By JANESS ANN J. ELLAO, ANNE MARXZE D. UMIL and ANGELA MANONGAN DOLORICON*
Graphics by DAWN CECILIA PEÑA
MANILA, Philippines — Eric, not his real name, a public nurse in Isabela province, north of the Philippines, can only speak freely in the “comfort” of his own home. The 30-year-old public nurse was hired in 2013 by the Philippine national government through its Human Resource for Health program that deployed health workers to impoverished communities, particularly in remote areas. The government’s program aimed to increase the workforce of rural health units which already had a meager government budget.
When the pandemic hit the country, Eric immediately realized that their dire working conditions would make them vulnerable to the dreaded virus. Sadly, he did not need to wait that long for his apprehensions to come true.
As of Aug. 16[i], the Department of Health (DOH) recorded that 22,559 health care workers were positive for Covid-19. Out of this number, 22,195 (98.4%) have recovered, 103 (0.5%) died and 261 (1.1%) were active cases. Of these active cases, 164 (62.8%) were mild cases, 57 (21.8%) were asymptomatic, 20 (7.7%) were in severe condition, 9 (3.4%) were in critical condition, and 11 (4.2%) were in moderate condition.
The Philippines was named as one of the top countries with the highest fatalities among health workers in relation to the total number of its positive cases. More than 500 days into the world’s longest and strictest lockdown, health workers are still up in arms over the insufficient government support. Even with his own life on the line, Eric is forced to remain silent in the workplace. He fears being singled out, or fired from the profession he loves.
Understaffed public health care
Even before the pandemic, public health care in the Philippines had been suffering from chronic understaffing, with over 13,000 plantilla positions in the health department remaining vacant[ii].
This has resulted in a long hour shift for public health workers while already suffering from very low pay. Filipino nurses attend to as many as 30 to 60 patients per shift, far from the ideal 1:12 ratio for ward patients and 1:1 for patients in intensive care.
In the Philippine General Hospital (PGH), one of the country’s end referral centers for Covid-19 patients[iii], one nurse attends to about a dozen patients that are considered moderate to severe cases, most of them on hi-flow oxygen cannula and intubated. Nurse to patient ratio in intensive care, on the other hand, has climbed from 1:1 to 1:3 following the recent surge in cases that led to reverting the Philippine capital and neighboring provinces to stricter lockdown.
In its 2020 report, DOH data showed that the country was way below the ideal 0.2 public health nurses per 1,000 population based on the World Health Organization’s 1993 report that looked into 147 countries[iv]. The WHO’s 2018 global average[v] stood at 3.8 nurses per 1,000 population. In the case of the Philippines, the public ratio of health nurses per 1,000 population was 0.139, as of 2019, according to DOH data.
As it stood, the physician’s ratio to population was at 1:33,000 population[vi], below the Philippine government’s target of 1:10,000, and even way below WHO’s 1:1,000.
Ulysses Arcilla, 49, a nurse and health workers union president in San Lazaro Hospital (the Philippines’ national center for infectious disease), said that the understaffing contributes to a heavier workload as they attended to Covid-19 patients. With the demands of the job more intense and more complicated than non-Covid-19 patients, Arcilla said that they should only be attending to four patients per shift at most. He shared that three nurses attended a 20-bed ward dedicated for Covid-19 patients during a 12-hour shift.
In every shift, nurses try to do their rounds swiftly but carefully. They even write down their to-do’s and tape their notes on their protective suit to keep them from forgetting their tasks. Apart from giving medicines, they also change the clothes and soiled diapers of patients showing severe symptoms of the virus.
Their exhausting and dangerous working conditions have pushed Arcilla’s colleagues to resign and just apply for work abroad where they are well-compensated and better protected. Some avail of early retirement. Such decisions further reduce the already dwindling number of health workers in these crucial times. To make matters worse, other health workers, mostly nurses, are either contracted by the virus or in quarantine because they are considered close contacts[vii]. “We cannot stop because the number of patients is increasing,” Arcilla said.
The Philippine government also missed the opportunity to hire more health workers when the P2.6 billion fund supposedly allocated to augment the understaffed public health care expired on June 30, along with the Bayanihan to Recover as One Act or Bayanihan 2 law. A Philippine senator claimed this law, if needed to be extended, is all in a day’s work.
But there have been no new proposals seeking for its extension as of this writing. Neither its extension nor the passing of Bayanihan Law 3 was certified as urgent by President Duterte during his last State of the Nation Address in June. Meanwhile, per its National Expenditure Program, the Duterte administration is seeking $75.8 million for Covid-19 Human Resources for Health Emergency Hiring in 2022.
Protection in workplaces
Health workers also suffer from a lack of necessary supplies, even the most basic like N95 masks. On some days, Filipino health workers recycle their N95 masks. These are washed, disinfected, or airdried for their next shift, Arcilla said. With the Delta variant now in the Philippines, health workers are now using their own money to buy N95 masks. They need at least two N95 masks per shift, with brands of good quality amounting to about $3 each. Even the face shields being provided to them, Arcilla added, are not medical grade. They are also forced to convert raincoats into improvised coveralls as protective gear.
Since the start of the pandemic, health workers have been relying on donations from private citizens and concerned groups such as the Alliance of Health Workers to somehow address the government’s limited supplies. Still, they find themselves without a steady supply of face masks, with the hospital management scrimping in hopes of getting more donations from the private sector, Arcilla said. For all the supposed tributes and adulation they receive, health workers have yet to get their longstanding demands for just compensation and benefits.
“Although we receive benefits as mandated by the Magna Carta for Public Health Workers, we still do not have the security of tenure. Any time the DOH dissolves [the Human Resource for Health program], we will lose our job,” Eric said.
They also do not receive benefits as mandated by Republic Act No. 11494 (Bayanihan to Recover as One Act), a law enacted to fund the government’s response to the pandemic. These include meals, accommodation, and transportation benefits.
Others like Eric received a special risk allowance but not the hazard pay and performance-based bonus last year. With their low salaries, health workers, as well as families, depend on these benefits (including their hazard pay) to meet their needs. Instead of heeding their demands, nurses were practically demoted when certain entry-level positions in government were given the same salary as Nurse II which was about P32,000 ($634) monthly.
The Commission on Audit (COA) has recently flagged the health department[viii] for its alleged deficiencies on the use of P67.32 billion ($1.33 billion) intended for the government’s pandemic response, but this has yet to be addressed by the government.
“In the midst of a health crisis, many patients are deprived of their right to quality health care and right to life because of lack of drugs, medicines, equipment, supplies, and medical facilities due to insufficient budget of public hospitals. And yet, it is so repulsive that there are billions of funds being unliquidated and unutilized,” said Benjamin Santos, secretary-general of the Alliance of Health Workers (AHW).
Meanwhile, a large portion of health workers was also hired by the local government, as public health is a basic social service passed on to them. Most were hired as “job orders” or contract-based workers who get a measly 14 percent of what their permanent counterpart workers were receiving from the national government
Aside from low pay, Eric said that the benefits and bonuses of those hired by the local governments were also at the mercy of their politicians. As a result, public health workers are prevented from speaking out.
“We have to endure our dire working conditions, otherwise we might lose our jobs. To speak out (as I am doing now) already puts me at risk. Our supervisors have told us that as government employees, we cannot speak ill of programs and policies being implemented (even if what we are saying is the truth),” he said.
Discrimination, mental health
Outside of their workplaces, safety issues continue to hound health workers. They were subjected to discrimination, often seen as walking carriers of the dreaded virus. Among the instances that were reported by the media include being driven away from their rented apartments, being splashed with chlorine, or being splattered with bleach all over the health worker’s face.
Eric said that while carrying out health programs in the communities of Isabela, health workers like him were being seen as a threat. They also endured people shouting at them whenever they were conducting contact tracing in communities. “People react badly whenever we are conducting contact tracing because they do not know the health protocols. They would insist that they are not feeling the symptoms of the virus. They also react negatively whenever they see an ambulance. We try to be more patient and understanding,” he said. For threats that have crossed the line, Eric said he has reported them to authorities.
These cases of discrimination are reminiscent of what health workers experienced when they confronted SARS in 2003 as their relatives and neighbors “want nothing to do with them as they may be carriers or even afflicted by the virus,” a health worker recalled.
Apart from appeals for understanding and laws that supposedly seek their protection from health workers, they continued to grapple with violence and discrimination. The lives of health workers were put in danger as they confronted red-tagging alongside their fight for better working conditions[ix]. Local and international human rights groups, including the United Nations, have long asserted that red-tagging leads to serious human rights abuses like arrests, enforced disappearances, and extrajudicial killings.
One example, red-tagged doctor Mary Rose Sancelan and her husband were shot dead on Dec. 15, 2020, near their home in Carmen Ville Subdivision, barangay Poblacion, Guihulngan City, Negros Oriental.
Sancelan, then city health officer and head of the Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF-EID), was named on a hit list as a ranking officer of the New People’s Army in their province.
The health department had, after holding a series of dialogues with health worker unions, issued a statement on this, saying they have been red-tagged “simply for asking for better benefits and pay.”
Another example is a group of Filipino doctors who sought “breathing space” amid the spike of Covid-19 cases in August 2020 was told by the president to just write a letter instead of seeking a revolution.
“We stand against any form of discrimination, intimidation, and violence against them. These acts will not be tolerated. We will hold perpetrators of these acts accountable and will collate reports from our HCWs for proper investigation and resolution,” Duque said.
Eric said that their mental health must also be looked into, adding that the deaths of both their colleagues and patients can be depressing. They fear that they could be next. Health workers also feel guilty of possibly being the virus carrier to their families.
New lockdown still overwhelmed public health care
The reverting to the strictest lockdown did not offer relief to the overburdened health workers as Covid-19 cases continued to climb, following pronouncements from the health department that there is already a community transmission of the Delta variant, a variant of concern per the WHO that has brought nightmares to the public health care of other countries hit by it. On Aug. 23, the DOH reported 18,332 new Covid cases, the highest since the pandemic reached the country’s shore, bringing the country’s total Covid cases to more than 1.8 million.
The AHW described health care workers as “drained and overwhelmed” during the said two-week lockdown, with their members now seriously mulling filing early retirement as they feel that they were abandoned to deal with the rising cases of Covid-19 without due protection in their workplaces.
Cristy Donguines, a nurse at the Jose Reyes Memorial Medical Center and current president of the employees’ union said this will further lead to severe understaffing in public hospitals that leads them to work for 12 to 24 hours per shift. “With exasperation caused by so much difficulty in our workplaces, many from our ranks are now entertaining to go on mass resignation,” Donguines said.
This was echoed by health workers in private medical institutions, as they threatened a medical lockdown if the government will not provide them their due benefits and better working conditions. In the University of Sto. Tomas Hospital alone, a private hospital in Manila, the Filipino Nurses United said over 150 health workers have contracted the virus but have yet to receive their due compensation.
According to the Philippine government’s pandemic response law, health workers who contract the virus in the course of their work are entitled to receive up to P100,000, while families of those who die will get P1 million.
While the Philippine law states that only health workers in public health care are entitled to receive “active hazard duty pay” amounting to P3,000 monthly, Filipino Nurses United president Maristela Abenojar said that when they “attend to Covid-19 patients, it does not matter if you are from private or government. The risk is the same.”
In an attempt to ease hospital capacity, more Covid wards have been opened in many parts of the country. There were also tents and modular containers that are now full of patients waiting for admission. However, Donguines said there should also be additional health workers. The pandemic, she added, has made their work heavier as companions are not allowed in the hospital.
Her colleagues that were stationed in the non-Covid ward still contracted the virus because they considered them as “less protected.” In other public hospitals, health workers decried the poor implementation of health protocols for non-Covid wards as having assigned health workers susceptible to the virus. The poor health protocols included companions going in and out of the hospital or an existing policy where the negative result of a rapid test is enough to admit patients to the non-Covid ward only to get a positive result from their RT-PCR test a few days later. When this happened, Arcilla said health workers who had close contact with a Covid-19 positive patient were told to quarantine, leaving them even more understaffed in the hospital.
Based on its monitoring on the ground, the following are the number of health workers infected with Covid-19 starting Aug. 1 in public hospitals in Metro Manila:
Philippine General Hospital – 54 health workers are positive Covid-19 and 2 have died
• Lung Center of the Philippines – 30 health workers
• Philippine Heart Center – 22 health workers
• National Children’s Hospital – 2 health workers
• Rizal Medical Center – 16 health workers
• Amang Rodriguez Memorial Medical Center – 16 health workers
What unions are doing
Health workers led by the AHW held a series of dialogues with the health department[x] but these proved to be “not truly fruitful” and that there were “no substantial gains.” They already requested the Department of Budget and Management (DBM) to look into their demands for the release of meal, accommodation, and transportation allowances, along with the special risk and active hazard pay duty allowances.
The DOH was later told to use its budget savings amounting to P1.21 billion ($25.26 million). However, health workers said that it is still not enough because at least P59 billion ($1.23 billion) must be allocated for their benefits.
In between these dialogues, health workers continued to raise public awareness of their plight. They organized protest actions and online conferences, even if they had signed a document a few years ago that prohibits them from speaking publicly. Arcilla stressed that they were not discouraged from speaking out especially when the public good is concerned. “It is only just to air our grievances.”
However, this is not the same for Eric who was forbidden from questioning government policies, even when it involved rights and welfare. Though in silence, Eric continued to serve the people, fighting for the rights of his fellow nurses and other health workers. (We Social Movements)
[i] Department of Health Report, Aug. 17, 2021, https://drive.google.com/file/d/1rKOEvktc1MaPN mcQ7cmsHYIDNZtjEia6/view
[ii] Agonies of health workers still unmet amid stricter lockdown, by Janess Ann J. Ellao, published on April 1, 2021, https://www.bulatlat.com/2021/04/01/agonies-of-health-workers-still-unmet-amidstricter-lockdown/
[iii] PGH as COVID-19 center: Capacities and Implications, by Janess Ann J. Ellao, published on April 4, 2020, https://www.bulatlat.com/2020/04/04/pgh-as-covid-19-center-capacities-andimplications/
[iv] The Relationship Between Nurse to Population Ratio and Population Density; A Pilot Study in a Rural/ Frontier State, by Jeri L. Bigbee, PhD, APRN, BC, FAAN1, Online Journal of Rural Nursing and Health Care, Vol. 7, no. 2, Fall 2007
[v] The World Bank Data, https://data.worldbank.org/indicator/SH.MED.NUMW.P3
[vi] #UndoingDuterte | Public health’s sorry state under an unapologetic regime, by Janess Ann J. Ellao, published on July 25, 2021, https://www.bulatlat.com/2021/07/25/undoingduterte-publichealths-sorry-state-under-an-unapologetic-regime/
[vii] Maliit na bagay? | Health workers’ lives not a small thing, by Janess Ann J. Ellao, published on March 19, 2021, https://www.bulatlat.com/2021/03/19/maliit-na-bagay-health-workers-lives-not-asmall-thing/
[viii] CoA finds DoH non-compliant on over P67B worth of COVID-19 funds, by Russell Louis C. Ku and Alyssa Nicole O. Tan, published on Aug. 11, 2021, https://www.bworldonline.com/coa-finds-dohnon-compliant-on-over-p67b-worth-of-covid-19-funds/
[ix] Health workers hold motorcade to press for rights, welfare, by Janess Ann J. Ellao, published on May 7, 2021, https://www.bulatlat.com/2021/05/07/health-workers-hold-motorcade-to-press-forrights-welfare/
[x] Health workers hold motorcade to press for rights, welfare, by Janess Ann J. Ellao, published on May 7, 2021, https://www.bulatlat.com/2021/05/07/health-workers-hold-motorcade-to-press-forrights-welfare/
*This article was earlier published in a journal titled Safety and Health is a Fundamental Right at Work by the International Network for Social Protection Rights: INSP!R Asia. The Alliance of Health Workers (AHW) is a member of INSP!R Asia.