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RES E AR C H A R T I C L E Open Access
Assessment of factors influencing retention in the
Philippine National Rural Physician Deployment
Program
Juan Alfonso Leonardia
1,2*
, Helen Prytherch
1
, Kenneth Ronquillo
3
, Rodel G Nodora
4
and Andreas Ruppel
1
Abstract
Background: The ‘Doctors to the Barrios’ (DTTB) Program was launched in 1993 in response to the shortage of
doctors in remote communities in the Philippines. While the Program has attracted physicians to work in such areas
for the prescribed 2-year period, ongoing monitoring shows that very few chose to remain there for longer and be
absorbed by their Local Government Unit (LGU). This assessment was carried out to explore the reasons for the low
retention rates and to propo se possible strategies to reverse the trend.
Methods: A mixed methods approach was used comprising a self-administered questionnaire for members of the
current cohort of DTTBs, and oral interviews with former DTTBs.
Results: Among former DTTBs, the wish to serve rural populations was the most widely cited motivation. By
comparison, among the current cohort of DTTBs, more than half joined the Program due to return of service
obligations; a quarter to help rural populations, and some out of an interest in public health. Those who joined the
Program to return service experienced significantly less satisfaction, whilst those who joined out of an interest in
public health were significantly more satisfied with their rural wor k. Those who graduated from medical schools in
the National Capital Region were significantly more critical about th eir compen sation and perceived there to be
fewer options for leisure in rural areas. With regard to the factors impeding retention, lack of support from the LGU
was most frequently mentioned, followed by concerns about changes in compen sation upon absorption by the
LGU, family issues and career advancement.
Conclusions: Through improved collaboration with the Department of Health, LGUs need to strengthen the
support provided to DTTBs. Priority could be given to those acting out of a desire to help rural populations or
having an interest in public health, and those who have trained outside of the National Capital Region. Whether
physicians should be able to use the Program to fulfil return service obligations should be critically assessed.
Keywords: Developing countries, Health personnel, Retention, Job satisfaction, Rural health
Background
The problem of attracting, recruiting and retaining
skilled health workers in rural areas has risen high on
the agenda of policy-makers. It is a global problem, the
effects of which are most pronounced in countries where
staffing deficits are severe and where rural areas are par-
ticularly inaccessible and difficult places to work [1].
The literature on the mobility of health workers sug-
gests that an interplay of “push” and “pull” factors influ-
ence an individual’s decision to leave or stay in a rural
workplace. Pull factors can attract health workers to
urban workplaces or even abroad. These include career
advancement, such as positions in centres of medical
and educational excellence, higher financial rewards and
improved living conditions. Concurrently, push factors,
such as professional isolation, poorly resourced facilities
and limited recreational possibilities, can provoke health
workers to leave [2].
* Correspondence: juanleonardia@gmail.com
1
Institute of Public Health, University of Heidelberg, Heidelberg, Germany
2
Present address: Deutsche Gesellschaft für Internationale Zusammenarbeit
(GIZ), Makati, Philippines
Full list of author information is available at the end of the article
© 2012 Leonardia et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Leonardia et al. BMC Health Services Research 2012, 12:411
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In general, retention is known to be influenced by per-
sonal origin, family and community factors, financial con-
siderations, career development, working and living
conditions, as well as mandatory service requirements
[1,3]. Rural upbringing of physicians has been associated
with a willingness to engage in rural practice [4]. More-
over, spouses with a rural upbringing have also been found
to integrate more easily with rural communities [5].
The Philippines suffer from a maldis tribution of health
workforce, with only 10% of doctors, dentists, and phar-
macists found in rural areas where more than half of the
population resides [6]. In 1993 the ‘Doctors to the Bar-
rios’ (DTTB) Program was launched. At the outset the
vision was that all municipalities in the Philippines
would have a doctor within 20 years. The program was
established in the wake of the devolution of health ser-
vices administration to local govern ment level in 1991.
The Local Government Code that formalised the process
granted local government units (LGUs) administrative
autonomy which allowed them to allocate budgets for
health services as they saw fit [7]. Devolution effectively
transferred the management of health workers to local
politicians with little or no experience in managing
health systems. The administrative transition thus led to
an initial decline in morale of health staff and resigna-
tion of key personnel [7]. Despite the financial autonomy
of the LGU, rural LGUs found it difficult to offer incen-
tives that attracted health personnel as compared to
urban areas [8]. By 1992, a rapid national survey identi-
fied 271 municipalities to be without doctors and the
Department of Health (DOH) launched the DTTB Pro-
gram as a response to this shortage.
The DTTB Program regularly assigns a cohort of phy-
sicians to underserved and difficult-to-access municipal-
ities for a period of 2 years. Initially, the deployment was
twice or three times a year. During this assignment, the
physicians receive good salaries and full benefits as
employees of the national DOH. Later on, they have pri-
ority access to a Master’s degree or to clinical residency
programs. These physicians have the role of Municipal
Health Officer (MHO) which includes technical and
managerial functions that cover national and local policy
and program implementation, financial effective ness,
human resource for health management and develop-
ment, provision of health services, information manage-
ment, and infrastructure development and preservation.
After completion of the two years, the DTTBs have the
choice to remain in their position and to be “absorbed”
as MHO of the LGU. However, LGU employees in low-
income (5th and 6th class) municipalities are only
entitled to part (65-70%) of what they would normally
receive from a national agency under the same salary
grade. Consequently, DTTBs experience a drop in their
total compensation upon absorption.
The DOH eventually expanded the deployment criteria
to take into account population growth such that more
than one doctor is required to meet the needs of the
municipality, and to temporarily replace MHOs on study
leave. A scheme of biannual Continuing Medical Educa-
tion (CME) as a further incentive for participants was
also introduced. By 2005 the Philippines were experien-
cing alarming levels of out-migration of doctors. The
media contrasted the image of doctors in high paying
jobs abroad with that of altruistic doctors choosing to
serve in rural villages across the Philippines. This heroic
portrayal of DTTBs increased attention for the Program
leading to higher application rates and greater political
backing. In the light of these developments, public med-
ical schools began to make the receipt of scholarships
dependent upon a period of mandatory service after
qualification as a physician. The current cohort of
DTTBs is the se cond batch that can make their CME
sessions count towards a Master’s degree in Public Man-
agement with a major in Health Systems and Develop-
ment offered through a partnership between the DOH
and the Development Academy of the Philippines.
Ongoing monitoring by the DOH showed that of the
452 DTTBs who took part in the Program between 1993
and 2011, only 81 (18%) chose to remain in their rural
posts and to be absorbed by their respective LGUs.
According to the DTTB Alumni Database, the numbers
of those choosing to be absorbed have in fact declined
since 2006 (Figure 1).
Against this backdrop, in April 2011 the DOH
requested an assessment of the DT TB Program to find
out why only so few physicians choose to remain in their
rural post after the initial 2 years have ela psed. The as-
sessment was guided by the questions: why do physi-
cians join the DTTB Program, what factors influence
their decision to remain or leave the ir rural posts, what
could the Program do to better respond to the needs of
the physicians whom it deploys and to increase reten-
tion. The results of this assessment are presented here.
Methods
For the assessment of the DTTB Program the research-
ers had the opportunity to meet with all the current
DTTBs (n=71) on the occasion of a forthcoming na-
tional CME session, and to a DTTB alumni database of
the 452 former Program participants – although, as
explained belo w, the contact information wa s later found
to be outdated which severely compromised its useful-
ness for random sampling and tracing purposes. Given
this con stellation, the changes in the design of the
Program that had taken place during the years of its
existence and constraints of time and other resources,
a mixed methods approach was selected: a self-
administered questionnaire for all current DTTB, and
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oral interviews by telephone with available former
DTTBs. The findings from both methods were ana-
lysed separately and later consolidated for the final in-
terpretation [9].
The development of the questionnaire for current
DTTBs was based on a review of formally publish ed as
well as grey literature on staff retention in rural areas. A
review of policy documents from the Philippines and the
DTTB Program was also conducted. These included the
DOH Revised Operational Guidelines for the Implem en-
tation of the DTTB Program and the Memorandum of
Agreement between the DTTB, the LGU, and the DOH.
Moreover, explorative interviews were conducted with
key informants including the Director of the DOH
Health Human Resource Development Bureau, and the
past and present DTTB Program coordinators in order
to guide the development of the questionnaire.
The questionnaire used in this study was inspired by
The ‘Stayers Questionnaire’ used in a health workforce
assessment manual in Uganda [10]. Permission was
kindly given by the author, Emily Bancroft of the Univer-
sity of Washington, to adapt this tool for the purpose of
the assessment. The tool covers the construct s: personal
and job satisfaction, career advancement, working envir-
onment, living conditions, and compe nsation. These
were all issues that the key informants had raised as
being relevant for the assessment. In addition constructs
dealing with loca l politics and DOH support were added.
Each of the constructs comprises a list of statements.
The respondents were asked to use a 5-point Likert scale
to indicate whether they strongly agreed, agreed, were
neutral, disagreed or strongly disagreed with the state-
ments. 41 of the 77 statements from the original ‘Stayers
Questionnaire’ were used in the version employed for
this assessment.
The variables retained and explored from the demo-
graphics section of the original Stayers Questionnaire
were sex, marital status, number of dependents, and
city/municipality of residence. After perusing the
responses from the key informant interviews it was
decided to expand these variables to include whether
respondents graduated from a medical school within or
outside the National Capital Region (NCR), whether their
main reason to join the Program was to return service
for a scholarship or not, whether the ir main reason for
joining was an interest in Public Health/Community
Medicine or other reasons, and whe ther they planned to
remain in the area of assignment for more than one year
or indefinitely after the Program, or alternatively to leave.
To reach the current DTTBs in an efficient manner,
advantage was taken of a CME session to request their
participation in the assessment. All of the current 71
DTTBs were in attendance and all agreed to take part.
Time was allocated at the session to introduce the study
and the use of the Likert scale. Completing the ques-
tionnaire took approximately 30 minutes. In all but one
case, the participants responded to all items of the
questionnaire.
Epi Info was used to analyse data obtained by the ques-
tionnaires from current DTTBs. The descriptive aspect
of the analysis measured the frequencies by which the
respondents gave a rating of “agree strongly” or “agree”
to a spe cific question and the corresponding mean score.
For the inferential component of the analysis, independ-
ent two-sample t-tests were run for the statements and
questions, and the differences between the mean scores
were tested for statistical significance (p-value ≤ 0.05).
The topic guideline for interviews with former DTTBs
was developed to broadly align with the sections of the
self-administered questionnaire and made use of open
questions so as to obtain further, clarifying and expla-
natory information. Both tools were tested by a small
panel including two former DTTBs, a former DTTB
Program Coordinator and the researchers conducting
the assessment. The topic guideline provided the key
themes for the analysis of the interviews with former
DTTBs. Sub-themes emerging from the responses were
then identified.
Figure 1 Number of physicians deployed under the Doctors to the Barrios (DTTB) Program and absorbed by the Local Government
Unit (LGU). The first batch was deployed in1993 and batch 27 in 2009.
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Tracing the former DTTBs proved to be extremely dif-
ficult, as the contact information in the Alumni Data-
base had not been maintained. Snowball sampling was,
therefore, used over a one-month period to generate a
productive sample [11], that included DTTBs who chose
to remain in their rural position after the Program, some
who left, and others who remained in rural service, but
preferred to re-enter the Program in a different geo-
graphical area. An effort was also made to include
former DTTBs from different cohorts since the Pro-
gram’s inception.
Former DTTBs (n=26) were interviewed either face-
to-face or, in the majority of cases for practical reasons,
by phone. All the interviews were conducted by the
same interviewer (JAL). None of those approached
refused to be interviewed. The interviews lasted an aver-
age of 20 minutes. The responses were translated into
English and directly transcribed by the interviewer.
This assessment was suggested and facilitated by the
Human Resources Development Bureau which obtained
ethical clearance from the Department of Health in the
Philippines. Informed consent was gained from all those
who agree d to take part in either the questionnaire or
the interviews. Respondents were allowed to withdraw at
any time or skip questions without having to give a rea-
son. However, no one made use of this possibility. All
data were de-identified during the analysis so that
responses could not be traced back to a particular
informant.
Results
Of the 71 current DTTB s who filled out the self-
administered questionnaire, 46 (65%) were female and
25 (35%) male. The mean age of the respondents was
29 years. Twenty-nine (41%) of the respondents had
dependents, with an average of 2 dependents each.
Eleven (15%) of them were married. Fifty-eight (82.9%)
were from urban areas and 45 (63.4%) graduated from
medical schools in the NCR.
Of the 452 DTTBs who had graduated from the Pro-
gram, a total of 26 DTTBs took part in the interviews;
14 of whom were male and 12 were female. The mean
age of the interviewees was 38 years, with a range of 28
to 64 years. Fifteen of them came from a rural back-
ground. Nine of the interviewees were employed as local
government health officers, 7 worked under the DOH
Central Office, 5 were hospital clinicians, 3 were private
practitioners, and 2 worked in other public health agen-
cies. Twelve of the interviewees had chosen to work as
municipal health officers for an average of 6 years after
completing the DTTB Program, while 6 had re-entered
the Program for a further rural deployment but to a dif-
ferent municipality. The remaining 8 had left the rural
assignment after finishing the Program.
Personal satisfaction
The perception of current DTTBs with respe ct to their
work situation is detailed in Table 1. Personal satisfac-
tion was high and most current DTTBs felt res pected,
fulfilled and appreciated by their communities, sup-
ported by their families an d had friends at work. Al-
though there is less agreement with the statements
about appreciation from the municipal government and
their primary employer (DOH), there is still a general
sentiment of appreciation.
Former DTTBs derived personal satisfaction from get-
ting to know a new part of the country with different
cultures, meeting new people and being ac cepted in a
rural community.
“[What I find to be most satisfying is] experiencing
new cultures and learning to live with them, while at
the same time making friends from the DTTB
Program.” (Female DTTB, deployed 2004)
Job satisfaction and career development
Most of the current DTTBs found their work meaningful
and stimulating as shown in Table 2. The majority were
clear about what is expected from them and considered
they have opportunities for career development. Fewer
agreed that they were provided with adequate prior train-
ing for their role. The statements pertaining to the fairness
of evaluation and support from municipal government
and the DOH Central Office drew only neutral responses.
The majority of current DTTB were not satisfied with the
quality of care that their health centres provide.
Former DTTBs derived job satisfaction from applying
their training in practice, gaining experience, successfully
lobbying for staff benefits and development of their
Table 1 Personal satisfaction of current DTTBs (n = 71)
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Number
who agree
or strongly
agree
Mean
(Std. Dev.)
My opinion matters at work;
I feel respected.
66 (92.9%) 4.32 (0.65)
The community in general to which
I am assigned appreciates my work.
63 (88.7%) 4.24 (0.64)
My family supports my decision
to work as a DTTB.
62 (87.3%) 4.35 (0.79)
I find fulfilment in serving my community. 60 (84.5%) 4.38 (0.78)
Considering everything,
I am satisfied with my job.
60 (84.5%) 4.08 (0.63)
I have a good friend(s) at work. 59 (83.1%) 4.17 (0.74)
The municipal government to which
I am assigned appreciates my work.
56 (78.8%) 4.00 (0.70)
The DOH appreciates my work. 53 (74.6%) 3.92 (0.73)
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respective health centres, as well as from improvement
in local health indicators. Some former DTTBs perceived
a decline in DOH support once they were absorbed by
their LGU. More than half of them enjoyed opportun-
ities for further education while being on the Program.
However, others mentioned that training on legal issues
was lacking. Others were dissatisfied with their adminis-
trative roles as MHO, had concerns that their clinical
skills could become out-dated, or had left to undergo
further training in clinical areas.
“I want to have more career options so that after
[clinical] residency I can choose between private
practice or public health.” (Female DTTB, deployed
2008)
Work environment
Current DTTBs considered their workloads to be manage-
able and that they had the flexibility to attain a reasonable
work-life balance as shown in (Table 3). Staff morale was
sufficient to create a pleasant work environment and util-
ities were generally available in the health facilities. Less
than half of these DTTBs agreed that there was good ac-
cess to essential drugs and resources for health programs.
Most disagreed about the availability of other medical
supplies and equipment. Moreover, less than half per-
ceived their LGU to be competent.
The former DTTBs described the difficulties of their
role brought about by weaknesses in local governance,
perceived inadequacy of LGU support, and local politics.
“It is hard to work with many bosses – you have to
satisfy many politicians who sometimes have conflicting
political interests.” (Male DTTB, deployed 1999).
Relations with the municipality mayor, as the MHO’s
direct superior, emerged as extremely important in this
regard. Former DTTBs who re-entered the Program ra-
ther than choosing to be absorbed felt that, as part of
the LGU, it would be harder to critique the system and
create positive change. Former DTTBs who stayed after
the 2 years all stated that support from their respective
LGUs wa s crucial to their decision to stay.
Living and community conditions
Current DTTBs reported having comfortable accommo-
dation with a clean toilet, regular electricity and, to a
lesser extent, running water as shown in (Table 4). Most
considered themselves part of their community and
reported feeling safe. Levels of agreement are lower
when it comes to transportation and availability of
Table 2 Job satisfaction and career development of
current DTTBs (n = 71)
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Number
who agree
or strongly
agree
Mean
(Std. Dev.)
I enjoy working as a DTTB; the work
I am doing is meaningful and stimulating.
64 (90.1%) 4.23 (0.61)
When I come to work,
I know what is expected of me.
57 (80.3%) 3.92 (0.73)
I feel that there are sufficient opportunities
to develop career-wise.
52 (73.2%) 3.80 (0.84)
The job matches my skills and experience. 50 (70.4%) 3.85 (0.77)
I receive recognition for doing good work. 48 (67.6%) 3.69 (0.84)
I am satisfied with the support I receive
from the DOH Regional Office.
44 (62.0%) 3.61 (0.92)
I receive encouragement to develop myself
from DOH staff or LGU officials
43 (60.6%) 3.66 (0.83)
I have been given the training needed to
perform the work expected of me.
43 (60.6%) 3.55 (0.94)
I am fairly evaluated on my work. 41 (57.7%) 3.56 (0.63)
I am satisfied with the support I receive
from the municipal government.
41 (57.7%) 3.46 (0.89)
I am satisfied with the support I receive
from the DOH Central Office.
40 (56.4%) 3.55 (0.89)
I am satisfied with the quality of care
that my health center can provide.
26 (36.6%) 3.10 (0.97)
Table 3 Work environment of current DTTBs (n = 71)
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Number
who agree
or strongly
agree
Mean
(Std. Dev.)
I can take time to eat lunch
and snacks every day.
58 (81.7%) 4.06 (0.81)
The workload is manageable. 56 (78.9%) 3.83 (0.72)
I have flexibility to balance the
demands of my workplace
and my personal life.
54 (76.1%) 3.83 (0.68)
I have regular electricity
at my workplace.
52 (73.3%) 3.83 (1.12)
I have a pleasant work environment;
I am satisfied with the morale
level of my health center staff.
49 (69.0%) 3.66 (0.84)
I have access to clean running
water at my workplace.
44 (62.0%) 3.42 (1.21)
My health center has good access
to essential drugs and medications.
30 (42.2%) 3.07 (1.09)
I work with a competent LGU 28 (39.4%) 3.25 (0.82)
My Rural Health Unit has access to
resources for health programs and projects.
21 (29.5%) 3.11 (0.90)
I have the supplies which I need
to do my job well and safely.
19 (26.8%) 2.75 (1.01)
I have the equipment which I need
to do my job well and efficiently.
13 (18.3%) 2.61 (0.98)
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supplies for personal needs. Only a quarter of the
respondents agreed that there were adequate options for
leisure and entertainment.
Many of the former DTTBs agreed that problems with
living conditions influenced their decision to leave their
rural post and those who stayed on reported having
good accommodation. Negative issues raised in the
interviews included difficulties with reaching and living
in storm-prone regions and political violence during
election times.
“I did not feel very safe in my area of assignment.
Elections were approaching and there were reports of
politically-motivated killings.” (Female DTTB,
deployed 2007)
Physical separation from one’s family and relatives was
frequently mentioned as a push factor. However, some
indicated that with the improved means of communica-
tion offered by internet and mobile phones the situation
today may be less difficult.
Compensation
Most current DTTBs considered their salary and bene-
fits to be fair. Less agreed regarding the representation
and travel allowances as shown in (Table 5).
Former DTTBs considered conditions to have been
good but felt better compensation was justified, as they
were practically on-call for 24 hours and carried a great
deal of responsibility. Some of the former DTTB who
were absorbed, described having received inadequate
allowances and incentives from the LGU and how they
engaged in private enterprise activities as a response.
As such possibilities were limited in rural areas, the
constrained rural economy ultimately became a reason
to leave.
Main reasons for joining the program
Table 6 shows that more than half the current DTTBs
acknowledged that mandatory rural service as part of
their medical scholarship was their main reason for join-
ing the DTTB Program (referred to hereafter as “return
service”). Almost a quarter entered the Program to help
those living in rural areas, while several respondents
cited their interest in public health and community
medicine.
By contrast, former DTTBs attached most importance
to having the opportunity to help rural populations.
Many described how their decision to join the Program
was influenced by community exposure and encounters
with rural physician role-models during their medical
studies and rotations in government hospitals. Several
mentioned joining the Program for adventure and travel,
although only one with this motivation remained in ser-
vice after the two years. Former DTTBs mak e no men-
tion of return service. This was to be expected, as this
Table 4 Living and community conditions of current
DTTBs (n = 71)
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Number
who agree
or strongly
agree
Mean
(Std. Dev.)
My accommodation has a
comfortable place to sleep.
58 (81.7%) 4.11 (0.77)
My accommodation has a
clean toilet and shower.
58 (81.7%) 4.10 (0.72)
I consider myself a part of the
community to which I am assigned.
53 (74.6%) 3.90 (0.80)
I have regular electricity at
my accommodation.
52 (73.2%) 3.75 (1.07)
I feel safe in my area of assignment. 49 (69.0%) 3.76 (0.82)
I have access to clean running
water at my accommodation.
47 (66.2%) 3.75 (0.97)
I have safe and efficient
transportation to work.
42 (59.2%) 3.55 (1.00)
Supplies for my personal needs
are available in my area of assignment.
39 (55.0%) 3.54 (0.88)
My area of assignment has sufficient
options for leisure and entertainment.
18 (25.3%) 2.73 (1.11)
Table 6 Main reasons for joining the DTTB Program
(n = 71)
What is/are your main reason(s) for
joining the DTTB Program?
Respondents may give
more than one answer
Number of respondents
who gave this answer
Return Service 38 (53.5%)
Opportunity to Serve 17 (23.9%)
Interest in Public Health and
Community Medicine
13 (18.3%)
Experience and Adventure 6 (8.5%)
Fulfilment and meaning in life 3 (4.2%)
Master’s degree and
career opportunities
2 (2.8%)
Good salary 1 (1.4%)
Table 5 Salary, benefits, and incentives of current DTTBs
(n = 71)
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Number
who agree
or strongly
agree
Mean
(Std. Dev.)
My salary is fair 56 (78.9%) 3.97 (0.83)
My benefit package is fair 51 (71.9%) 3.80 (1.04)
My representation and
travel allowances are fair
40 (56.3%) 3.49 (1.08)
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reflects a more recent trend of conditionality that has
been subsequently introduced by public medical schools
and scholarship foundations.
Associations between variables
Associations between variables were next analysed from
the data collected from the current DTTBs. Only those
that were found to be statistically significant are consid-
ered in the following:
Differences between sexes (Table 7) revealed that male
DTTBs felt significantly more respected and were more
likely to have good friends at work than females.
DTTBs who joined the Program because of return ser-
vice enjoyed significantly lower personal satisfaction
than those who joined the Program for other reasons
(Table 8). Other less positive perceptions were also
linked with mandatory service obligations.
By contrast, DTTBs who joined the Program because
of their interest in public health or community medicine
were significantly more likely to find fulfilme nt in their
work with rural communities (Table 9).
Two thirds of the DTTBs who graduated from a med-
ical school in the NCR joined the Program to return ser-
vice. To avoid confounding, the participants whose main
reason for joining the Program was return service were
excluded from these t-tests.
Graduates of medical schools from the NCR were less
satisfied with DOH support compared to those who
graduated from schools in the provinces (Table 10). The
graduates from the NCR also found less flexibility to
enjoy their personal time and were less likely to find suf-
ficient options for leisure and entertainment. They were
more likely to disagree with the statement that health
programs are sufficiently resourced and significantly less
satisfied with their compensation.
Only 7 of the 71 current DTTBs declared plans to re-
main in their rural post for more than one year or indef-
initely after completing the Program. The mean age of
these physicians was 28 years, 4 of them were male, 3
were married, 4 had dependents, 5 originated from
urban areas, 4 trained in the NCR and 3 had entered the
Program to return service.
DTTBs who planned to remain in the Program gave
significantly highe r ratings to the support they received
from the DOH Regional Office an d the municipal gov-
ernment (Table 11). They were also more likely to agree
that their health center had good access to essential
drugs and that they worked for a competent LGU. Fur-
thermore, those who planned to remain found adequate
options for leisure and entertainment in their respective
areas of assignment.
Most important deciding factors for retention
LGU support was the most frequently cited factor fol-
lowed by compensation, factors related to family con-
cerns and career advancement opportunities as shown in
(Table 12). Former DTTBs who remained in their areas
of assignment indicated that both intrinsic and extrinsic
factors played a role, with mention made of the import-
ance of responding to a felt need, making a difference,
enjoying the work, and affinity with the community. Ex-
trinsic influences included marriage to a local resident,
offers of higher education, or whether the LGU provided
adequate benefits.
Table 7 Differences between sexes
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Mean (Std. Dev.) p-value
Male
n=25
Female
n=46
My opinion matters at
work; I feel respected.
4.56 (0.51) 4.20 (0.69) +
I have a good friend(s) at work. 4.44 (0.58) 4.02 (0.77) +
p-value legend: + = p ≤ 0.05.
Table 8 Main reason for joining is return service for
scholarship
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Mean (Std. Dev.) p-value
Return
Service
n=38
Other
Reasons
n=33
Considering everything,
I am satisfied with my job.
3.84 (0.44) 4.36 (0.70) +++
I have a good friend(s) at work. 3.95 (0.70) 4.42 (0.71) ++
I find fulfilment in serving
my community.
4.08 (0.78) 4.73 (0.63) +++
The job matches my skills
and experience.
3.63 (0.67) 4.09 (0.80) ++
I enjoy working as a DTTB;
the work I am doing is
meaningful and stimulating.
3.92 (0.54) 4.58 (0.50) +++
I feel that there are sufficient
opportunities to develop career-wise.
3.58 (0.89) 4.06 (0.70) ++
I have a pleasant work environment;
I am satisfied with the morale level
of my health center staff.
3.39 (0.82) 3.97 (0.77) +++
The workload is manageable. 3.66 (0.81) 4.03 (0.53) +
p-value legend: + = p ≤ 0.05; ++ = p ≤ 0.02; +++ = p ≤ 0.005.
Table 9 Main reason for joining is interest in Public
Health or Community Medicine
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Mean (Std. Dev.) p-value
Public
Health
n=13
Other
Reasons
n=58
I find fulfilment in serving
my community.
4.85 (0.38) 4.28 (0.81) ++
(++ = p ≤ 0.02).
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However, most of the former DTTB who initially
remained in their rura l post after the Program eventually
left. The most frequently cited reasons for this were
related to family and career development. Specific family
reasons included the need to spend more time with their
children, to raise their children in the city or at least in
their hometowns, and to be within reach of their aging
parents or relatives as the doctor in the family.
“My father died and I was not there [for him]. I don’t
want this to happen to my mother.” (Male DTTB,
deployed 2002)
Those who did not continue in their rural post after
completing the Program also stated career advancement
as a major reason for leaving. Several preferred to under-
take further clinical training to have more flexibility in
their choice of work in the future. Some left because
they felt they had done their part for the underserved, or
from the frustration of witnessing the poverty in the
rural areas.
Suggestions to improve retention
Better compensation was the most frequent suggestion
made by both former and current DTTBs to encourage
remaining in their rural posts. The under-provision of
prescribed benefits and the previously described reduc-
tion in total compensation upon absorption by the
LGU were shown to be key issues. Increased remote-
assignment allowances and benefits, including support
for dependents, were suggested as ways to mitigate
this situation.
Former DTTBs who chose to remain in their posts
highlighted how the DTTB Program itself was instru-
mental in their decision by having enabled them to face
the challenges of their ro le or facilitated a smooth trans-
fer to the LGU. In this regard, the DOH, as the imple-
menter of the DTTB Program, was considered to play a
crucial role in lobbying for LGU support. In some cases,
the experience derived during the 2 years in the Program
drove the desire to serve and was also instrumental in
the decision to stay. Former DTTBs who decided not to
remain in their posts , nonetheless attributed to the Pro-
gram their interest in pursuing a career in public health.
Lack of LGU and DOH support were frequently
mentioned as impediments to retention. However, no
Table 10 Graduated from a medical school in the
National Capital Region (NCR)*
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Mean (Std. Dev.) p-value
NCR
n=15
Non-NCR
n=18
I am satisfied with the support
I receive from the DOH
Central Office.
3.07 (1.03) 3.89 (0.68) ++
I am satisfied with the support
I receive from the DOH
Regional Office.
3.20 (1.01) 3.94 (0.73) ++
I have flexibility to balance the
demands of my workplace and
my personal life.
3.67 (0.49) 4.22 (0.55) +++
My Rural Health Unit has access
to resources for health programs
and projects.
2.67 (0.82) 3.61 (0.78) +++
My area of assignment has
sufficient options for leisure
and entertainment.
2.07 (1.16) 2.89 (0.90) +
My salary is fair. 3.60 (0.83) 4.33 (0.59) ++
My representation and travel
allowances are fair.
2.67 (0.90) 3.89 (1.13) +++
p-value legend: + = p ≤ 0.05; ++ = p ≤ 0.02; +++ = p ≤ 0.005.
*Excluding respondents with return service obligations.
Table 11 Differences between those who plan to stay or
leave
To what extent do you agree
with the following statements?
(5=strongly agree, 4=agree,
3=neutral, 2=disagree,
1=strongly disagree)
Mean (Std. Dev.) p-value
Stay
n=7
Leave
n=64
I am satisfied with the support
I receive from the DOH
Regional Office.
4.29 (0.76) 3.53 (0.91) +
I am satisfied with the support
I receive from the municipal
government.
4.14 (0.69) 3.39 (0.88) +
My health center has good access to
essential drugs and medications.
3.86 (0.90) 2.98 (1.08) +
I work with a competent LGU 4.00 (0.82) 3.17 (0.79) ++
My area of assignment has sufficient
options for leisure and entertainment.
3.71 (0.76) 2.63 (1.09) ++
p-value legend: + = p ≤ 0.05; ++ = p ≤ 0.02; +++ = p ≤ 0.005.
Table 12 Most important deciding factors for retention (n
= 71)
What would be the most important
deciding factors for you to remain
in your area of assignment after
your term as a DTTB? Respondents
may give more than one answer
Number of
respondents
who gave
this answer
Local government support 31
Good salary and compensation 20
Family (distance from family, finding
a spouse in the community,
livelihood opportunities for spouse)
10
Career advancement opportunities 8
Sustainability of health projects 6
DOH support and re-centralized
health human resources
5
Needs of the poor and underserved 3
Ease of transportation 1
Passion for public health 1
Personal reasons 1
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concrete measures to improve LGU support were pro-
posed by the DTTBs that took part in this study. As
for the DOH, it was proposed that they improve the
technical, operational, career development, legal, and
even moral support (e.g. improving communication
and interaction with the regional office) provided to
DTTBs. Further suggestions included the targeted re-
cruitment of physicians with rural backgr ounds, par-
ticularly those who are from the areas included in the
Program, tailored career-development coaching for
those who choose to stay in the rural areas, improved
pre-deployment orientation to better prepare the
DTTBs for their roles and the introduction of a rural
physician network.
Discussion
Effect of reasons for joining the program
Job satisfaction among health workers has been found to
positively correlate with greater work commitment and
retention [12,13]. While many of the former DTTBs
reported being satisfied because their role allowed them
to make a difference, the situation regarding the satisfac-
tion of current DTTB is more complex. Those who
joined to return service experienced less job satisfaction.
In particular, graduates from the relatively affluent NCR
complained about their compensation and leisure possi-
bilities. It can thus be implied that these respondents are
less likely to remain in rural service.
On the other hand, those who joined out of an interest
in public health were more satisfied with their rural
work. It is arguable that the current DTTBs have a
stronger focus upon themselves and their individual
needs and wishes. This might be the effect of the chan-
ging profile of Program applicants over time, or actually
reflect a shift in societal values.
Factors influencing DTTBs in their decision to leave or
remain
The LGU was shown to play a pivotal role in retention
and has the most important influence on DTTBs’ deci-
sion-making. It becomes apparent that, if LGU support
is in place, then the MHO can rely on the availability of
utilities, infrastructure, logistics, services, funding, and
human resources – thus considerably facilitating the
management of the local health system. Conversely,
where LGU support is lacking, personal security, the
availability of drugs, medical supplies, health program
funds and even the provision of DTTB benefits become
problematic. Moreover, once DTTBs are absorbed by
the LGUs, they become more susceptible to the pres-
sures of local politics. This would explain why some
former DTTBs preferred to re-enter the Program and be
assigned to another area and to retain their more neutral
DOH employee status than to become an LGU
employee.
DOH support is also important for retention, particu-
larly when DTTBs consider or embark upon absorption.
Some of the former DTTBs expressed regret that DOH
support wane d once they became part of the LGU des-
pite efforts from the DOH to continually contact and in-
vite former DTTBs to CME sessions. This implies that
former DTTBs may have either been poorly informed of
the support available to them or they may have expected
support in other areas, particularly in dealing with loca l
governance issues. DTTBs graduating from medical
schools in NCR were significantly less positive about
DOH support. This could be because these physicians
are overall less likely to remain in their rural post and
perceive the linkage with the DOH to be crucial for their
immediate and future careers.
Career advancement is one of the most common rea-
sons why former DTTBs gave up being a rural physician.
Many of those who joined the Program were doctors at
the start of their careers and still quite mobile career-
wise. Meanwhile, DTTBs who choose to be absorbed
face less opportunities of going up the career ladder, es -
pecially because the position of MHO is typically the
highest non-elected position for a doctor in the munici-
pal government. The lack of career mobility is an estab-
lished problem in decentralized settings. Aside from the
difficulties involved in moving up to the national level
and between devolved administrative units, information
regarding career opportunities is hardly shared [14].
The majority of the current cohort are females, yet fe-
male DTTBs are significantly less likely to feel respected
and have good friends at work than their male counter-
parts. This may indicate that women find it more diffi-
cult to deal with local politics in rural areas. It is also
likely that men dominate the key LGU positions in such
areas.
Most current DTTBs consider their workloads to be
manageable and agree that utilities such as water and
electricity are generally available at their respective
health facilities. However there is strong disagreement
with the statements regarding the availability of medical
supplies and equipment. DTTB who intend to remain in
their rural posts are significantly more likely to be satis-
fied with the availability of essential drugs. It is worrying
that the majority of current DTTB are found to be dis-
satisfied with the quality of care that their health centres
provide. Whilst not specifically articulated, it is possible
that this reflects a frustration with the possibilities of
rural practice that may erode DTTB readiness to remain
in their post.
Most current DTTB have adequate accommodation
and feel safe in their communities. The interviews with
former DTTBs revealed that insecurity, due to natural
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hazards or political tensions, can rapidly undermine a
physician0s readiness to remain, as documented in other
studies in the Philippines [15].
Family issues also considerably influence retention.
The DTTBs mentioned the need to be closer to aged
parents as a greater constraint to retention than the
needs of spouses and children, which are more com-
monly cited in the literature [16,17]. It is possible that
the importance of parental support for DT TBs, perh aps
in admiring their idealism or being fearful for their
safety, may have been underestimated. Moreover, family
expectations may put increased pressure on physicians,
as they get older, to maintain a standard of living not
found in rural areas [18]. Compensation plays a promin-
ent role in the decision-making of DTTBs. While most
current DTTBs agree that they are fairly compensated,
the views of former DTTBs show that this is not the
case after absorption. The issue of the effective salary
downgrade has haunted the DTTB Program since its
conception. The suggestions made by respondents to
offset this with other benefits and allowances need to be
examined by the Program management. However, the
findings suggest that increasing compensation as a
stand-alone measure will not be sufficient [19], but
needs to go hand in hand with efforts to strengthen
LGU capacity and support.
How the DTTB Program can increase retention
The findings suggest that the DTTB Program could gain
from exploring physicians’ backgrounds and reasons for
joining. There could be potential to more actively recruit
physicians from rural areas, or to consider strategies, in-
cluding advocacy and scholarships, to encourage rural
students to consider medicine as a future area of study.
Reasons for joining could be examined during interviews
or through letters of motivation. Priority should be given
to qualified physicians with an interest in public health
and community medicine and who trained outside of
NCR. In particular, a decision should be taken whether
to continue to automatically accept return-service physi-
cians. Given that these physicians have already enjoyed
the benefit of a scholarship based on an agreement to
undertake rural service, it can be argued that they can
be directly assigned to rural municipalities as part of the
terms of their contract, thus foregoing the issues related
to the transition of employment from the DOH to the
LGU. For physicians with no obligation to return service,
the DOH could con sider invo lving LGUs in the choice
of DTTBs from the outset to maximise the chances of a
harmonious relationship between the two parties. The
experience of the University of the Philippines Manila
School of Healt h Sciences which promotes close early
contact, and the elaboration of a social contract,
between health workers and partner LGUs could be
drawn upon here [20].
On the other hand, it should be noted that 3 of the
7 physicians who planned to extend beyond the initial
2 years had originally joined the Program to return ser-
vice. The number of those plan ning to continue is low
and their profiles are so disparate that generalisation s
cannot be made. Yet, every physician counts in such a
context a s observed in the rural Zamboanga province of
the Philippines, where the presence of just a small num-
ber of physicians already had a positive effect on com-
munity health outcomes [15]. A network of rural
physicians could be usefully established to facilitate com-
munication and experience sharing and to advocate for
greater political support for rural health issues.
The role of MHO involves both administrative and
clinical skills. For DTTBs who intend to work as clinical
specialists in the future, the DOH needs to offer more
opportunities for clinical updates and rotations in cen-
tres of medical excellence. For those that see their future
in more managerial roles, the currently offered Masters
course in Public Management appears to be a good
choice.
Conclusion
This assessment suggests that the DTTB Program needs
to work on enhancing the factors that drive retention,
whilst mitigating those that impede it. Through
improved collaboration with the DOH, LGUs need to
strengthen the support provided to DTTBs. The findings
suggest 5 areas for future attention:
The motivation to join the DTTB Program was, in
some cases, awakened through meetings with inspiring
rural physicians and rotations undertaken during train-
ing. This underlines the importance of continued advo-
cacy at medical schools, with a particular focus on those
located outside of the NCR, and of ensuring that all
medical students are routinely afforded exposure to rural
practice.
DTTB Program coordinators would be well advised to
invest in exploring why individuals seek to join. Priority
should be given to physicians motivated by a wish to
help rural populations or by an interest in public health,
to those who have trained outside of NCR and those ori-
ginating from rural or disadvantaged areas. Whether
physicians should be able to use the Prog ram to fulfil re-
turn service obligations should be critically assessed.
The DTTB preparation provided by the DOH needs to
be intensified with regards to political, legal and admin-
istrative aspects and made more gender-sensitive. Mod-
ern communication technology should be made available
in MHO offices.
Greater efforts are needed to ensure that absorbed
DTTBs continue to receive DOH support so they can
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keep abreast with new clinical developments, and access
new positions readily once the agree d retention period
has been completed.
Finally, most DTTBs will not remain in a rural area
for an open-ended period of time. The retention period
that is aspired to needs to be mor e clearly defined
and aligned with LGU timetables, career development
options and succession planning. The assessment high-
lights the importance for the DTTB Program to invest
in an effective monitorin g and tracking system.
Abbreviations
CME: Continuing Medical Education; DOH: Department of Health;
DTTB: Doctor to the Barrios; LGU: Local Government Unit; MHO: Municipal
Health Officer; NCR: National Capital Region.
Competing interests
The authors all declare that they have no competing interests.
Authors’ contributions
JAL conceived the study, undertook the literature review, adapted the
questionnaire, developed the interview guideline, collected the data,
conducted the analysis, and wrote the first draft of the manuscript and took
the lead for all later versions. HP assisted with the literature review, with data
analysis, contributed at all stages of manuscript preparation including
submission. KR contributed to the study design, provided clearance for the
study, supervised the thesis, coordinated the data collection, and contributed
to the background and discussion. RN contributed to the study design,
tested the tools, coordinated the data collection, and contributed to the
background and discussion. AR contributed to the study design, oversaw
development of the tools, supervised the thesis, revised the later stages and
final version of the manuscript. All authors read and approved the final
manuscript.
Acknowledgements
This study was part of the master thesis by JAL, who gratefully
acknowledges a scholarship from DAAD (German Academic Exchange
Service). The study was approved by and received logistic support from the
Health Human Resource Development Bureau (HHRDB) of the Department
of Health, The Philippines. Access to the alumni database was permitted by
the Doctors to the Barrios Foundation. Cooperative support was jointly
provided by the HHRDB and the DTTB Foundation in organizing interviews
and allowing for distribution of questionnaires. Special thanks are given to
Emily Bancroft, Amy Hagopian, and Dr. Samuel Luboga, for generously
granting permission to use the Uganda Health Workforce Study Manual and
the tools therein. Profound gratitude is expressed to all the former and
current DTTBs who gave of their time to take part in this assessment.
Author details
1
Institute of Public Health, University of Heidelberg, Heidelberg, Germany.
2
Present address: Deutsche Gesellschaft für Internationale Zusammenarbeit
(GIZ), Makati, Philippines.
3
Department of Health, Health Human Resource
Development Bureau, Manila, Philippines.
4
Human Resource Development,
World Health Organization, Western Pacific Region, Manila, Philippines.
Received: 5 June 2012 Accepted: 17 November 2012
Published: 20 November 2012
References
1. WHO: Increasing access to health workers in remote and rural areas through
improved retention: global policy recommendations. Geneva: WHO; 2010.
2. Eastwood JB, Conroy RE, Naicker S, West PA, Tutt RC, Plange-Rhule J: Loss
of health professionals from sub-Saharan Africa: the pivotal role of the
UK. Lancet 2005, 365:1893–1900.
3. Tulloch J, Henderson LN: Incentives for retaining and motivating health
workers in Pacific and Asian countries. Hum Resour Health 2008, 6:18.
4. Grobler L, Marais BJ, Mabunda SA, Marindi PN, Reuter H, Volmink J:
Interventions for increasing the proportion of health professionals
practising in rural and other underserved areas. Cochrane Database Syst
Rev 2009, 1:CD005314.
5. Mayo E, Mathews M: Spousal perspectives on factors influencing
recruitment and retention of rural family physicians. Can J Rural Med
2006, 11:271–276.
6. Dror DM, Preker AS: Social reinsurance: a new approach to sustainable
community health financing. Washington DC: World Bank; 2002.
7. Grundy J, Healy V, Gorgolon L, Sandig E: Overview of Devolution of Health
Services in the Philippines. Rural Rem Health 2003, 3(2):220.
8. Dussault G, Franceschini MC: Not enough there, too many here:
understanding geographical imbalances in the distribution of the health
workforce. Hum Resour Health 2006, 4:12.
9. Creswell JW, Plano Clark VL: Designing and conducting mixed methods
research. Thousand Oaks, California: Sage Publications; 1996.
10. Bancroft E: Uganda Health Workforce Retention Study Manual. Washington
DC: Capacity Project and Ministry of Health, Republic of Uganda; 2006.
11. Marshall MN: Sampling for qualitative research. Fam Pract 1996,
13(6):522–525.
12. Irvine DM, Evans MG: Job satisfaction and turnover among nurses:
integrating research findings across studies. Nurs Res 1995, 44(4):246–253.
13. Dieleman M, Viet Cuong P, Vu Anh L, Martineau T: Identifying factors for
job motivation of rural health workers in North Viet Nam. Hum Resour
Health 2003, 1:10.
14. Kolehmainen-Aitken RL: Decentralization’s impact on the health
workforce: Perspectives of managers, workers and national leaders. Hum
Resour Health 2004, 2:5.
15. Cristobal F, Worley P: Can medical education in poor rural areas be
cost-effectie and sustainable: The case of the Ateneo de Zamoanga
University School of Medicine. Rural Rem Health 1835, 2012:12.
16. Smith JP, Thomas D: On the road - Marriage and mobility in Malaysia.
J Hum Resour 1998, 33:805–832.
17. Feeley TH: Using the theory of reasoned action to model retention in
rural primary care physicians. J Rural Health 2003, 19:245–251.
18. Kyaddondo D, Whyte SR: Working in a decentralized system: a threat to
health workers’ respect and survival in Uganda. Int J Health Plan M 2003,
18:329–342.
19. Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P:
Motivation and retention of health workers in developing countries:
a systematic review. BMC Health Serv Res 2008, 8:247.
20. Lueddeke GR: Transforming Medical Education for the 21st Century –
megatrends, priorities and change. Milton Keynes: Radcliffe Publishing; 2012.
doi:10.1186/1472-6963-12-411
Cite this article as: Leonardia et al.: Assessment of factors influencing
retention in the Philippine National Rural Physician Deployment
Program. BMC Health Services Research 2012 12:411.
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