Author: Diana Francesca Gepte
Editor: Akihiko Ozaki M.D.,
I was 13 years old when I watched my uncle as the Department of Health spokesperson on Philippine television during the 2003 SARS outbreak, and I decided in that moment that I wanted to be a medical doctor. At such a tender age, I had no conception of the challenges ahead, but I chose to take the path anyway, both with excitement and a deep sense of courage.
The Philippine education system, including medical education, is heavily influenced by the American system of education. This is primarily due to periods of foreign occupation, with the United States leaving the most remarkable impression. In this system, it is a requirement that, in order to pursue higher education (i.e., postgraduate studies such as law or medicine), a student must be able to complete elementary education, high school, and an undergraduate or bachelor’s degree program. The duration of a bachelor’s degree program is a minimum of 4 years. A high school graduate who would later like to pursue medical education may actually choose any degree program for undergraduate studies; for example, he or she may choose a health-related course (e.g., BS Nursing, BS Occupational Therapy, BS Speech Pathology) or a non-health related course (e.g., Culinary, Engineering, Music) as a pre-medical course. Those who have completed a non-health related course will need to add Biology, Chemistry, Physics, and Math units to be eligible for medical school.
I was 17 when I began my Bachelor of Sciences in Public Health as a pre-medical course in the University of the Philippines-Manila. I chose Public Health as an undergraduate course with only the knowledge that it would help me achieve my ultimate goal. Later, after immersing myself in 4 years of Public Health, I realized that it has given me gifts other than the competencies I needed to enter medical school. It has granted me insight and the passion and patience required for research.
I describe myself as an average student, as there are a lot of brilliant others who perform exceptionally in class, but I truly believe I am lucky. Being competitive is a requirement since the admission process of medical schools is a rigorous competition. Generally, the criteria for selection include the student’s grades in the undergraduate course, the results of the National Medical Admission Test (NMAT), and a final interview with a panel from the admissions committee. The NMAT is a set of tests that measure a student’s aptitude in the Maths and Sciences. The NMAT scores required by medical schools vary; for example, at the University of the Philippines College of Medicine and the Ateneo School of Medicine and Public Health, the minimum score is a 90th percentile, while the minimum score is a 85th percentile at the University of Santo Tomas. At the medical school I attend, the NMAT requirement is a minimum of a 45th percentile, but this relatively low requirement does not reduce the level of competition. In order to beat thousands of applicants for the prized slot, the NMAT score should be greater than or at the level of the 99th percentile. Lastly, an individual needs to convince the panel interviewers that he or she deserves the opportunity to be educated and that he or she will one day be useful to society in prolonging life and promoting health. The interview stage is key; some applicants have very high grades and NMAT score but still do not make the cut because they fail the interview process. Alas, the average but lucky student is not accepted to a medical school, such as the Pamantasan ng Lungsod ng Maynila College of Medicine.
To date, there are about 38 medical schools in the Philippines. Out of the ten best performing medical schools in the Philippine Physician Licensure Exam (2016), only 3 out of 10 are public medical schools, and the rest are private institutions. The tuition and other fees are exorbitantly high: the private medical education of a course costs more than that in public medical schools. Studying in a public institution, my tuition and other fees amount to about Php 160,000/year (about USD3200), while my friends who attend private schools pay about Php 300,000/year (about USD 6,000). Additionally, there are other costs such as condominium or dormitory rent, food, and living allowances for the entire duration of medical school. Despite the high medical school fees, Philippine medical education is cheaper compared to other countries; for example, in the United States, the cost of attendance ranges from USD 50,000 to over USD 70,000. Because Philippine medical education is relatively affordable, a considerable number of foreign students from India, Nepal, Africa, and other parts of the world are enrolled in mostly private medical institutions for training.
The duration of a proper medical school is typically 5 years. In the first and second year, students are taught basic medical sciences, and on the third year, clinical and diagnostic approaches are emphasized. The last 2 years are spent on a clerkship and internship, which include practical years of intensive hospital training. After the internship, the medical student becomes eligible to take the Physician Licensure Examination (PLE). The PLE is administered twice a year, in the months of September and March. Every time it is conducted, about 3,000 students take the examination, yielding about 6,000 medical doctors every year. Despite the large number of doctors produced annually, many medical and healthcare positions in rural and geographically isolated and disadvantaged areas (GIDAs) remain vacant since work opportunities in the urban setting and abroad appear more attractive and profitable. As a result of this undersupply of medical doctors in rural areas, the delivery of healthcare is delayed as sick patients endure long travels to other municipalities or to the provincial capital to seek consult.
New medical doctors are given many opportunities for training and practice. The duration of the residency training programs duration from 3 to 5 years, and further specialization entails longer years of education. According to the Philippine Health Systems Review in 2011, the most common tracks taken by doctors are Internal Medicine (17.5% of all physicians), Pediatrics (15.5%), OB-Gynecology (12.5%), and Surgery (10.6%). For those who do not want to pursue further training immediately, they can choose to do moonlighting. Moonlighting is the practice of medicine as licensed physicians with direct financial compensation. This provides avenues to reduce the debts incurred during medical school, augment the doctor’s income, and provide experiences and insight that could not be realized within the walls of a hospital.
I believe one of the most serious issues regarding the health workforce is that the meager compensation for doctor, nurses, and other allied medical professionals is not commensurate with the cost of education and workload. Although the salaries of medical doctors are higher than the national capital’s minimum wage of Php 12,500 (USD 250), these are not sufficient to pay the debts incurred during the study of medicine as well as the needs of doctors and their families. Presently, a junior resident in a government hospital earns only about Php 30,000 (USD 600) per month, while a more senior resident earns more or less Php 40,000 (USD 800).
This mismatch in wage and the labor offered by the physician prompts immigration to higher-income countries. Other reasons for migration include professional and career development and the attraction to higher living standards. These result in a large shortage of 1 doctor for each population of 28,493, which is far below the WHO recommendation of 1 doctor for each population of 1,000. According to the Philippines Health Systems Review (2011), from 1997 to 2008, there is a total 3,678 physicians who work overseas, and of these, 66.3% have migrated permanently. Also, according to Dr. Alberto Romualdez (2008) from the University of the Philippines College of Medicine (UPCM), 90% of the graduates of the class of 1960 and 88% of those from the class of 1965 have left the country.
In order to address the issue on the dispersion of Filipino doctors, the University of the Philippines College of Medicine (UPCM) implemented the Return Service Agreement (RSA) in 2011. It is a contract that requires all students to render 3 years of return service in a health-related public or private institution in the country after completion of the medical program and obtaining the licenses. This strategy is not a definitive solution but will delay the migration of physicians while the next batches are still undergoing training.
It is also worth mentioning the Department of Health’s (DOH) Doctors to the Barrios Program (DTTB) as a strategy to address the shortage of doctors in remote areas in the country. This 2-year deployment of medical doctors to rural areas was launched in 1993, but monitoring and evaluation of the program showed that very few doctors chose to remain for an extended period and/or be absorbed by their Local Government Unit (LGU). Several factors affect the retention of doctors in the community, which include DOH and LGU support, family issues, and career advancement opportunities. In order to make this program more attractive to volunteer doctors, the compensation was increased to Php 54,000 (USD 1,080) as of 2014. Hopefully more doctors will volunteer to join this program and cater to the needs of the poor and underserved.
With regard to the reduction of the cost of medical education, the current president of the Philippines, Rodrigo Duterte, recently approved free tuition fees but only to state universities in the Philippines. Presently, Senate Bill 526, which was filed by Senator Antonio Trillianes, is waiting to be passed. The bill aims to increase the basic pay of Filipino doctors to no lower than Salary Grade 27 or 73,937 (USD 1,586). Unless the government offers decent wages, salaries, and other incentives, the diaspora of medical professionals will continue to threaten the workforce, which will severely affect the delivery of healthcare.
As a third-year medical student, I understand that the journey is far from over. I have a long way ahead—a lot of lessons to learn, skills to develop, and experiences to gain. Despite the difficulties of the medical program, and the gaps and failures of the Philippine healthcare system, I feel confident and positive that our contributions to healthcare can indeed make the world a better place.