Leyte. An idyllic island in the Western Pacific.

The island of Leyte, together with the neighboring island of Samar, and the tiny islet of Limasawa, were the three original Philippine Islands, before the name was applied to the entire archipelago. The three were named "Islas Felipinas" in 1543 by the Spanish explorer, Ruy Lopez de Villalobos, in honor of Prince Philip, who later became King of Spain and Emperor of Europe.

Leyte was the recommended gateway for expeditions across the Pacific Ocean during the Age of Discovery in the 16th century, following the path of the first circumnavigators of the world led by Ferdinand Magellan in the 1520s.

After the Americans replaced the Spaniards as colonizers of the Philippines, Leyte became the showcase of American benevolent administration, and the model province for the propagation of American-style democracy in the country.

And in October 1944, Leyte was the scene of a major battle during World War II, following the landing of the Allied Forces led by General Douglas MacArthur. The Battle for Leyte Gulf was considered the greatest naval battle in history. It was won by the Allies and marked the turning point of the war against Japan in the Pacific.

These historical events earned Leyte the fame as "The Island of Firsts." But they were not to be the last.

In the 1970s, Leyte marked another first, as host of the School of Health Sciences or SHS, which would trail-blaze the training of relevant health professionals and the development of primary health care for the deprived rural communities in the Philippines.

Welcome to the School of Health Sciences.

The SHS was established by the University of the Philippines in Tacloban, Leyte, in 1976, as an experiment in medical education. It was known then as the Institute of Health Sciences or IHS. The IHS aimed to develop community-oriented health workers who would return to render service in the underserved places of origin from where they were recruited.

In 1989, the IHS was renamed the School of Health Sciences and became a separate, regular unit of the University of the Philippines Manila.

The SHS represents a bold strategy to counteract the twin problems of the "brain drain," which refers to the alarming exodus of more than 50 percent of Filipino physicians to more affluent countries like the Unites States, and of the maldistribution of the available health manpower in the country, whose concentration in urban areas left some 70 percent of the Filipinos in the rural areas without adequate health and medical services.

The objectives of the SHS are:

1. To produce a broad range of health manpower that will serve the depressed and underserved communities; and,

2. To design and test program models for health manpower development that would be replicable in various parts of the country and, hopefully, in other countries similarly situated as the Philippines.

To accomplish its objectives, the SHS operationalizes "counter-culture" ideas for health manpower development - ideas that radically depart from traditional training programs. These include:

- Highly democratized admissions procedures that delegate most responsibilities for student recruitment to the community level;

- A step-ladder curriculum 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 with a concept of "service leave" between each stage of professional training, which serves to continually link the students with their home communities.

In turn, this process generates an active partnership with the communities in training and shaping the outlook of SHS students, a responsive entry-and-exit mechanism to and from the formal curriculum, and linkages with other agencies for their cooperation and support to SHS operations.

Research and development or R&D as a component seeks to contextualize the SHS academic pursuits with community realities.

The SHS admissions program is based on the premise that people who are actually members of socio-economically deprived communities will have greater commitment and, therefore, are more likely to return to serve their own underserved areas.

Students nominated for studies at SHS must be 17 through 25 years of age, high school graduates with not more than one year of college experience, and financially unable to pursue their education.

Per recruitment guidelines provided by SHS, the student is to be selected by the barangay, or village, in an open community meeting. Upon nomination, the selected scholar, with the consent of his or her parents, publicly pledges to return to the community to render service as a health worker. This pledge operates as a type of "social contract" entered into by the nominee and his or her barangay. In turn, the barangay pledges to provide moral and material support to the student while training at SHS.

The admissions process is designed in such a manner that the underserved communities are themselves involved in the process of student selection.

The high school education of SHS students can be considered as "handicapped." Baseline data show that the average SHS student has a literacy level of Grade Six based on the Nelson Reading Test, an American test. However, this literacy level could still enable the SHS students to pursue college work, but only using different "success" criteria.

Because SHS students come from rural communities and lacked in academic background, it was necessary to prepare teaching materials and pedagogic methods suitable to students whose life experience had been predominantly rural. Thus the faculty de-emphasized past academic performance, at least until the Midwifery level, in favor of appropriate rural cultural values.

The step-ladder curriculum is the main feature of the SHS academic program. Here, instead of the usual fragmented approach to health professions education, the training of a broad range of health manpower from Barangay Health Worker to Doctor of Medicine is integrated into a single, sequential and continuous curriculum.

After one quarter, or an equivalent of 11 weeks of training, a student, if he or she so desires, may drop from the program. If so, he or she shall have acquired knowledge and skills to qualify him as a Barangay Health Worker or health auxiliary.

Should the student go on for another five quarters, he or she would enroll in the Community Health Worker or CHW program. The graduate of the CHW program qualifies into the practice of Midwifery after passing the nationally-administered Midwife Licensure Examination.

If the CHW graduate continues for another four quarters, he or she shall qualify as a Community Health Nurse or CHN, the equivalent of the graduate nurse from a hospital school of nursing.

Two more quarters of study will qualify the CHN graduate for the degree of Bachelor of Science in Community Health or BSCH, which is the local equivalent of the Nurse Practitioner in other countries.

The final level of the SHS curriculum is the Doctor of Medicine or MD program. It consists of a yearly interval of didactic work and community experience over a period of five years.

Between each program level of the step-ladder curriculum, the students are required to undertake the so-called "service leave." In practice, this leave usually lasts for three months after the BHW program, nine months after the CHW program, six months after the CHN program, and six months after the BSCH program. But a student may stay in service working in the government health system or as a volunteer for an indefinite period.

The concept of the "service leave" was derived from the need to integrate the instructional contents and processes at SHS into a unified and understandable whole in the context of the realities and circumstances of the student’s home village.

During the "service leave," the students are monitored and supervised mainly by the local Department of Health staff. They are expected to render voluntary health and related services in their home communities, which are considered training venues where the students "learn as they serve, and serve as they learn."

We have proofs that it is the service leave that determines or firms up the fitness of SHS students for community health work.

After collecting written accounts of memorable service leave experiences of BHW students, a faculty member of SHS noted in a paper that those students who had successfully grappled or come to terms with intensely challenging or traumatic experiences during their service leave turned out to be better motivated and more responsible in the next program levels.

Like the case of C.P. When she returned for BHW service leave in her village in central Luzon, she ran into a political feud involving her family and the barangay captain, or elective village chief. The continuing friction was traumatic for her. Yet, this did not deter her from rendering valuable service such as motivating and assisting the village residents in planning and implementing sanitation activities. After all, she had the support of the other village officials and the residents who nominated her for studies at SHS.

Towards the end of her service leave, necessity forced C.P. to attend at the successful child delivery of a pregnant village woman. Her BHW service leave experience had matured her outlook, both as a health worker and a human being.

C.I. performed her CHW service leave in her remote hometown in Cagayan Province, in the northernmost part of Luzon. During this service leave, she planned, implemented, and evaluated community health development activities together with the residents of her farming village.

At the start of the nine-month CHW service leave, C.I. called for community meetings, one attended by adult representatives of the village households, and another attended by the youth. Community health activities were discussed, planned, and scheduled for implementation during these meetings.

C.I.'s activities included health education and herbal medicine preparation attended by village mothers, assistance in case-finding and treatment of malaria, home visits of sick persons and pregnant mothers, and coordination efforts that led to the establishment of a communal garden and the repair of a footbridge in her village, a self-help feeding program for malnourished children, and the construction of toilet bowls for distribution to households without water-sealed toilets.

All these activities were evaluated by a team sent by the municipal health office. The results were presented during a community assembly that included the awarding ceremonies for the village zone contests.

C.I. briefly left her village to review for and take the Midwife Licensure Examination. A few days before the exams, she received word that her mother died. Despite her loss and sorrow, she took the scheduled exams. She ranked No. 2 nationwide when the results came out.

On her part, E.P. spent extended periods of time in community health work in Mindanao before returning to SHS. A member of the first batch of students in 1976, E.P. finished her CHW studies in 1978 and passed the Midwife Licensure Examination that year. However, she did not return immediately to pursue her CHN studies. She volunteered as a midwife in her hometown, and served her village for a year. Later, she worked with a non-government organization involved in health work.

In 1980, E.P. returned to SHS for her nursing and BSCH studies. She finished her BSCH in 1981, and then took and passed the Nurse Licensure Examination that same year. She joined another NGO that worked for health development in the hinterlands of Agusan and Davao in Mindanao, got married in between, and raised a family. Her husband is a staff of another NGO involved in human rights advocacy.

In 1990, E.P. returned to SHS and enrolled in the medical program. She completed her Doctor of Medicine degree in 1995 and passed the Physician Licensure Examination last year. While waiting for her graduation and reviewing for the licensure examination, E.P. joined the faculty of SHS. She is the first SHS graduate in the faculty.

E.P.'s case also exemplifies the lateral entry mechanism of SHS. The SHS has provided a model of a progressive career structure that offers different categories of health workers with opportunities for lateral and vertical movements linked to a system of continuing education.

The SHS was established as a joint venture of several government agencies. These were the University of the Philippines System, the Department of Health, the Department of Local Government and Community Development, and the Provincial Government of Leyte.

The Provincial Government of Leyte provided the political will and influence that led to commitments of generous support from various government agencies and virtually launched the SHS in 1976.

The Department of Local Government and Community Development, now the Department of the Interior and Local Governments, is an agency which deals with local government officials and operations. It remains involved in the recruitment of SHS scholars.

For its part, the Municipal Government of Palo donated an old building, now repaired, and the lot that has been the campus of SHS since 1981.

The Department of Health, the main partner, agreed to make available to SHS the facilities and personnel of the Eastern Visayas Regional Medical Center, the government’s regional hospital, and of the various health units and district hospitals in the Leyte-Samar region, which were necessary for the training, teaching, and supervision of SHS students.

International agencies and organizations were also involved in the SHS. WHO and UNICEF provided technical and/or financial assistance to SHS during its fledgling years. And the Nelly Kellogg van Schaick Charitable Trust provided "seed money," including scholarship grants, during the first five years of SHS operation.

It was for the sake of SHS that the late Dr. Florentino Herrera, Jr., former Dean of the University of the Philippines College of Medicine and founder of SHS, joined the founder’s group that formed the Network of Community-Oriented Educational Institutions for Health Sciences in Jamaica in 1979.

After 20 years of existence, we at the SHS can look back with pride and satisfaction at our outcome and accomplishments.

As of April 15, 1997, a total of 1,327 students from 18 annual batches, or some 66 students per year, have been enrolled at SHS. Five out of eight (63 percent) of the SHS students/graduates come from the Leyte-Samar region which has a population of 3.2 million. One-fifth (20 percent) come from Mindanao, with a large portion from the Autonomous Region for Muslim Mindanao (ARMM). The others come from other parts of the country, including the Cordillera region and the lahar-stricken areas of Central Luzon. Nearly 80 percent are females.

The students/graduates of SHS represent 65 out of 77 provinces of the country.

One thousand one hundred fifty-four (1,154) had finished the Barangay Health Worker program, 899 had finished the Community Health Worker or Midwifery program, 426 had finished the Community Health Nursing program, 281 had finished the Bachelor of Science in Community Health program, and 45 had finished the Doctor of Medicine program, including a lone foreigner from Bangladesh.

Of the 899 CHW graduates, 816 or 91 percent had passed the Midwife Licensure Examination. And of 335 CHN graduates who had taken the Nurse Licensure Examination, 300 or about 90 percent had become licensed nurses. Ninety-one (91) CHN graduates since 1992 had not taken the Nurse Licensure Examination, because of a discriminatory provision in the Nursing Law of 1991 that only Bachelor of Science in Nursing or BSN graduates shall be allowed to take this professional examination.

Of the 44 Filipino MD graduates of SHS, 37 or 84 percent have passed the Physician Licensure Examination. Almost all of them work in their region, province, or town of origin.

Thus, the SHS graduates have not only overcome the basically inferior quality of their high school education in the rural communities. They have also out-performed their peers from traditional health sciences schools in the nationally-administered academic tests.

However, the statistics we mentioned merely reflect the academic capabilities of SHS graduates from the viewpoint of the traditional professional regulatory boards in the Philippines. There is as yet no standard test that determines the community-related capabilities of SHS graduates, which comprise a significant part of their training, and in which they are unique in the country!

There are about 600 Barangay Health Stations in the Leyte-Samar region. We estimate that 20 percent of the Rural Health Midwives managing these village health centers are graduates of SHS. They personalize the low-key, but effective approach to rural health delivery that the SHS sought to achieve.

The midwives are the most versatile graduates of SHS. However, they belong to the least recognized and appreciated profession in the Philippine health care delivery system, which remains physician-oriented.

SHS researches have shown that the midwives have the most comprehensive coverage among all categories of health workers in the rural areas (i.e., at least 60 percent of the village mothers according to a 1994 survey). But the centrally-determined, target-oriented, and efficiency-based evaluation system is such that they can be reprimanded for effective field performance.

The case of Mrs. G.E. is an example. G.E. is a first batch CHW graduate of SHS. After finishing her CHW studies and passing the Midwife Licensure Examination in 1978, she opted to work as Rural Health Midwife in a catchment area centered in her home village in central Leyte.

A 1988 survey funded by the United Nations Population Fund showed G.E.’s village to have the best health status indicators among six study villages in Leyte. Yet, it was for this same health status that her supervisors reprimanded her in the past for "under-performance."

There are about 164 Rural Health Units or RHUs in the Leyte-Samar region. We estimate that about 40 percent of the government public health nurses assigned to these RHUs are CHN or BSCH graduates of SHS. A number of CHN or BSCH graduates are also employed by the DOH as staff nurses of district hospitals or as nurse supervisors responsible for overseeing public health programs in the field.

At present, however, the chances of rank promotion as nurses for our employed CHN and BSCH graduates have been hampered by discriminatory regulations of the new nursing law, which provide that only a Bachelor of Science in Nursing or BSN degree is considered the basic educational qualification for the nursing profession.

Among the 45 MD graduates of SHS, 34 or three-fourths are natives of the Leyte-Samar region, where the SHS was established. Of the 34, 28 or 82 percent are already licensed physicians. Of these 28 licensed physicians, 22 or nearly 80 percent work in Leyte and Samar as physicians of different district hospitals, or with provincial and rural health units. Four are municipal health officers of their remote hometowns.

We further estimate that 75 percent of our graduates from all levels are based in rural and underserved communities, and that 95 percent of them are still in the country. The few graduates who now work mainly as nurses in several Arab countries (about 25 of them) or in the United States (about 12 of them), serve to underscore the fact that economic plight is at the root of our country’s rural health problems. Indeed, addressing the country’s "western-oriented" medical and health sciences curricula is just one, although crucial, part of the solution.

As mentioned earlier, the SHS also engages in Research and Development or R&D activities to contextualize the school’s academic pursuits with field realities.

Through a joint Research and Development Project with the Department of Health Regional Office for Leyte and Samar, the SHS contributed to the formulation of the policies on Primary Health Care and Health for All, not only for the Philippines but also for the Western Pacific Regional Office of the World Health Organization.

The collaborative R&D Project was implemented in the Carigara Catchment Area in nothern Leyte from 1977 to 1982. It received technical assistance from WHO and funding from the Danish and Swedish governments.

Utilizing an "action research" approach, the Carigara project developed and tested various methodologies by which the communities, the health services and other sectors could jointly design, implement and evaluate health development programs. The thrust towards "district health systems" in the Western Pacific region derived much insights from the Carigara project.

From the SHS perspective, the Carigara project provided the faculty and students with a critical look at the needs and potential of our rural communities, at the shortcomings of the existing health services, and opportunities to modify the work patterns of health workers and their interface with the communities, and to measure the impact of these changes. The SHS curriculum grew out of this formative experience.

One SHS research showed that our medical graduates possess high "rural bias" or preference for rural work. Several other researches provide socio-economic profiles of diverse communities in the Leyte-Samar region.

In 1993 and 1994, a UNICEF-funded Maternal and Child Health Survey was spearheaded by a faculty of SHS in Eastern Samar Province. The results of this research were used in the Municipal Health Planning for Maternal and Child Health in four (4) towns of that province. From the research, the SHS was also able to look into the performance of three SHS midwifery graduates working in remote rural areas, and of an MD graduate who works as the Municipal Health Officer of her hometown.

Some concepts introduced and experimented by the SHS are gaining wider acceptance and recognition. For instance, the step-ladder system has been adapted for the fields of computer education and secretarial training.

In 1993, the Department of Health included "step-ladder education" as the third among its 23 main thrusts for that year. The purpose was to replicate the SHS innovations to meet the need for health workers in depressed and marginalized communities of the country.

Since then, four other schools, two in Luzon and two in Mindanao, have started their step-ladder health sciences education with DOH funding and support.

After 20 years, the SHS has certainly gone a long way.

Script: Prof. Rolando O. Borrinaga

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