multi-factorial, hence the approach needs to take on a systems perspective so that all bases are covered and the complexities are addressed in a comprehensive manner, and not biased for or against any particular group..

Minerva  Yes indeed, Evidence to drive Strategies and Advocacy to drive Change!

Ted  Edge. I agree with you. This problem has been there since the 1960's. This is not a sole Philippine issue. To think sin taxes can solve it nor should we blame a decentralized health system. We need to have also a global view as the Philippines is sourced by other countries for HRH. Globalization factors play a major role. Then there is an issue of geographic and economic maldistribution.

Maria  We need to analyze the impact of devolution on health services. People keep on thinking that health is just a domain of the DIG. While the direction and general programs emanate from DOH, the implementation rests on the LGUs. Agree that evidence is key but we need to look at areas where research is needed.

We need to analyze the impact of devolution on health services. People keep on thinking that health is just a domain of the DIG. While the direction and general programs emanate from DOH, the implementation rests on the LGUs. Agree that evidence is key but we need to look at areas where research is needed.

Gilbert  Not news anymore. It has been like that for ages. Hindi pwedeng madaliin ang solution kasi Baka lumabnaw. Mas mahirap Kung ang manggagamot ay hilaw. Think out of the box. Fix the system. It may obviate the need for numbers.

Edge  Hi Sir Ted, yes, the HRH problem is not just a national problem, it is a huge global challenge. Hence, if we are to think outside of the box, as Gilbert suggests, the policies that should be adopted must be a combination of both "train for export" and "train for local needs" approach so that the numbers being produced will be able to cater to both markets. The western-oriented medical education we are getting from Philippine schools makes our graduates capable of competing in the global HRH market, which is both a boon and a bane for the country. Nevertheless, from a global perspective, it is not at all bad for the global community if you look at HRH as global "common good".

Looking more closely at the national situation, the greater challenge is the maldistribution of doctors and other health workers in favour of urban areas, hence much more effective "HRH deployment policies" are needed, coupled with attractive incentives to make our graduates want to go and work in rural settings, as well as retention policies that would want them to stay. This goes without saying that the training of medical students should include skills development in managing municipal or community-based health systems, from advocacy to resource mobilisation, community financing, health planning, etc..

If we are looking at "structural change policies", then clearly, financing of training as well as remuneration of health workers, focusing on provider payment mechanisms should be radically revamped. Investments in training should cater to both the global and local markets, while compensation package for doctors or other HWs should be made much much more competitive to ensure a decent quality of life for the HW and his/her family. International development organizations and multinational companies have an adjustment rate depending on the degree of risk present in the area of deployment. Same approach could be used in the country where there is a factor to be added to the compensation package depending on how remote or underserved the rural area is. Of course, based on our experience with the DTTBs, an attractive training programme like the MBA-Health from Ateneo, supported by Pfizer and other private corporations, should be made available to those who would decide to work in these areas.

Holding them back to work in the country for a couple of years before they're allowed to compete in the global market is fine, but without providing the requisite training, structural changes and support systems will stifle our graduates' professionaldevelopment rather than incentivize them to stay and work for health development in the countryside. And I am saying this based on personal and professional experience as a community-based health practitioner from way back...

Tony No one has ever thought of addressing health inequities in one piece. Always fragmented. People. Process. Infrastructure. System approach.

Two years to ago in this admin - nothing has changed. . Still hopeful.

Ted to plan for both is just too expensive and risky. If we don't have excess HRH, why export it? Simple supply and demand, if we don't have enough doctors, then shouldn't we just ban them from leaving the country? The DOH gives a clearance for any physician who wants to train abroad. It certifies that their training is necessary and yet they never come back! Just some radical thoughts. Shouldn't we just ask those doctors licensed by PRC to come home and serve the country or loose their license? They can't practice abroad without a current license from their origin, well except those who have immigrated. Wouldn't these double the Physician numbers locally? Radical solutions an authoritarian state would do!

Nonoy Oplas A year ago, Jan 23, 2013, Dr. Jaime Galvez Tan gave a lecture at the AIM on "Who will Heal Us Now?" re unavailable or under-utilized health human resources. Gave figures like to balance the need for more doctors, some P3.07 B will be needed by the government; P13.6 B to get more nurses; P7.06 B to get more midwives; total, P23.77 B. Then he explained why government should focus on getting more nurses. Some of his slides here, http://funwithgovernment.blogspot.com/.../socialized...

Re Edge  proposal to liberalize the mobility of Fil doctors globally, it is a wise proposal. Why?

1. "Brain drain" is temporary; they leave as young doctors, many of them will come back as highly specialized physicians, or as doctor entrepreneurs, putting up their own hospitals and specialized clinics. Plus the money, network, tech transfer they bring in. That's "brain gain".

2. The more restrictions and prohibitions that government will impose, the more government corruption and black market transactions will happen. Classic cases are prostitution, drugs, jueteng and other gambling, all are supposed to be non-existent due to blanket prohibition, yet they are all around.

3. Being a physician or nurse, etc. is not a crime that practice anywhere should be heavily regulated by government. Government should focus its resources and energy in catching outright criminals, like the manufacturers and traders of fake and counterfeit medicines, fake and deceptive "cure all diseases" food supplements and drugs, etc.

4. Physicians who graduated from private universities (ie, non-taxpayers funded), the more that government should not dictate where they will practice. For UP College of Medicine and other state universities' medicine graduates government may impose conditionalities in exchange for taxpayers' subsidy of their education.

Rosel  One dimension of the issue is to understand health economics. Market forces will play a role. The supply of manpower to under served areas will rise if financial resources support it . We can look to the Petilla Model in Leyte. Incentivization schemes married to Philhealth enrollment and reimbursement strategies have provided a solution to the once serious physician manpower problem.

Ted  I disagree that the Brain Drain is "temporary" it's a lame excuse. 50% of success in anything is being present. The problem is lack of doctors. If 90% of your doctors leave for abroad or just stay in urban private healthcare! you can only serve as a factor for the richer countries. The real economic solution is to provide doctors compensation similar to what would make them leave. Yung doctors of first world countries don't go abroad for training, they lead the world with innovation from their own countries. Factory for the richer countries!

Adrian  I also agree that the brain drain is still continuing until now. With very poor incentives to stay, medical graduates will keep on leaving.

Nonoy Oplas So USec Ted, there is zero "brain gain" at all? None, zero of those Fil doctors who migrated and practiced abroad, ever come back to either practice here again or put up their own hospitals or clinics, and hire more young doctors, nurses, admin staff? I doubt that it is a realistic assumption.

Many doctors in rich countries cannot practice in developing countries because the latter impose protectionism and double standards. Their doctors, other professionals, can practice in N. America, Europe, Australia, etc. but they do not tolerate doctors from those rich countries to practice in their countries. Local doctors (and lawyers, engineers, accountants, nurses, pharmacists, etc.) are protected, they compete only among themselves here.

Adrian The trickle back is too little to support a viable health care system.

Ted  Yes the education of a doctor is just too long and expensive. All that investment is gained by the country that hired them. We have become a HRH factory for the world while our own people lack medical care.

Ramon Solutions should be systemic, from the selection of students from the rural areas, to a transformative health professional education, and to proper support from national govt, DBM and LGus. It certainly can not be achieved under the present "rationalization" plan of govt which is a euphemism for downsizing in the face of an increasing population!

Ted  The rationalization plan is for offices. The hospitals and health facilities have an increased staffing pattern. We have hired the 25% of the total required fot health personnel and downsized offices or Bureaus. More to services delivery.

Nonoy Oplas The one who made medicine education too long, too costly, is... government, through curricular regulations. The one who removes 1/3 of the monthly pay of fixed-income doctors (and other professionals and ord employees) via witholding tax alone is... government. The government is intervening, regulating and taxing more than what the regulated could tolerate. Adding another regulation like banning Fil doctors to practice abroad will only create more corruption, bribery and black market in government.

Doc Paterno, I do not see any significant indicators that the government is "downsizing" in healthcare. The opposite is happening, actually. Public health spending is rising via many govt agencies: (a) DOH and PhilHealth, (b) UP-PGH, AFP hospital, PNP hospital, other agencies, (c) own clinics with full time medical staff, free medicines, etc. in many big agencies (HOR, Senate, SC, BSP, state universities, etc.; (d) PCSO, PAGCOR spending and subsidies; (e) provincial, district, city hospitals; (f) regular LGUs health centers, from provincial down to barangays.

Adrian  Sir Nonoy: In the post-9/11 world, it's more difficult to smuggle in doctors than drugs. Comparing the effect of banning migration to banning these harmful substances is not a viable argument.

And protectionism preventing the practice of foreign doctors here? Requiring foreign physicians to get a visa, and to pass our board examination isn't such a significant barrier to practice. I don't think that's what's really preventing foreign doctors from practicing in developing countries. I think they DON'T WANT to practice here. Why? Financial incentives 

Nonoy Oplas Hi Doc Adrian. I am referring to large-scale corruption and bribery at DOH, Bu of Immigration, if there is a policy to ban Fil doctors to work abroad. That's what's happening now, large-scale corruption and bribery in government why prostitution, addictive/dangerous drugs, jueteng and other gambling, are still around even if the official policy is that they are prohibited, banned, disallowed. Even minor restrictions like rice protectionism creates large-scale corruption, like the on-going rice smuggling controversy. You create more prohibitions, more restrictions, you create more corruption, more robbery in government.

Protectionism is explicit in the Constitution. Not only foreign investments are restricted or banned, foreign professionals -- doctors, lawyers, engineers, accountants, etc. -- are also banned or restricted. There is big money to be realized here, otherwise big/multinational hotels, restos/food chains/coffee shops, banks and insurance firms, BPOs, etc. will not come here.

Adrian  Give us an example of those protectionist restrictions placed by the Philippine Government on foreign doctors, beyond the Medical Board Exam and a working visa.

And remember we are speaking of health professionals here, not prostitutes and drugs. How can a doctor practice abroad when he doesn't have legitimate credentials of entry?

Nonoy Oplas 1987 PH Constitution,
Article XII, National Economy and Patrimony
"Section 14. …. The practice of all professions in the Philippines shall be limited to Filipino citizens, save in cases prescribed by law."

There is no law yet as far as I know, allowing foreign doctors, nurses, pharmacists, dentists, etc. to practice here.

From Arangkada, it says,
"laws regulating... pharmacists, and radio and x-ray technologists state the profession is restricted to Philippine nationals and contain no reciprocity provision."
http://www.investphilippines.info/.../foreign-equity-and.../
All countries allow, prohibit, or restrict foreign economic activity within thei...See More

Adrian There is a law, dear sir. Sections 8 and 9 of RA 2382 show that foreign professionals are allowed to register and practice as physicians once they pass the board exams here, as long as the countries reciprocate with similar regulations.

http://www.lawphil.net/.../repacts/ra1959/ra_2382_1959.html
Republic Acts -THE MEDICAL ACT OF 1959

Nonoy Oplas Come on, Medical Act of 1959, enacted on June 20, 1959, has precedence or supremacy over the 1987 Constitution? Can you cite foreign doctors practicing here using RA 2382 as their basis, and they are allowed by the PRC?

Adrian  Um, the Supreme Court has also settled this legal question.

http://sc.judiciary.gov.ph/juris.../2008/july2008/166097.htm
sc.judiciary.gov.ph
          Before the Court is a Petition for Review on Certiorari assailing the ...See More

Melvin  Doctors are leaving because of low pay and oppressive taxes. Then there are so many pseudo doctors and pretenders like some nurses I know, some hilots, comadronas, fake doctors. Many patients are poor and would rather "borrow" the prescription of their neighbors, friends and relatives. Then there is Philhealth which strictly adheres that all Filipinos should have Philhealth. Good idea but there are loopholes. How fast does Philhealth pay doctors fees? Ages or probably never.

Adrian The question, sir Nonoy, is: why aren't they coming here? Is it possible that practicing here isn't as attractive as it seems? 

Nonoy Oplas  "Yasuyuki Ota (respondent) is a Japanese national, married to a Filipina... failure of respondent to prove that there is reciprocity between the laws of Japan and the Philippines in admitting foreigners into the practice of medicine. Respondent has satisfactorily complied with the said requirement and the CA has not committed any reversible error in rendering its Decision dated November 16, 2004 and Resolution dated October 19, 2003.

WHEREFORE, the petition is hereby DENIED for lack of merit."

Yes, the SC has ruled on it -- foreign doctors, even if they took their medical education here, even if they practiced intership here, even if they pass the PRC medical board exam, can NOT practice medicine here, unless there is explicit reciprocity bet. their governments and the PH government.

So to your question, "why aren't they coming here?"
Because they are not allowed to come and practice here.

Ramon Ted agree RAT plan is for offices but take this example: probably one of the more important office in DOH and for that matter in the health sector, is the health promotion bureau. RAT plan has reduced , decimated its personnel. Rat plan is a manifestation of a small govt mentality that DBM is applying to HHR in the community. LGUs are constrained from increasing their HHR because of PS/MOOE ratio requirements

Eduardo  Kung ang salary packages ng gobyerno sa congressmen at senators ay at least 200k a month...bakit Hindi sa MDs?

Nonoy Oplas Doc Ed, Senators and Cong. have slam-dunkin salary + pork barrel packages because they are also expert in slam-dunkin tax-borrow-tax policies. Would MDs also want to follow their path? J

Eduardo  that's the simplest way to entice MDs to practice outside the cities....Baka nga konti pa rin pumatol dyan....Kung yung mga taong nagbibigay ng inessential services nga binabayaran natin ng ganyan eh bakit Hindi MDs?

Melvin  The worsening lack of doctors indicates that the number of doctors graduating from med school, passing the board exam and eventually deciding to practice here in the Philippines cannot keep pace with the growing population of baby bloomers who are by now in their 50's 60's and 70's plus the growing pediatric age group and women in the reproductive age group. Doctors leave because of lack of incentives to stay and the lucrative practice abroad is very attractive. Raising doctors salaries to 200k is a very attractive incentive. Well trained doctors are equivalent to the CEOs of private and government corporations and much more because doctors care for the well being of Filipinos and their families.

Adrian  Nonoy: Sorry, I think you misread. The petitioners are the Board of Medicine. The respondent is the Japanese doctor. The petitioners were unsuccessful at preventing the practice of the Japanese doctor here, that's why, as you quoted very nicely, the "petition is denied for lack of merit" 

Nonoy Oplas OK Adrian, Yes I misread the SC decision, thanks for persisting on it. Then there should be other regulatory bottlenecks that discourage or even outrightly prevent foreign doctors from practicing here on a long term basis. I think short-term practice is allowed, like bringing in a foreign specialist if the patient is incapable of travelling abroad, the PRC gives temporary permit.

Adrian  I'm just puzzled why you refuse to engage on the point that there really is a lack of incentives for any doctor (Filipino or foreign) to practice here.

Bakit kelangan dahil sa barriers ang lahat? I mean, I know you're with the NGO Minimal Government Thinkers because we share mutual friends who know you. But sometimes, we have to think beyond our own advocacy.

Nonoy Oplas Look Adrian, there ARE foreigner bankers, hotel managers, securities traders, headhunters, BPO leaders, etc. here, meaning those foreigners smell the profit and money in practicing their profession here so long as there are no clear and explicit barriers to them. Medical and legal practices, engineering, architectural and accounting practices, are big money making professions here, so the attractiveness -- financial and professional -- is there. Why the foreign doctors (and lawyers, engineers, pharmacists, etc.) are not here, the most likely factors are government bureaucracies or outright prohihbitions. Not fear of the NPAs or Abu Sayyaff or professional kidnappers.

You can extend the question to Why are Harvard, Wharton, other big international universities, not here? Or big international hospitals not here? It's not financially attractive to put up a business here? The answer is No. Many Filipinos can afford expensive international schools from elementary to high school, many Filipinos send their kids abroad for tertiary education. The root is with government regulations if not prohibitions, starting from the Constitution down to getting certification or authorization from various agencies and departments.

Adrian  Are you saying that these protectionist policies are selective for "big money-making" professions? Because even the examples you cited, like BPOs, hotels, food franchises, are making it big here. They've made it past all these regulations and they're earning a lot.

I will agree that corruption is a turn off for investment. I will also agree that the less red tape there is, the better things are.

But at THIS MOMENT, is there any more red tape than there is in, let's say, the US? or in Japan? or in the other ASEAN countries?

Don't you think that there are OTHER things that affect a decision to invest, or migrate, than government red tape? Because you make it seem like it's the single most important reason why people don't stay 

Nonoy Oplas I did not even mention "corruption" or "red tape" above. I mentioned "regulations if not prohibitions". Putting up a foreign university, foreign media, etc. here is not allowed under the Constitution.

Adrian  But we're talking about the health care workforce. There's already a legal precedent for foreigners to practice here. Clearly, the migration of doctors, nurses, physical therapists, is NOT because of government clamping down on them.

In fact, it might be the reverse. The government may not be paying enough attention to the welfare of government health workers! There is little incentive to stay.

And red tape refers to government regulations and prohibition. Just in case you thought it meant something else.

http://en.wikipedia.org/wiki/Red_tape
en.wikipedia.org
Red tape is excessive regulation or rigid conformity to formal rules that is con...See More

Nonoy Oplas I avoided using "red tape" above because I don't think it's the main explanation why foreign HC professionals are not coming here. You just keep using it as if it's coming from me.

Again from Arangkada,
"laws regulating... pharmacists, and radio and x-ray technologists state the profession is restricted to Philippine nationals and contain no reciprocity provision."

It's the outright prohibition, bawal, hindi pwede.

Adrian  Sigh. There is an SC decision. Hope we don't have to post that again 

Nonoy Oplas You should have your own answer to your question why foreign HC professionals are not coming here.

Adrian  I stated it earlier, and repeatedly. Lack of incentives. 

Nonoy Oplas So be it. You may be right.

Re Docs Ed and Melvin's proposal to raise the monthly pay of (government) doctors to P200k/month so they may be encouraged to practice outside of M.Mla and not work abroad, and hence plug the lack of doctors, I don't think it's a sound proposal. For one, hiring of govt physicians receiving that level will be heavily poiticized. Congressmen and Senators who approve and appropriate the annual DOH budget (raise or retain or cut it) will definitely pressure the DOH to hire their kids or siblings ot close relatives and friends despite lack of eligibility.

Two, the fiscal cost will be very high. You don't just give doctors high pay, you must also provide high caliber facilities and laboratories to maximize their talent. In a situation where even a P2/tablet can become P10 or more under some govt procurement, abuse of such new high spending is not a far out possibility.

The PH's public debt or government debt stock is rising by P400 to P450 billion a year. With or without econ crisis, the government simply over-spends yearly and hence, over-borrows yearly. Interest payment alone of about P334 billion a year is the single biggest leakage from the annual budget. The big challenge for government actually is how to live within its means, to limit spending to what its domestic revenues can finance and avoid borrowing whenever possible.


Tony  We need to plug all loopholes. Human resources and infrastructures should be improved with sin tax funds. It's a big opportunity that past admin missed out. I see silver lining here.
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