DOCTORS AND PATIENTS

15 February 2025

DOCTORS IN THE CITY:

Dr. Enrique Reyes, a urologist, and his wife Brenda, an anaesthesiologist, have both been practising in Manila for some 20 years. After graduating from medical school, Enrique took his speciality training in the UK, whilst Brenda took hers in Singapore.  

For doctors like the Reyeses, life in Manila is busy, busy, busy. Dr Brenda reminds the interviewer, “There is only one doctor per 1,500 residents in Metro Manila".  

To cope with their number of patients, husband and wife wake up early in the morning, navigate their way through traffic to reach the major hospital where they hold clinic. They don’t get back home until well after nightfall, when they then have supper. “It’s not only the number of patients we see, but also the horrendous traffic situation in Metro Manila”, says Dr Enrique.

“It used to be worse”, he continues, “There was a time when doctors would hold regular clinic hours in two or even more hospitals on a given day. But the commuting time was unpredictable, so patients would sometimes have to wait for a long time as doctors were often late, and then because of time pressure, they could spend only 15 minutes or even less per patient.  

“Lately, though, as we might have long-standing patients in different clinics, we have grown more realistic and have concentrated our practice in one or, at most, two hospitals—dividing our clinic hours by the days of the week. Thus, Mondays, Wednesdays, and Fridays, we might go to Hospital X, and Tuesdays, Thursdays, and Saturdays to Hospital Y. 

“Another way to cope with the situation is to dispense with appointments altogether and treat patients on a first-come-first-served basis. The downside of this is that patients, especially those coming from the nearby provinces, might have to wake up very early in the morning and get to the clinic before local residents start to arrive—this is if they wish to ensure that they get back home the same day. Waiting time could be very unpredictable. I have seen patients wait in a doctor’s clinic for more than four or five hours. That’s the reason we both don’t hold clinic this way”.

Despite their own long hours, husband and wife say in unison that coming back after their training abroad was an easy decision to make. “Medical doctors here are highly valued. We live on better paychecks relative to most other professionals in the country, and simply from the multitude of patients we treat, our clinical experiences are great learning opportunities. Besides, both Brenda and I are patriotic.

“Our patients are indeed very grateful for what we do, and you know how expressive Filipinos can get. This is especially the case for our free patients at the Philippine General Hospital, a public hospital where we also practise. For these patients, we might even have to shell out our own money for supplies and medicines, but they are all worth it.

“We are likewise very pleased that, lately, the government seems to have awakened to the health needs of the country. The salaries of doctors, nurses, and other health practitioners in public hospitals are now often higher than those in private hospitals, so much so that more nurses who can’t get into the former leave the country rather than be employed by the latter.

“This is not to say that all big problems have been addressed. There's still a lot of labour migration amongst healthcare practitioners, particularly nurses who could earn much more abroad, resulting in the paucity of well-trained nurses in many of our hospitals.  Another problem we have is the lack of systems here. The provision of medical services is often slow—we need to ensure safety and efficiency by streamlining processes for, say, admission and discharge. Diagnoses are sometimes confusing because of a lack of necessary details in reports, or worse, they are contradictory. Still, things are looking up. I hear that the Department of Health (DOH) is currently appointing professional managers to more senior positions instead of yet more medical doctors. Moreover, a new initiative, the Universal Health Care, requires the provision of more family medicine doctors for every Filipino family. To date, there are relatively few family doctors".

The Reyeses have seen practices abroad that they wish were adopted in the Philippines. For example, akin to family doctors are general practitioners (GPs). Patients here often go directly to specialists for specific ailments. This precludes a more holistic approach to health care that a GP could provide. “In my own practice”, says Dr Enrique, “Patients would sometimes tell me they take some medication prescribed by, say, their cardiologist, but the cardiologist wouldn’t know that I am likewise treating that patient for his kidney problems, or that a particular medication could be contra-indicated with another pill this patient is taking, so we two doctors are working at cross-purposes.  Also, specialists undergo further training, and so would often be more expensive than a GP.  

“On the other hand, GPs can treat minor ailments, or in more serious cases, can refer a patient to a specialist whilst retaining their health care history for referencing. In the UK, for example, specialists often require a referral from the GP, then after seeing the referenced patient, the specialist would have to write a note to the GP outlining what they did for that patient. The patient is copied on this, thereby becoming better informed.  In short, the GP’s clinic acts as a clearing house for the patient’s health history”.

In lieu of the system of GPs as practised in countries like the UK, Dr. Brenda has seen in Singapore how every patient is tagged with a unique barcode which contains all their medical records. Each doctor the patient would thereafter visit would have access to this barcode, thus ensuring efficiency in the delivery of medical services.

On balance, husband and wife have observed that many Filipinos would still rather get their medical treatments here than abroad, even for those who can well afford to go overseas, primarily due to our malasakit (compassion) culture. As a culture, we have better EQ (Emotional Quotient) than many medical practitioners in foreign countries. We are more caring, and our families are here to give us support at a time when we might need it most. This caring attitude of Filipino healthcare workers is confirmed by the reputation of Filipino nurses abroad – our best-loved service export. 

The Reyeses’ account is, however, counter-balanced by the narrative of a patient, as told below.  From the point of view of Alice and Bert Sanchez, the medical facilities and services in the city are discouraging them from seeking medical attention – but what to do when they have no option? 

Alice Sanchez is a school teacher. She hates hospitals. “But I guess hospitals are a necessary evil. My husband Bert and I don’t believe in hilots (therapeutic massage from an unlicensed “midwife”) and albularyos (medicine men who treat illnesses with herbs and other alternatives, including faith healing)”.

Additionally, because public hospitals are reputed to have low-quality health care and long queues for the most basic of services, Alice and Bert opted to deliver their first baby in a private hospital in Manila. “This was the most important event of our lives”, adds Bert, “We didn’t want to skimp and take any risks. Besides, we found out that there was a promo in one of the good hospitals – a normal delivery package would cost only about Php75,000, excluding doctors’ fees. Our obstetrician told us she would charge Php30,000 and the anaesthesiologist Php20,000. With our joint salaries and our savings, we decided to go for it.  We also found out we could avail of the health card (HMO) of my school for a bit more funds. Together with our small PhilHealth medical insurance – a contributory health care program from the government – we had a bit of an extra to grease the pan.”

Alice did deliver normally soon after they arrived at the Manila hospital. But the baby boy refused to be fed. He was diagnosed with an infection and would have to be treated with antibiotics. A paediatrician was called, and the baby was promptly transferred to the NICU (Neonatal Intensive Care Unit), where he would have to stay for seven days.

“This was when our troubles started," continued Alice. “If the baby indeed needed to be monitored during the next seven days, we asked if he could be transferred to a regular room. I was already discharged, but my husband and I could stay in his room. The NICU was extremely expensive, and we weren’t sure if it was all that necessary. But we were told we had to follow protocol. Also, we needed a paediatrician. Not only was she costly, but she only came twice a week, so we had no option but to wait for her. My husband and I finally decided to stay in a hostel nearby.

“To make matters worse, the paediatrician was not very sympathetic to our plight: ‘If you’re thinking of the money to pay for all of this . . . I have to tell you, gano’n talaga. Wala tayong magagawa. (That’s the way it is. We can’t do anything)’. We had further questions, but she told us to ask the resident doctors whatever else we wanted to know as they were taking care of everything. Then, she moved on to her next case. 

“I remember telling myself, bahala na (come what may), we'll think of the money later. As it turned out, our bill came to Php250,000: this was before the pandemic, I imagine it would cost a lot more now. The paediatrician charged us Php44,000. Philhealth covered Php14,000, and my company, unfortunately, didn’t cover most of the expenses related to birthing but paid for some miscellaneous expenses amounting to Php3,000.  

“Our out-of-pocket was thus twice what we had projected and could have afforded. But we were extremely touched when my fellow teachers passed the hat around, and we collected another Php10,000.

“I have heard of worse cases, of how other people would have to sell assets in order to pay for the hospitalisation of a gravely ill family member—maybe their car, or even their house, just to have a new lease on life. 

“I am sorry to have to say this. I am sure there are many doctors who take their vocation seriously and honestly wish to serve, but there are also a lot who are mukhang pera (greedy). They will fit in as many paying patients as possible even if they can no longer properly care for them, or ask patients to come back even if there is no need, or order unnecessary procedures just to be able to charge more money. Of course, these are only my own observations”

Whilst the experiences of going to doctors in the city leave much to be desired, Alice compares their situation with that of people who reside in provincial rural areas. Alice adds, “Sometimes I think people in the province are luckier. Many may not have access to scientific medical care, but they believe the sorohanos or albularyos (medicine men or healers) can help them, so they have better control of their lives and are happier”. As it turned out, Bert had a classmate who became a doctor and practised in the province. He thus arranged for the research team to interview Dr. Ruben Dimayuga.

DOKTOR-SA-BARRIO:

Ruben, now a Municipal Health Officer (MHO), doubles up as the Doktor-sa-Barrio of San Gabriel—a farming community with a population of 35,000 in Iloilo Province. As the town’s sole medical doctor, he mans the clinic in San Gabriel, taking charge of planning and implementing health programmes whilst training its small staff and visiting the surrounding areas.

The programme DokKtor-sa-Barrio (DTTB) was initiated in 1993 by the Department of Health (DOH) to service the needs of the rural population within a given catchment area. The goal is to provide one doctor per 40,000 residents. Accordingly, medical schools give specialised DTTB training. As with Ruben, many of these doctors hail from the vicinity where they serve, and therefore, are familiar with the area. “We come back even if we have been away for years—in my case 15 years—because we are attached to our communities and want to give back”.

“I am lucky,” Ruben adds, “I have a friend from med school who is also an MHO. He takes care of over 90,000 people—waiting forever for his partner, a Doktor-sa-Barrio that DOH has been promising him.

“San Gabriel is one of those forgotten locations in the Philippines. When I first came back to the town where I was born, my feeling was that it was a place frozen in time. It hadn’t changed much since I left after graduating from high school and earning a scholarship. But now, as I had nowhere to stay, the mayor offered a small room in their renovated garage for me to rent. At the munisipyo (town hall), my clinic was an old stockroom, similarly small and damp. During my first week, I made these two rooms more comfortable with money from my own pocket, as they would be my residence, clinic, and office. By the end of the second week, I was ready to open the clinic, but surprisingly, not a single soul came to see me. Days passed. Except for staff from the munisipyo coming for an occasional band-aid, or perhaps to check on their blood pressure, I had nary a patient. In a way, I felt relieved. I had a meagre budget and limited medical supplies.

“Maybe, I thought, it’s because San Gabriel is by the national road, and the other town clinics, as well as the provincial hospital, are quite accessible. Things should change when I put on my other shoe as Doktor-sa-Barrio, and visit the hinterlands. So, over the next week, I readied my backpack and generic medical supplies. I contracted a young man who worked as messenger for the municipyo, driving around with the municipyo-owned motorbike. I would pay for gas and his merienda (snack), I proposed, and he would act as my guide and assistant, ferrying me around the more remote villages of San Gabriel. Since he was under-utilised by the town, anyway, he readily agreed.

"We drove through the vast expanse of land adjoining the town proper—old haciendas that dominate the landscape closest to the nearest foothills. I knocked on the doors of mostly nipa huts where I found more interest in my offered services. Too far from the national road that connects these villages to towns, the alternative would have been for the residents to hire tricycles that serve as motor-taxis at “exorbitant” rates. Simply to visit my town clinic, for example, they would have to pay as much as a day’s wage. On the other hand, I could visit them for free.

“These village folks otherwise survive through traditional beliefs and practices. Many swear by herbal medicine: turmeric or ginger for sore throat; lagundi, oregano, or tawa-tawa leaves for coughs and asthma; and sambong leaves when one has a fever. These herbs provide ginhawa (overall relief) to the patient, and for most, they are sufficient to meet their idea of “good health.”

“When the herbal remedies fail, it might be time to see a sorohano or an albularyo to drive out illnesses caused by an evil spirit. Likewise, a hilot (unlicensed midwife) can apply pressure to muscles and joints to promote body healing. I think these practices are completely understandable when access to modern medicine poses a real challenge. Also, these can actually be beneficial if the patient develops a more positive outlook and a sense of agency towards health care. In fact, I believe in some of these treatments myself.

“I have since had many experiences showing how traditional practices can complement modern medicine. Early on, for example, my motorbike driver and I met a woman and two men along a pathway, carrying a small child on a hammock supported by wooden poles. They were going through the jungle to the next village to see an albularyo. I introduced myself as the new town doctor and asked if I could be of help. Thereupon, perhaps desperate for any help, the group put the hammock down.

“The little girl—about eight years old—had an unhealthy pallor, and she was burning with fever at my touch. I always take with me a little medical kit, so I brought out my thermometer and registered her temperature at 39 degrees Celsius. As she was also dehydrated, I offered her some water from a paper cup and tumbler I kept in my supply bag, and I gave her mother a foil pack of eight tablets of paracetamol and some rehydration sachets, together with some instructions.

“The mother narrated what had happened. Her daughter was playing near the dug-out well from where the family got its water. But disobeying her orders NOT to go near the huge lunok (balete tree) close to the well, the little girl hid there whilst playing with her friends. That afternoon, she came down with a high fever along with vomiting and diarrhea. It had been a couple of days since, and the mother suspected that her daughter had disturbed the duwende (elf) living in the lunok. A part of me still believes in these. Nonetheless, when we arrived in the village, I went to the well myself and saw how murky the water was—probably the result of the recent dry spell. So, I instructed them to boil their water before drinking it.

“Even as they nodded, I wasn’t sure that they trusted me. But then, suddenly, I got an idea. I asked them the name of their albularyo. Leaving the group, I proceeded to search him out. Even from afar and some fifteen years between then and now, I instantly recognised Artemio. He worked the banana plants and the nearby fields when, as a schoolboy, I was staying with my Lola Ising. He now goes by the name of Tata Teming the Albularyo. He told the villagers he got his anting-anting (talisman) when, one Good Friday, he swallowed a banana blossom under a full moon. For a small donation, he could henceforth heal people.

“As chance would have it, there was a toddler being brought before him, and I followed everyone to his “clinic”, a darkly lit room. The boy was complaining of light-headedness and loss of appetite—he also had a slight fever. Tata Teming immediately diagnosed his symptoms as usog (an evil eye hex). He proceeded to perform a ritual called pagtatawas to determine who had hexed the child. On a basin of water, he sprinkled holy water—which he said was supplied by a priest. He blessed it again, uttering a strange language. Then, he held a large spoon with wax over a burning candle. More prayers as he made the sign of the cross whilst pouring the molten wax on the water, hardening it. A strange figure rapidly formed. Everyone gasped! Tata Teming rotated the figure on the water this way and that until he saw a man on a bicycle, the bits and bobs of wax, he explained to the family, were the wheels of a bike, and the silhouette in the middle was that of a man. It looked random to me, but it all made sense to the parents of the child. Such a man did approach them a couple of days before and commented about their son. But the parents failed to counter the usog by uttering “puwera usog” (forbid hex). Anyway, with the pagtatawas done, the child should now get well. But just in case, they could come back, and Tata Teming would perform another ritual called pagpapausok to smoke out any remaining hex. Surprisingly, after the pagtatawas, and to everyone’s relief, the toddler said he felt a lot better. I thought “placebo”, but who was I to question?

"When we were alone, I approached Tata Teming with my proposal—perhaps we could have a partnership: he with his traditional medicine and I with my modern medicine. Tata Teming knew my Lola quite well and readily agreed—his practice was doing well, but he was getting old and needed to slow down. Ours proved to be an auspicious partnership, especially when the coronavirus struck, and we needed to inoculate everyone. I would never have been able to do this without Tata Teming.

"I am now proud to say I am well settled in San Gabriel—going back to my roots, and serving the community I love. I stay in town three days a week, and the next three days I spend on barrio visits. I got myself a motorcycle and have trained two orderlies—one to help me in the clinic and the other to function as my assistant during my barrio visits. I was also able to lobby for a nurse from the provincial hospital who is now on loan to my clinic.

"I must admit, however, that even so, Tata Teming plays a critical role. I call on my partner to help me persuade a difficult patient and/or their family to follow my instructions, perhaps coupled with an incantation from him, as many folks still trust his treatments more than mine".

COMMENTARY:

In a country of 110,000,000 people, there are only approximately 35,000 medical doctors practising (figures vary widely), giving an estimated ratio of one doctor for every 3,000* Filipinos. This compares with 250-350 inhabitants per doctor in the developed world. The World Health Organisation suggests there should be a minimum of one doctor for every 700 inhabitants if one were to provide adequate care.

How this affects the treatment of patients is shown in the stories above, where doctors are often overwhelmed by their number of patients to such an extent that they are overworked whilst their patients might not get sufficient attention. This is exacerbated by the lack of, or the inefficiencies of systems and procedures in many clinics and hospitals. The coronavirus pandemic created many hardships and sacrifices in the country, but one good thing that resulted from it was that it raised the awareness of our healthcare workers how systems and procedures imported from more organised countries could be adapted to the Philippine setting.  

Another practice in Western countries, de facto missing in the Philippines, is the possibility of a malpractice lawsuit.  The steeply hierarchical nature of Philippine society precludes many patients from challenging their doctors’ opinions and actions. More than any other professional, medical doctors are accorded the highest esteem in the country and are often seen as people who can do no wrong. Further, they are protected from the ire of patients who dare challenge them by the fact that no malpractice lawsuit has ever succeeded in the country. On the one hand, this lack of check and balance could encourage carelessness on the part of the physician; on the other hand, in a country dominated by the rich and powerful elite together with a less than impartial justice system, the possibility of successful lawsuits could dissuade many a doctor from engaging in medical practice.   

Unlike health care in more developed countries, the Philippines cannot afford socialised medicine—the government’s PhilHealth Programme notwithstanding. The programme uses funds contributed by the registered person and their employer, with subsidies from the government. It is designed to ameliorate the financial burdens on a patient during their hour of need, but often remains woefully inadequate as it can only cover a fraction of the costs involved. Hence, many Filipinos are discouraged from seeking medical interventions even when seriously ill, instead depending mainly on herbal treatment or other forms of alternative medicine. In turn, lack of medical care is a big contributory factor to a lower life expectancy. The table below shows the life expectancy in the Philippines compared with its neighbouring countries.

Source:

Worldometer. (2025). Countries ranked by life expectancy. Retrieved from Worldometer.

From the stories above, we readily see that in the cities, adequate health care is often unaffordable; whilst in the rural areas, they are often unavailable. Today, approximately half of the population of the Philippines lives in rural areas and the other half in urban areas. Cities continue to grow as rural migrants flood the cities in pursuit of better opportunities. These migrants and their families carry with them their old belief systems in the efficacy of hilots, albularyos, and sorohanos -- good coping mechanisms amidst the uncertainties of health care. As the government cannot provide working alternatives, should migrants to the cities therefore not be disabused of these belief systems? Rather, should schools be encouraged to provide these ersatz healers training on modern medicine whilst recognising and appreciating their valuable contribjution? Some voices may object on the grounds that giving credibility to these healers would perpetuate the under-education of Filipinos. However the case may be, the rationalisation of the delivery of affordable medical services in the country remains a herculean task for the Department of Health.

_________________________

*This figure is probably conservative, but government statistics are contradictory. What is obvious is that, by far, most physicians practice in Metro Manila. The figure given by the doctors interviewed was 1:1,500 ratio of doctors to Metro Manila residents. This ratio would be much higher in the provinces: 1:3,000 in the provinces surrounding Metro Manila; and 1:20,000 for the rest of the Philippines excluding provincial city capitals. However, if the estimated medical practitioners in the country are 35,000, there should be one doctor for every 3,142 inhabitants.

Reference:

Department of Health. (6 November 2023). The Population-to-Physician Ratio per Region in the Philippines. Freedom of Information, Philippines. https://www.foi.gov.ph/requests/the-population-to-physician-ratio-per-region-in-the-philippines/