Barangay Health Worker (BHW) level students, with bags, plastic pails and basins and all,
prepare for departure to their laboratory communities following nine weeks of didactics at the SHS.

The "service leave" is an innovation introduced by the School of Health Sciences (SHS) as an integral component of its step-ladder curriculum. The concept of service leave was derived from the need to integrate the instructional content and processes introduced in the school into a unified and understandable whole in the context of the realities and circumstances of the student’s home barangay (village).

Following a three-month, in-school training under the Barangay Health Worker (BHW) program, the students of SHS are required to undertake a "service leave." This usually lasts for three months after the BHW program. Each student implements, on his/her own, a structure of experiences learned in school, including the conduct of a community health survey and rendering first aid services in his/her home community.

In this analytical paper, we present written accounts of memorable experiences encountered by SHS students during the "service leave" following their BHW studies. Nearly 40 accounts were selected out of 146 classroom compositions collected by the senior author since 1991. The nature of the actual problems met by the SHS students, and the transdisciplinary character of their required solutions, illustrate the practical promise of the new field of "health social science."

A new field of study is being developed by academicians and researchers who belong to the field of social sciences on the one hand, and of the health and medical sciences on the other. The hybrid is called "health social science." (1)

"Health social science," according to a primer, "focus(es) on health issues. It banners the idea that health is not a medical concern only; that it should be looked at holistically to ensure more sustainable solutions to human health problems." (2)

"Health social science" emphasizes a "transdisciplinary approach" towards collaborative research. According to Dr. Patricia Rosenfield, the transdisciplinary approach can "provide a more comprehensive organizing construct (because) representatives of different disciplines are encouraged to transcend their separate conceptual, theoretical, and methodological orientations in order to develop a shared approach to research, and build a common conceptual framework. Such framework can be used to define and analyze the research problem and develop new approaches for health care that more closely represent the historical and present-day reality in which the health problems are situated." (3)

The School of Health Sciences (SHS) of the University of the Philippines Manila (UPM) seeks to contribute its share in the development of "health social science" as an academic field, initially through this case study. In primordial form, the SHS has documented aspects of what is now being described as "health social science" since its establishment as an institution.

The Institute of Health Sciences (IHS), as the SHS used to be known, was established in Tacloban, the capital of Leyte Province, in 1976. It started out as an experiment in medical education, aimed at developing community-oriented health workers -- barangay health workers, midwives, nurses, nurse practitioners, and physicians. The SHS represents a bold strategy to counteract the twin problems of the "brain drain" and the maldistribution of health manpower available in the Philippines. (4)

The objectives of the SHS are:

1. To produce a broad range of health manpower that will serve the depressed and other under-served communities; and

2. To design and test program models for health manpower development that are replicable in various parts of the country and, hopefully, in other countries with similar situations as the Philippines.

To accomplish these objectives, the SHS operationalizes "counter-culture" ideas for health manpower development that radically depart from traditional training programs. These include highly democratized admission procedures that delegate most responsibilities for student recruitment to the community level, a step-ladder curriculum (see Figure 1) that offers a sequential yet integrated approach to health manpower education, and an educational principle that emphasizes community relevance rather than academic excellence. These principles are reinforced by a concept of "service leave" between each stage of professional training, which serves to link students continually with their home communities. This generates an active partnership with communities in training and shaping the outlook of SHS students, a responsive entry-exit mechanism to and from the formal curriculum, linkages with other agencies for cooperation and support to SHS operations, and research and development (R&D) activities that seek to root SHS academic pursuits within community realities. (5)

All students admitted to the SHS initially go through the Barangay Health Worker (BHW) program, or what is commonly known as paramedic training. After one quarter or 11 weeks of training, the student receives a certificate as a BHW, qualifying him/her to be a practicing paramedic.

The subjects taken under the BHW program are Fundamentals of Obstetrics, Fundamentals of Health Care, Fundamentals of Sociology, Community Hygiene and Sanitation, Fundamentals of Nutrition, and Remedial English. After eight weeks of classroom didactics, the students also undergo three weeks of Community Practicum in designated laboratory communities. (6)

The BHW program is not a terminal program. Rather, it is intended to initiate the student to community work and enable him/her to determine his/her fitness for the community health profession. Fitness and commitment are further determined through the student’s work as a BHW during the minimum three-month "service leave" after the BHW program.

The "service leave" is an innovation introduced by the SHS as an integral component of its step-ladder curriculum. The concept of the service leave was derived from the need to integrate the instructional content and processes into a unified and understandable whole in the context of the realities and circumstances of the student’s home barangay.

During their service leave, the students are monitored and supervised mainly by the local Department of Health (DOH) staff. They are expected to render voluntary health and related services in their home communities. In Region 8, they usually receive a routine faculty visit. During the service leave, the home communities are considered training venues where the students "learn as they serve, and serve as they learn."

Annex "A" presents illustrative accounts of memorable experiences of SHS students during the "service leave" following their BHW studies. These experiences were encountered in their home communities in different parts of the country.

The selected accounts were culled from 146 classroom compositions collected by the senior author since 1991. The 146 accounts were first classified into categories as reflected in Table 1. Then 38 accounts of representative memorable experiences, classified under the identified major categories, were selected for inclusion in this paper.

The major categories indicated the common involvement of the BHW students during their service leave. Among others acitivities, each of them held a community entrance assembly, conducted a household survey to gather baseline health and socio-economic data for the formulation of a community profile, assisted the Rural Health Unit (RHU) or Barangay Health Station (BHS) staff in the delivery of health programs and services, and attended scheduled sharing sessions by provincial groups (in Region 8) or regional groups (outside Region 8).

The most common category pertained to those experiences that could be described as either intensely traumatic or exhilarating (or both) for the concerned BHW students. These were largely focused and very emotional experiences that may have firmed up the personal commitments and dedication of the affected students toward health work. Cases No. 1 to 15 belong in this category.

Cases No. 1 and 2 dramatize the personal shock experienced by two BHW students in relation to the process of giving birth, whether to a dead fetus or to a live child.

Case No. 3 presents a BHW student who tried to be of help, but whose help came rather late. The patient she was helping died.

Case No. 4 presents a BHW student who was faced with a real-life phenomenon she had only read in books. She was struck with guilt and pity, which she tried to ease through a visit to the house of the malnourished child and with some token gifts.

Case No. 5 presents a BHW student who was somehow blamed for a death in a household that she had interviewed. She said she was neither afraid nor guilty of the accusation, but the incident hounded her.

Case No. 6 presents a BHW student whose service leave schedules were disrupted by a prevailing natural disaster. Still, she was able to comply with all her service leave requirements in time.

Cases No. 7 and 8 present two BHW students from neighboring towns of a province where river transportation is the main mode of inland travel. Both figured in sinking accidents during their service leave, the trauma of which they viewed and coped with in different ways.

Case No. 9 presents a BHW student confronted with an impact of the counter-insurgency war in our far-flung areas. Realizing the general helplessness of the situation and her limited health skills, she offered personal help to the staff of line agencies in their relief activities.

Case No. 10 presents a BHW student, the wife of a soldier, whose service leave was initially held suspect by a protagonist group in the ideological war in our countryside. A brief private conference between the student and two armed rebels was sufficient to dissipate both the tension and the suspicions.

Case No. 11 presents a BHW student faced with the threat of physical harm associated with health development work. In this case, the better part of the valor was to run.

Case No. 12 presents a BHW student in an odd situation. A male, he had assisted and handled several child deliveries himself during his BHW service leave. Some mothers in fact wondered about this "male midwife."

Case No. 13 presents a BHW student, already a mother herself, faced with the problem of convincing and then helping a destitute (and indifferent) family seek hospitalization for their sick (and handicapped) child. Her effort apparently failed and, in the process, she also incurred some debts that she owned up.

Case No. 14 presents a BHW student whose service leave activities were hampered by the misperception of a partisan political agenda in their conduct. The false impression, attributed to a local agitator, was eventually clarified with the help of the rural health midwife, but only after the damage had been done.

Case No. 15 presents a BHW student who was caught in the continuing political feud between her mother and the barangay captain. The latter in fact tried to sabotage and misrepresent her service leave work, but the local residents and other barangay officials supported her and cooperated in her activities. Her success was capped by another feat: she successfully attended the problematic child delivery of a local resident.

The community survey is the most strenuous activity during the service leave of BHW students. The second group of memorable experiences focuses on specific observations from this activity. Cases No. 16 to 23 belong in this category.

Case No. 16 presents a BHW student who grappled with the conflict of time-and-fact perception between "lowlanders" and their "tribal" counterparts. Though the student here is partly tribal herself, her educational orientation somehow alienated her from the mindset of her tribal origin.

Case No. 17 is similar to Case No. 16, except that the BHW student here is a typical lowlander. Faced with the oddity of a tribe’s time perception, she was struck with a sense of frustration and pity for her respondent.

Case No. 18 presents a BHW student faced with a threat of physical harm like in Case No. 11. The whole incident was dismissed as a habitual joke, but it gave a real scare to the innocent student.

Case No. 19 presents a BHW student caught in yet another facet of the ideological war in the countryside. The help of a recognized mediator and memories of past association dispelled the local suspicions.

Case No. 20 presents a BHW student using an ingenious method of extracting household data from an elusive respondent. In the process, he became a confidante for the legal problem of his respondent.

Case No. 21 presents a BHW student who confronted a problem instead of evading it. As a result, he gained insights about "acceptable" aspects of adult behavior related to pregnancy.

Case No. 22 presents a BHW student who, in his effort to act like a sociable adult in his tribal culture, got drunk and had to crawl home.

Case No. 23 presents a BHW student who lost the product of her weeks’ work to floodwaters. She took the loss as a matter of fact, and then reconstructed what she had lost all over again.

Memorable experiences of the third group of BHW students viewed the service leave not from a focused personal angle, but from a general perspective. They did tell some tales about how physical and perceptual barriers were overcome in specific instances. Cases No. 24 to 27 belong in this category.

Case No. 24 presents a BHW student who tried to hide his physical hunger and thirst when he conducted his survey. Still these showed in his face, for which some respondent kindly attended to. The sight of patients suffering in the hospital seemed to have firmed up his commitment towards health work.

Case No. 25 presents a BHW student who was assigned a personally difficult task by a person he could not refuse. He rose up to the occasion and claimed that he managed well.

Case No. 26 presents a BHW student who was elated by the success of an effort he thought was beyond his capability to achieve. He overcame his own physical and perceptual barriers, and this made his service leave memorable.

Case No. 27 presents a BHW student who tested the limit of a personal handicap to accomplish his service leave tasks.

The memorable experiences of a fourth group of BHW students highlighted their participation in, and observations of, Rural Health Unit and Barangay Health Station programs and clinic activities. Cases No. 28 to 32 belong in this category.

Case No. 28 presents a BHW student who was mistaken for a physician in the RHU. He politely corrected the misperception.

Case No. 29 presents a BHW student who highlighted her participation in daily RHU routines. She claimed the experience enhanced her technical knowledge and skills.

Case No. 30 presents a BHW student and his midwife companion suddenly confronted by a band of New People’s Army (NPA) guerrillas, who asked some medicines from them. The incident scared the student, but the intended activity he was assisting in still had to be done.

Case No. 31 presents a BHW student on her first experience to assist a child delivery. It turned out to be memorable one for her. She also hiked for hours, only to find a laboring mother who was supposed to deliver in a hospital. But transport problem delayed their alternative plan until the mother "normally" delivered a baby on a feast day that became the name of the child.

Case No. 32 presents a BHW student in a situation that looks funny to the reader. He was made to assist the child delivery of a first-time mother. The process involved some comedy of errors, the hilarity of which seemed to have escaped the student, who looked at the incident as a purely learning situation.

Several memorable experiences focused on the observations of some BHW students pertaining to the community assemblies that they conducted. Cases No. 33 to 36 belong in this category.

Case No. 33 presents a BHW student from a lahar-affected area of Zambales. Her talk about the future benefit of her efforts (health development) gave way to the present concern of the residents (relief goods for the lahar victims) when the latter presented itself. Her community assembly was untimely disrupted.

Case No. 34 presents another BHW student in another lahar-affected area. Her scheduled community assembly was scuttled by the need to evacuate their resettlement area due to flooding.

Case No. 35 presents a BHW student who thought he could not facilitate the conduct of a community assembly in his home barangay. The positive result of his effort was the opposite of his fears.

Case No. 36 presents a BHW student in a situation like the one in Case No. 35. Her fears were also dispelled by the positive outcome of her preparatory efforts.

A few memorable experiences cited the difficulties related to the process of attending provincial sharing sessions. Cases No. 37 and 38 belong in this category.

Case No. 37 presents a BHW student who arrived in a strange place at an unusual hour. Some kind-hearted soul helped solve her predicament.

Case No. 38 presents a BHW student faced with nature’s fury on her way to a sharing session. She thanked the heavens for the relief, but seemed to have forgotten the sailor who worked to avert a certain disaster.

Experience in the best teacher, went the dictum. We had expounded on this same theme ten years ago, using another set of field experiences encountered by SHS medical students. (7)

We noted the following insight at that time: "Actual experiences with life-and-death situations had always provided our students with opportunities for continuous self-realization and reassessment of their own strengths and limitations in terms of the required health knowledge, skills and attitudes at the community level. Their helplessness over some failures have always inspired them to study more and perform better the next time around."

This insight had been quoted or echoed in several technical papers and now form part of the literature on community-based education of health personnel. (8, 9) The same insight can also be inferred from many of the experiences described in the annex.

It is worthy to mention here that the BHW students described in writing only those experiences that each of them considered memorable. After being made to verbally present what they had written in class, the students found out that they also encountered some of the other experiences deemed memorable by their classmates. Indeed, they discovered certain commonality underlying their individual experiences, though they differed on the aspects they personally considered as memorable.

The service leave activities of the BHW students were individual applications (or replications) of what they had learned by groups in their assigned laboratory communities during their BHW studies. In these communities, the students’ activities were facilitated, supervised and monitored by assigned faculty members. In their home communities, each BHW student had to depend on his/her own talent, creativity and resourcefulness to accomplish the tasks outlined in the service leave plan he/she formulated at SHS.

In retrospect, we have found out that most of those students who had successfully grappled or come to terms with their intensely traumatic experiences during the BHW service leave also turned out to be the better motivated and more responsible students in the next program level (midwifery).

It is almost easy to overlook the experiences described here were encountered by young men and women, mostly 16 to 18 years old adolescents. The real-life experiences they described certainly contributed to the early maturation of their respective outlooks, both as health workers and as human beings. Surely, the lessons and insights each of them acquired from their service leave were not the type that could be generated in the academe or in simulation exercises.

As the illustrative experiences in Annex "A" have shown, the health sciences and the social sciences are inextricably linked in the community context. In fact, what appeared to be health and medical problems also required practical solutions from the fields of sociology, psychology, anthropology, public administration, and even political science (!), in addition to the technical knowledge about health and medicine.

There is, therefore, a real-life basis for pursuing "health social science" as a field of study.

The Philippine Health Social Science Association (PHSSA) has identified a practical procedure for the further development of this new field of study. Through its Case Study Project, a databank of field experiences from different areas can be generated. Hopefully, the use of this databank can help crystallize of those critical but nebulous and vaporous lessons and insights from parallel field experiences. This process will in turn help build up a common conceptual framework for "health social science."

At SHS, we have collected a vast array of field experiences in health development work. Many useful lessons and insights have been generated from our efforts. However, we also continue to grope for a workable framework that can rationalize or systematize what we have collected so far, a framework that independent observers can easily grasp and identify. We already have a "forest"; what we still lack is a clear and representative image or images of the "trees" inside it.