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 Table of Contents  
BRIEF COMMUNICATION
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 168-173

A community-based strategy in medical education of the university of the philippines manila-school of health sciences – Lessons from innovations in human resources for health development in a developing country


Medical Department, School of Health Sciences, University of the Philippines, Manila, Philippines

Date of Web Publication23-May-2019

Correspondence Address:
Charlie Ercilla Labarda
Medical Department, UP Manila-School of Health Sciences, Bgy. Luntad, Palo, Leyte
Philippines
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_366_13

  Abstract 


Background: After nearly four decades of testing an innovative model for training health workers for marginalized communities, the evidence base for the impact of University of the Philippines Manila-School of Health Sciences (UPM-SHS) medical program needs to address important gaps. Has it succeeded in contributing toward socially accountable medical education where medical schools will be evaluated in terms of their contribution to society's health outcomes? To answer this question, this study examined human resources for health (HRH) inequity in the Philippines and reviewed the medical school's performance in terms of addressing HRH distribution. Methods: The evaluation of the school's performance was done through two phases. Phase 1 involved generating HRH inequity metrics for the Philippines through secondary data. Phase 2 involved gathering primary data and generating performance metrics for UPM-SHS. Results: We found challenges that UPM-SHS needs to address based on the analysis of its student admissions from 1976 to 2011: targeting the right underserved communities, especially at the municipal level; addressing issues of high leakage and undercoverage rates in the program; ensuring mechanisms for return service are in place at the community level; and tracking and measuring program outputs and impact on community health outcomes. Discussion: Given this study on the performance of UPM-SHS to produce a broad range of health workforce to address the needs of marginalized communities in the Philippines and in similarly situated countries, there is a need to reassess its HRH development strategy. If it wants to build a critical mass of transformational health leaders to meet the needs of poor communities as part of its social accountability mandate, it needs to accelerate this development process.

Keywords: Health human resource, health inequity, medical education, social accountability


How to cite this article:
Labarda CE, Pilar Labarda MD. A community-based strategy in medical education of the university of the philippines manila-school of health sciences – Lessons from innovations in human resources for health development in a developing country. Educ Health 2018;31:168-73

How to cite this URL:
Labarda CE, Pilar Labarda MD. A community-based strategy in medical education of the university of the philippines manila-school of health sciences – Lessons from innovations in human resources for health development in a developing country. Educ Health [serial online] 2018 [cited 2019 Jul 19];31:168-73. Available from: http://www.educationforhealth.net/text.asp?2018/31/3/168/258928




  Background Top


A cornerstone of the work of the University of the Philippines Manila-School of Health Sciences (UPM-SHS), toward health equity, is its innovative student recruitment policy, directly admitting scholars endorsed by targeted poor communities in need of health workers.[1] Over 36 years of testing this innovative model for training health workers for marginalized communities, UPM-SHS is at the crossroads. Thus, there is the need to assess what it has achieved in terms of its mandate to become a relevant center of excellence for innovative human resources for health (HRH) development for the attainment of health, particularly for underserved and marginalized communities.[2] The evidence base is not robust, with retention rates of medical graduates serving as the only proxy measure for evaluating performance of UPM-SHS.[3] Although attrition of health workers due to out-migration continues to characterize the Philippine health system,[4] there is an increasing demand to measure the impact of medical schools related to other population-based health indicators.[5]

In its mission statement, UPM-SHS was tasked: (1) to produce a broad range of health workforce that will serve the depressed and other underserved communities and (2) to design and test program models for health human resource development that could be replicated in various parts of the country and hopefully, in other countries similarly situated as the Philippines.[6] The mandate of UPM-SHS expressly identified the recipients of its activities as an academic institution – to serve the needs of marginalized communities. The definition of marginalized communities refers to poor and underserved groups. Therefore, income class and health workforce complement of communities were important parameters for targeting client municipalities and villages.

The WHO report of 2006 suggested a threshold of 2.28 health-care professionals (defined as doctors, nurses, and midwives) to achieve 80% coverage of the population.[7] With a health professionals density of 0.82 [Table 1] and a population of around 92 million at the time of the study, this meant the Philippines has an absolute shortage of 138,000 health workers to deliver critical health services in an equitable health system. To enrich the analysis on health workforce distribution, the degree of inequality among various regions of the country was compared, using the Gini coefficient as index of inequality. The formula developed by Deaton was utilized for this purpose.[8]
Table 1: Regional health workforce density per capita and index of inequality

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  Methods Top


The objectives of this study were as follows: (1) to review UPM-SHS performance in terms of addressing inequity in HRH distribution and (2) to generate a set of key performance indicators (KPIs) for the institution. In [Figure 1], the mission statements of the UPM-SHS were linked to key result areas and KPIs generated through key informant interviews.
Figure 1: Performance measurement matrix

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For the first mission, to produce a broad range in health workforce, five performance indicators were identified. They were proportion of students from each region, proportion of students from each municipal income class category, proportion of each type of health worker produced by the school, annual average rate of production of each type of health worker, and proportion of medical graduates who passed licensure examinations.

For the second mission, to design and test program models for HRH development for the Philippines and countries similarly situated, KPIs were proportion of graduates absorbed and retained by sending communities, proportion of graduates serving at various levels in the health system, and proportion of graduates who migrated.

The recruitment units of the school were local government units, particularly poor rural municipalities. The focus on rural communities recognized that the urban–rural maldistribution of health workers has exacerbated the lack of access to health care of poor communities.[9] A KPI was the percentage of students coming from each municipal income class classification based on the government's classification system.

Analysis of the school's graduates was based on data generated by the College Secretary's Office and the Dean's Office from the graduate tracking survey of SHS students from 1976 to 2011. Two thousand and thirty-one students who entered the stepladder program as midwifery students and had complete records were included in the study. Six hundred and seventy-six students who either did not have complete records or had dropped out of school were excluded from the study. About 126 students entered the medical program and were included in the analysis of the medical program. Nearly 21% of the medical graduates were lateral entrants, mostly coming from the Autonomous Region in Muslim Mindanao (ARMM), nominated through the department of health.


  Results Top


Assessing University of the Philippines Manila-School of Health Sciences targeting system

A review of the geographic source of students of the UPM-SHS showed that as of 2011, they came from all regions of the country, except for the National Capital Region. Most of the top-sending regions are among the most impoverished areas of the country, including Eastern Visayas, Caraga, ARMM, Cordillera Autonomous Region, and Bicol Region [Table 2].
Table 2: Regions with poorest human resources for health density versus top 10 School of Health Sciences source regions

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About 1096 students who entered the program came from Eastern Visayas, comprising 54% of total enrollment. Region 4B (MIMAROPA), with 164 students or 8.1% of total, was a distant second. It was apparent that the geographic location of the main campus in Tacloban City and then later to Palo, Leyte, had a significant influence in terms of recruitment since both are located within Eastern Visayas.

Source municipalities and their socioeconomic characteristics

In the Philippines, municipalities are classified according to six income classes, depending on their average annual income for the past 4 years. Municipalities with the highest incomes are classified as first-class municipalities with the poorest categorized as sixth-class towns. Most students came from fourth- and fifth-class municipalities comprising about 55% of the total admissions. Students from first- to third-class municipalities comprised 43.2% of total enrollment. Only 1.8% came from sixth-class municipalities, the poorest income class unit.

Types of health professionals produced

UPM-SHS offered three major programs that produced three categories of health professionals: midwives, nurses, and physicians (Levels 1, 2, and 3, respectively). The majority graduated as nurses with about 50.9% of the total number of graduates. Students who finished midwifery comprised 44.5% of graduates with only 4.6% graduating from the medical program. The very low figure for medical doctors and the high number of nurses reflected the distortions in the national health workforce complement. The bottleneck occurred at the nursing program with very few proceeding to the medical program (Level 3).

Number of health professionals produced

For the past 36 years, UPM-SHS produced an average of 99.6 health workers annually or about 100 health professionals. Of the 100 graduates each academic year, the school produced five physicians, 33 nurses, and 62 midwives. This showed that the bottleneck occurred at the nursing to medicine transition with the medical class only 12% of the nursing cohort. That is, out of every 100 nursing students, only 12 went on to the medicine program.

Licensure examination passing rates

About 79% of medical graduates passed the National Physician Licensure Examination. Recent performances in board examinations have been encouraging with several instances where graduates had a 100% passing rate in the physician licensure examination.

Return service to communities: School of Health Sciences medical graduates

A return service leave provision was integrated in the stepladder curriculum where midwifery and nursing students return to their communities for at least 1 year to serve before they can proceed to the next level in the ladder. Data showed that among medical graduates, 53.6% returned to their sending communities while 46.4%, for one reason or another, were not able to return to their communities. Several factors were identified as contributory to this lack of retention in these communities: (1) lack of regular item or position in the municipality; (2) political persecution by virtue of being identified with another politician (e.g., being endorsed by the former mayor or official who is now out of power); (3) lack of economic incentives to stay; (4) lack of opportunities for professional growth; and (5) better offer somewhere else.

Location of health service delivery and migration

Most of the medical doctors from the school, at about 55.2%, are serving in primary care level facilities. Only 20% are in the secondary level and 12.8% in the tertiary level facilities. In terms of migration pressure, only about 10.4% of medical graduates have migrated while losing 1.6% to other sectors (e.g., business and education). This low attrition rate due to migration is a significant achievement considering that other publicly funded medical programs are losing many of their graduates to the global labor market for health professionals.


  Discussion Top


Lessons learned after 36 years

This attempt to evaluate the performance of a socially accountable medical school, using its mandate as a framework, has yielded some valuable insights.

Maldistribution of health workers

Addressing maldistribution of health workers is harder at the lower levels of community organization. The analysis showed that of the top 10 regions in terms of poor HRH density, only five of these were included in the top source regions of the school. A closer look at the provincial level showed a more significant pattern of mismatch between target communities with the poorest HRH densities and the top provincial sources of students for the last three decades of operations. Of the 10 worst provinces in terms of HRH density, only two made it to the top 10 source provinces [Table 3].
Table 3: Comparison of provincial human resources for health density and provincial admission source

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Undercoverage and leakage plague recruitment efforts

Both undercoverage rates and leakage rates are serious problems in interventions designed to address health workforce issues. The high proportion of students coming from first-, second-, and third-class municipalities (i.e., higher income class towns) reflects the operational challenges of achieving a more equitable distribution of health workforce among depressed and underserved communities. The target communities for recruitment were fourth- to sixth-class municipalities, with the higher income class municipalities not the priority communities for student recruitment. However, targeting accuracy was problematic as revealed by looking at Type 1 (undercoverage or exclusion) error and Type 2 (leakage or inclusion) error.[10] Undercoverage rate shows the proportion of target communities not able to avail of the program while leakage rate refers to beneficiaries who were not actually targets for the program but were able to avail of it. An analysis of the targeting performance of UPM-SHS in terms of recruitment at the municipal level showed a leakage rate of 50% and undercoverage rate of 62% [Table 4].
Table 4: Leakage rate and undercoverage rate for target municipalities

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Global and local labor market forces shape the supply of health workers

Despite community-based processes to ensure commitments from student scholars to return to their home communities, a large proportion failed to go back for return service. Securing formal return service agreements and legislating local ordinances guaranteeing employment can help address this issue. Further, despite efforts to broaden the number of programs being offered by the school to include pharmacists, dentists, medical technologists, and sanitary inspectors, there has been no substantial progress on this front. This is a major issue that needs to be addressed by the school to fulfill its mandate to produce a broad range of health workforce for the country.

Imperative for linking health outcomes with admission policies

The need to link the school's work in health workforce development to community-based health outcomes is imperative to address declining public investment in the program. The fact that admission to the school is not by application but by community nomination has its drawback. It deprives the school of a pool of applicants coming in through the regular admission process of the university through a competitive entrance examination. Thus, the small pool of students makes the program expensive to run compared to the other units of the university. Further, recruited students have poorer academic backgrounds compared to other students who passed the admission test of the university. The generally poor passing rates of UPM-SHS students in the past compared to the other university students could reflect this disparity, putting more pressure on the school to justify public expenditure for the program.


  Conclusions Top


After nearly four decades of work in training health workers for poor and underserved communities in the Philippines, it is an opportune time to reflect on the accomplishments of UPM-SHS. It has produced >2000 health workers, among who are >100 medical doctors. Ninety percent have stayed in the country, counter to the trend of migration of health workers. Nearly 60% have continued to serve in their local communities or within immediate environs. Nearly 60% also have stayed in primary care level facilities. All of this occurred despite problems of implementation, like the gross regional imbalance of recruited students and the difficulties in targeting appropriate poor communities.

With very little public investment due to declining budgetary allocation, the UPM-SHS as an institution has continued to faithfully pursue partnerships with poor communities with the help of like-minded stakeholders from the private and public sectors. It is hobbled by the lack of facilities for training and research, funding limitations, and seeming isolation from the larger academic community due to its innovative programs.

The next challenge is to transform these innovations from being an “experiment” to a science, by building appropriate knowledge management based on research evidence. To build a critical mass of transformational health leaders as part of its aspiration to contribute toward socially accountable medical education, the school needs to accelerate this development process.

Acknowledgments

We wish to acknowledge Prof. Jusie Lydia Siega-Sur (former Dean) and Prof. Zenaida Varona (former College Secretary, retired) of UPM-SHS for their help in providing the data in this study.

Financial support and sponsorship

Fellowship grant from the University of the Philippines supported the author during the research for this paper.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bonifacio AF. The institute of health sciences: A strategy for health manpower development. In: Tayag JG, Clavel L, editors. Bringing Health to Rural Communities: Innovations of the U.P. Manila School of Health Sciences. Manila: U.P. Manila Press; 2011. p. 17-20.  Back to cited text no. 1
    
2.
The University of the Philippines-Manila. School of Health Sciences Recruitment Primer Stated the Goal of the School – To Train Midwives, Nurses and Doctors who will Stay and Serve in Depressed and Underserved Areas of the Philippines Rather than go Abroad. The University of the Philippines-Manila; 2013. p. 2.  Back to cited text no. 2
    
3.
Tayag JG. Where are the alumni? In: Tayag JG, Clavel L, editors. Bringing Health to Rural Communities: Innovations of the U.P. Manila School of Health Sciences. Manila: U.P. Manila Press; 2011. p. 209-17.  Back to cited text no. 3
    
4.
Labarda MP. Career shift phenomenon among doctors in Tacloban city, Philippines: Lessons for retention of health workers in developing countries. Asia Pac Fam Med 2011;10:13.  Back to cited text no. 4
    
5.
Global Consensus for Social Accountability of Medical Schools; 2010. Available from: http://www.healthsocialsccountability.org. [Last accessed on 2016 Apr 12].  Back to cited text no. 5
    
6.
University of the Philippines Manila. U.P. Manila Catalogue of Information. Manila: University of the Philippines Manila. U.P; 2005-2010. p. 221.  Back to cited text no. 6
    
7.
World Health Organization. The World Health Report 2006: Working Together for Health. Geneva: World Health Organization; 2006. p. 11-3.  Back to cited text no. 7
    
8.
Deaton A. The Analysis of Household Surveys: A Microeconometric Approach to Development Policy. Baltimore MD: Johns Hopkins University Press (Published for the World Bank); 1997. p. 139-40.  Back to cited text no. 8
    
9.
Salafsky B, Glasser M, Ha J. Addressing issues of maldistribution of health care workers. Ann Acad Med Singapore 2005;34:520-6.  Back to cited text no. 9
    
10.
Grosh ME, Baker JL. Proxy Means Test for Targeting Social Programs. Living Standards Measurement Study Working Paper Number 118. Washington, DC: The World Bank; 1995. p. 8-9.  Back to cited text no. 10
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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