The Rural Health Unit in the Philippines
MALCOLM J. FORD, M.D., M.P.H., and AMADEO H. CRUZ, M.D., C.P.H.
JN the couniitries of the Elast, ml-ore aiid m lore
iinterest is being(, focused oni rurial areas b-
cau11se of the rise in population, the importallce
of food piroducctioni, anid the progress of lancd
health services to rurlal inhabitants is of mlajor
sionificance aild, ill the Philippines, the gov-
erlment's lhealtlhp)iogramiilhas recently been
mniciplality ill the Repuiblic.
serv-ices to every
l'iublic lhealtlh in the 1Philippines appears to
have beeni fostered by the Franciscani friars.
In 1577, Friallr Cleiiienlte of the Order of Friars
luilova set uip a miiedical dispensary for the
in(ligenit of Manila in the l'osteria of the Fraln-
ciscan convent ini the Intramutiros, or old walle(d
city of AlsInila.
This eventually becamiie the
Sain Juian de Dios lHospital, whiclh operated at
its origyinal site for 368 years, up to the Second
AW'orld War. Followiing the creation of this in-
stitntiOll, otlher lhospitals were built in miianyv
otlher parts of the Plilippinies.
In 1690, dntring the Spanisl occuplation,the
Doml-inican Padre Juani de Pergero was instru-
menital in installinig a water system for the towin
of Sani Juan
Charles IV of Spaini senit his personal physi-
ciall, Dr. Francisco Javier de Balmnis, to MIexico,
Cenitral anid Soutlh Amiierica, aand the Plhilip-
piies, whlere lhe ariived in 1805 to introduce
At the time of this study, Dr. Ford was rural health
adviser to the United States Operations Mission
to the Philippines.
He is now chief, Special Health
Cruz serves as project director of the rural health
7, Public Health Service.
the Clentral Botard of VIaccinationI waC.S estab-
It wvas the earliest officical public lhealltl
organizationl in the Philippinies.
Spanislh Goverinment appoinited medicos titua-
1are.s,wh-lio were esseintially the provincial lhealth
officers of that day, anid, by the encd of the
Spaniislh regime, there was ani official of this type
in ev-erv province but oine.
lale,8 were Spanish.
A fumrther step in the developmienit ofp)ublic
lhealtlh was the creation- of the Superior lBoaird
of Healtlh anid Clhairity in 1888, and(l onie of the
last aclhievemnenits in lhealtlh uinder the Spaniislh
occulpationi was the taddition of a 2-year couirse
ill somle funidaiimenital medical and dential siub-
jects to the curriculllum, of the UIiiversity of
Sanito Tomiias inl 1898. Giraduates of this couirse,
chwjatnos in,inistrantes, served as male nurses
an-d sanitary inspectors.
miniisteredl to the sick in the absence of a plhysi-
Al'itlh tIme AmlleriCillOcctil)pationcanie a chanige
Plhilippine Comlimission in 1901 set uip a Bo.ard
of Health of the Philippine Islanids; aind( in the
saime year, Acts 307 tlhroug,lh 309 provided for
proviiicial anidml unllicipalboards oflhealth,witl
botlh Filipinio and ANmerican members.
Ill 1906, tlhe provincial boards of lhealtlh were
replaced by district lhealtlh officers witlh juris-
were usually coextensive witlh a province but
soin.etimles encomil)assed imiore tlhan one prv-
ince or parts of provinices.
in piblic healtlh took place in 1912 witlh the
"Fajardo Akct," wlhlich created saniitary divi-
sions, essentially geograplhic (livisions of munici -
palities within the provinces.
1 to 4 muinicipalities;
"presidenit," whlo hIad to be a duly qualifiedt
In 1876, the
AMost 7;1,nedwiPos tit-
In remuote areas, they-
eaclh was assigned
Vol. 72, No. 8, August 1957
plhysician, for supervision
Usually a sanitary inspector and occasionally
a nurse were also assigned to the sanitary
Dr. Jose Fabella, the
broughlt about the establislhment of puericul-
ture centers in 1925 for nmiaternial anid child
health car'e in local areas. They were supported
by voluintariy contributionis m-iatched by
tional funds received from the Nationial Sweep-
These puericulture centers wvere
staffed for the nmost. part by a niurse or midwife
and a woman attendanit, assisted by a l)art-time
pliysiciani. Trhe programli was largely confiined
to prenatal services concenitrCatiing oIn the de-
These ceniteirs still suffer from
inisuifficient loc-alsup,portand lack of year-round
tnder Dr. Fabella, mulnicipal miiaterniity ancd
clharity cliniics were also set up) in 1939.
operated in muniicipalities anid mutnicipal dis-
tr'icts of less tlhani 8,000 in population aind were
directe(l by eitlher a plhysician, llurse, or mid-
Salaries included a basic compensation
n(l danaccadditionial amiiouniit for (leliveries per-
sonally attenided, up to a s,pecified maximum.
Compenisation of personnel assignied to certain
lhardslhip aireas was dooubled if they were iion-
riesidents of these areas at the timie of appoinit-
In some instances, treatment of the inI-
dligenit sick in these cliniics duplicated the work
of the sanitary divisions.
the Philippine Department
Health reorganiized into butrieaus: the bureau of
lhospitals; the bureau of quaraintine; and the
bureau of health, for supervising prevenitive
health services throughout the counitry.
reorganization placed administration of city
lhealth departments at the bureau level and
p)lacedmuany specialty programs, suclh as tu-
berculosis control, liealtlh education, and nu-
trition in the division of laboratories.
municip)almaterniity anid clharity clinics were
now unider the bureau of lhospitals, and the
saniitary divisions, unider the bureau of lhealth.
At the mid-centuiry mark, many separate
local lhealth programs lhad accumulated.
president of the sanitary division was clharged
witlh duties in l)reventive medicine in addition
of health work.
first Secretary of
to medical care.
than 1 or 2 sanitary inspectors to assist him.
He was required by the act creating his office
to "provide hiimself with the necessary ap,pli-
ances and also the instrumnents for all einer-
gency cases, nmedical, surgical, and obstetricall."
He lhad an advisory relation only to the ptueri-
culture centers. There were about 400 sanitary
divisionis servinig about 1,200 muniicipalities.
The activities of all local lhealtlh Iuniits were
conifined almiiost entirely to the poblacimo
town' ceniter, leaving the outlyinig barrioiu
ruial areas relatively uniserved.
The specialty programs concenitrated oni iso-
lated plhases of the lhealtli problem, suclh as
A program-i of inmmuniza-
tioln, principally foIr sallpox, was carried out
by vacciniatingc parties, wlhiclh were mnade up
of nioniprofessionial workers whlo covered speci-
Their sclhedule called for a visit to
eaclh provinice onice in 5 years.
)eI'ViSill(r tllis gr'oupt) of activities in the pro-
vince was the district lhealtlh officer', whlose ac-
tual authlority apparently extenided onily to the
presideintsof the sanitary divisionis.
lhad general supervision of the lhealtlh of the
people of the province.
tary inspectors, nurses, anid clerks he had to
assist himii depenided on the size anid popula-
Frequently, he had no more
The number of sani-
Nurse at the El Salvador Rural Health Unit, Misa-
mis Occidental, gives prescribed medication to
Public Health Reports
The largest number of rural health unit personnel were trained at the Quezon City Rural Health
and Demonstration Center, a part of the rural health program
center's project director illustrates its scope and functions.
in the Philippines.
tion of the province.
gramizationis were inactive, his ownl local activi-
ties offered the sole mnedical services to the coni-
He apparenitly lhad no official con-
trol over the pueiriculture ceniters and essen-
tially nonie over the var'ious specialized pro-
In 1954, the bureaui of health lhad 402 physi-
cianls, 152 nlurses, 15 midwives, an(1 1,478 sani-
tary inspectors in the rural areas.
450 charity clinics operated by the bureau of
hospitals anid 500 active puericulture centers,
theIe were an additional 880 physicianis, 1,185
nurses, and 295 miidwives employed at least part
time in the rutral areas.
Ofteni, whlere other or-
Professional Health Workers
The duties of the sanitary inspector cover a
wi'der field of activity thain they do in the
Inited States. In the Philippinies, the sanitary
inspector is an all-rounid healtlh worker.
gives first aid and inmmnunizations, makes sanli-
tary surveys, diagnoses anld treats disease, and
fills out birth, death, anid morbidity certificates.
There is one stationed in more than 90 percent
of the country's municipalities. In many areas,
he is the first and only official health worker and
sometimes the only government, worker of any
school graduation, and, before 1954, traininlg
was by the apprentice method. He still favors
the khaki uniform with appropriate inisignia
and assumes the "parade rest" posture wlhen in
the presen-ce of lhealth officers, suggesting the
quasi-military background of hiis specialty.
Midwifery is fairly well advanced in the
Plhilippines, tlhough tlhere are many opportuni-
ties for improvement..
license from the Board of AMedical Examiners,
applicaiit must halve completed an
months' course in a school approved by the
c'overnmeiit and have actually performed
specified numbei of deliveries unider supervi-
In order to receive a
Vol. 72, No. 8, August 1957
Schlools of nursinig also leave somnethinig to
be desired but are generally very acceptable.
A bachelor's degree in public lhealtlh niursing
is offered by the UIniversity of the Plilippinies,
and nuirses were recenitly admiitted to the In-
stitute of 1Hygiene, the governiment uiniversity's
postgraduate school of public lhealth.
Plhysicians anid engineers receive good spe-
cialty trainiing in public, healtlh in the iinstitute,
wliclh grcanits the certificate of public healtl
adl, piovided a specified (rilade is mniainitained
anid a thesis appioved, the degree of imiaster of
ptublic health. Approximately 50 stutdenits are
graduated each year, abouit 40 of wlhom are
visiting teaclhers are l)rovidlel by Johns Hlop-
Rockefeller F'onii(lationi ani(l by the 1T. S. In-
terniiational CoopeiratioIn Administration.
is well triainied, an(l
According to ani official estim-cate, the popula-
tiOln of the Plhilippinies in 1956 was 22,265,330.
Of the three genier-al areas in the Republic,
LuJIzoni Islanid is the mnost (lensely populated.
-isa}'yani group of miianiy smiialler islainds, and
last is Mindanao Islanid.
daniao Islands, with the inost acreage of essen-
tially iuinhalibited land, are the m-iaini areas in-
v-olvled in the resettlemlienit (area program of the
'I'lhe Filipino is predoininately a rurial citizeni.
At lealst 70 l)ercent of the people live in rural
aireas aind engage in predomini ately agricultural
The .53 proviinces are subhdiI ided
inito nmunicil)alities, the basic governmlilenit unllits,
an(l the seat of muinicipal governimeint is in the
p)oblacion,situated whlere the population
denisest.Elected officials of the iuniiicipality
police, and jtustice of the peace.
the poblacson is also the site of ani anicienlt
clhurlch constructed durinig the Spaniislh regime.
Scattered tlhrouglhouit the remainider of the
muinicipality are more or less clearly definied
subdivisions kniowni as barriios.
erned by a teniente or commliulinity leader, who
is elected in some cases buit wlho usuially serves
witlhouit pay, anid a bairrio counicil.
ill population density
is the central or
Palawani anid Mmin-
a nmayor, couniicil
These are gov-
smilaller divisionl is the sitio, lhardly miiore than
a collection of lhouses.
tirates the poptulationi levels of the muniici-
palities accordinig to tlhe cenisuis of 1948:
IUnder 5,000 _-- _----
40,000 and over
Anotlher geographic division is the muniicipal
district, wlichl is administered entirely by ap-
poiinte(d officials anid lhas less auitonlomy,v tlhani a
A l)eculiarity of the couniitry is the large ex-
pauseof some of its 27 cities.
lhave large areas that are defiinitely riural.
is said to be larger in are-a tlhani ani
in the world, and aniother lhaspartswlichli,
recently, were un-explored.
The followiingc illus-
,'r of miunicipalitic.'9
Some of these
The cities have
Medical and Auxiliary Personnel
The (listribtitioin of miledical aind( auxiliary
1955, physicians in AManila anid otlher urbani
areas nutimbered 4,996 ouit of an estimatedPopn-
lation of 6 million, wlhile the estimated rural
populationof 15 millioni lhad onlv 3,331.
number of miedical school gcradtiates examinied
anniiually by tIme Board of MAledical Examiniers
more tlhain qutadrupled (249L to 1,050) between
1949 and 1954.
In 1954 theIe were 3,030 gcraduate nurses
active it the country, a ratio of 1: 5,400 of popui-
The ratio ranged fromii 1: 940 in Manila
to 1: 2(1,972 in onie of the pirovinices.
provinmceshad less tlhain 1 nurlise for eaclh 10,000
During the 3-year period 19.50-34 a
total of 2,533 nurses were licensed by the Na-
tional B3oarld of Nurse Examiinlers. There were
2,167 inactiv-e inurses in April 1954.
same mnonth, there were 1,173 registered imlid-
wives, 287 of wlhom were in Ainila.
Aks with most iiatioiis of AItllayaii ancestry,
pulnionary tuberculosis is an importanit prob-
lelll ill tlle Plhilipplines. Tbe tropicIal climal l-e
Public Health Reports
ICA nursing consultant and her counterpart, a Filipino rural health nurse, make a home visit to a
rural home in Tala, Rizal.
colltributte(l miuheli to tile role of ml-daria asaI
lea(lin'e, cauise of m11or1bidity Iand(l mortality, btit
fortuna-Itely tlis disease is rapidly- dis(appearning
as the restult of a stuccessful residual spray pro-
3Because of poor sanitation, the eniteirit-
ides anid schistosoini-asis colntiinuie to be preva-
ilpl)ortantenilemeiic ar-ea in the world for 8S(/hlb-
to(.wiut jaOl o10i(-m;
clildreni, yaws, dermlaltophytoses, scalbies, anid
"tropical ulcer" are coi:mmiioni.
of livinig have conitribuited to the reported high
illcidlence of nuiitiitionial deficiencies.
Campaigns aglainst hliglllv epi(lemric diseases,
Smlall outbr-eaks have occuirred, b it
110 simolificant ilncidence lhas beei rel)ortedl for
Tlhe last recorded case of sniall-
pox was in 1949, and ofclholera, in 1935.
Aplropos of this is the qutality of mortality
Also, the effect of
hal)its and relatively low standards
as Cholera an(d SmallI)ox, lave beeni suc-
amnd morbidity re)ortilg whliclh leaves muntichl to
Rlel)orts fromi rurllal arieals lha-ve beeni
in a hig( lipercentange of cacses, froimi niouniiedical
lersonllel or fronii plyN,sicianlis wh1o hlave never
seeni the calses.
Higlh inifalnit mort(ality, plresulablyrelated to
poor ol)stetrlical (clrle, 1)01oo sanitfation ai(l nim-
tritioll, is aiotherlul)pliclhealtlh problem.
1953 m-iore than onie-fourtlh (29.9 lelcenlt) of
tile (leatlis in tile Philippines occutrred l)elow
g(re 1, anidmllore tllall olle-lmalf (53.5p)ercellt)
Afost, deliver ies are l)elfor'mne(l
by the traditional lbirtll atteni(lanit
l)orts oftIle pelrcen1tacgeofdeliveries by hilot7s
p)roportionof (leliveries by liceilse(l miidwives
aiid iiiiises are albolut 10 pel)celit, andl b)y l)hysi-
Hospitals usually take catre
of only abnorimal (leliv-eries, mlost wollnell pie-
feiiiiing to be (leliv-ered lat lhomile.
or- bl0t, an
Estimlates of the
Vol. 72, No. 8, August 1957