B. Individual Environment
Demographic factors and location
Three out of ten interviewees highlighted marital status and proximity to hometown (i.e., being married and far from home) made staying less desirable:
My area is 1 hour and 30 minutes away by boat, 3 hours away by land travel from my area of residence. I just got married, so the distance is really a factor in assessing (whether to stay or not). That is one of the factors I’m looking into if I’m planning to extend. (DTTB # 2)
Many respondents found fulfillment in serving in their respective areas (94%) and found work as meaningful and stimulating (83%). The majority of the interviewed DTTBs weighed in service to country and personal growth on their decision to be retained. Regarding service to the country, the DTTBs said a “higher purpose” – the need to serve and impact the public health system – brought them back to their community and would make them stay.
Meanwhile, according to one DTTB, the current generation values personal growth more than rooting down, hence fewer DTTBs stay now compared to those from older batches. Another respondent mentioned that one should become and remain a DTTB because of the benefit of holistic personal development.
Well-being was repeatedly discussed by the majority of the interviewed DTTBs. Central to well-being was the experience of burnout, which was managed through various coping strategies. Mental health, particularly depression, and the sense of stability (i.e., family and financial stability) also emerged as influencing factors on the DTTBs’ decision to stay.
The interviewed DTTBs highlighted the following coping strategies: [a] taking breaks, [b] having a support system, [c] emotional detachment, [d] problem prioritization, and [e] human resource management. The DTTBs discussed taking breaks by emphasizing the importance of leisure and “returning to normalcy” (e.g., going to the mall) to temporarily escape from the stresses of work. Their support system consists of other currently deployed DTTBs, DTTB alumni who frequently become mentors, friends, and “family”. Emotional detachment allows the DTTB to go through the two-year deployment without expending all emotional energy. Problem prioritization involves discerning then choosing the winnable battles and letting go of the futile ones. Finally, managing work relationships involves knowing how to approach or interact with people in such a way that they can be swayed to aid the DTTB in reaching his/her goals for the municipality.
One interviewed DTTB was diagnosed with major depressive disorder (MDD) during his tenure as a DTTB, while another DTTBs discussed how depressive feelings interfered or could possibly interfere with their work. Feelings of hopelessness, loss of purpose, and blunted affect can discourage functionality in society, thus, discourage retention:
I questioned why I was doing this. I like what I’m doing but it’s not rewarding in my opinion at that time in my area ... It’s like I’m constantly depleted. I feel like I’m always giving to the community, but, in the end, I become depleted. It looks like you are doing good, but it seems like nothing good is happening to you. (DTTB # 6)
Friends and family dynamics
Around three quarters of respondents reported that their families supported their decision to become a DTTB (73%). This is remarkable considering that relationships with friends and family, particularly having a significant other, children, nostalgia for family, and actual family dynamics were important in the DTTBs’ decision to stay or leave.
One DTTB said that distance from a significant other became an issue in their relationship. Another DTTB said that she would consider staying because it is easier to start a family as a DTTB rather than as a resident physician in a hospital, given that work arrangements (e.g., leave credits, relaxed pace, fewer demands, thus, more personal time) are more flexible as a DTTB. This same DTTB went on to share that it would be good for her child to see her as a DTTB, as it would educate the child about the public health situation of the Philippines.
Furthermore, one DTTB talked about how he missed his mother cooking for him. Some DTTBs also added that a supportive and less demanding family encourages retention. Conversely, a high-strung, excessively worried family makes retention less appealing.
Perceptions about work
Two perceptions were particularly influential in the DTTBs’ decision to stay or leave: the multiple roles of a DTTB, and the “I wish I could do more” mentality.
The majority of the interviewed DTTBs stated that they found their workload to be heavy and tiring due to the multiple roles that they must adopt: physician, public health manager, and MPM-HSD student. The administrative work is particularly difficult for them because they feel that they were not adequately trained by their medical school and the DOH for this role. In some cases, such workload has led to burnout and ultimately decreased well-being. Nevertheless, the workload has also led to professional skills development, which encourages the DTTBs to stay.
Many of the interviewed DTTBs feel that they were not able to fulfill their goals (e.g., complete a project) as a DTTB. Consequently, the DTTBs think “I wish I could do more,” which makes them want to stay longer in their localities to fulfill these goals.
C. Work-related Environment
Many DTTBs feel that their opinion is valued and respected (83%), that their community appreciates their effort (82%), and that they have good friends at work (80%). However, only a quarter of DTTBs reported having adequate supplies (25%) and time to eat (25%), which could adversely affect retention (Fig. 1).
Figure 1. Percentage of DTTBs, who agree or strongly agree with work-related factors (n = 102)
Social working conditions
Among all the work-related influencers, social working conditions (i.e., related to people like the staff and leadership) emerged as the most talked-about factor for the majority of the interviewed DTTBs. Four main conditions served to shape the DTTBs’ thoughts regarding staying in their assigned municipalities: [a] the organization of the DOH-Local Government Unit (LGU)-DTTB system, [b] informal social networks, [c] relationship with subordinates, and [d] relationships with patients.
The haphazard interaction between DOH, the LGU, and the DTTB are characterized by inefficient communication (e.g., faulty emergency referral system to tertiary hospitals), and disparate expectations regarding the role of the DTTB in the rural health unit (i.e., municipal health officer or rural health physician). Furthermore, the differences in goals for the municipality between the LGU and DTTB, and feelings of lack of DOH and LGU support make it difficult for DTTBs to fulfill their tasks and help the municipality, leading to stress and discouraging retention.
Being able to form and navigate informal social networks (i.e., professional connections not defined by the official organizational structure) helps in accomplishing work or making it easier. These include dealing with the health center staff, local government officials, DOH officials, and other local health stakeholders on a day-to-day basis. Successful informal social networks and having good relationships and being appreciated by patients make retention more feasible. On the other hand, some DTTBs talked about health center staff whom they felt were unprofessional, under-skilled, insubordinate, insufficient in number, unnecessarily absent and poorly motivated, among other reasons. These unsatisfactory relationships with health center staff discourage retention. Moreover, compromising work-life balance due to the workload makes retention less appealing.
The availability or lack of opportunities leading to career growth in the assigned municipalities influence the DTTBs decision to either stay or leave, respectively. Some DTTBs, however, were more aware of career opportunities than others. Additionally, the majority of the interviewed DTTBs felt that they have learned from the DTTB experience, particularly with regards administration, human resource management, and inventory management, among other skills, which they feel would help them throughout their careers.
Infrastructure, medical equipment, and supplies
The DTTBs think that infrastructure, medical equipment, and supplies in the community are insufficient, inadequate, and substandard; nevertheless, these were not considered enough to discourage retention. They merely referred to these shortcomings as “challenging”.
D. Local Environment
Many DTTBs report that they have accommodations that are comfortable for sleeping (85%) and have a clean toilet and shower (84%). However, less than half of them have clean running water (46%) and regular electricity (45%) in their workplace. Lastly, only 31% have sufficient options for leisure and entertainment; such local environment factors also play a role in their decision to stay in their locality (Fig. 2).
Figure 2. Percentage of DTTBs that agree or strongly agree with local factors (n = 102)
Only three out of ten interviewees talked about this factor, largely because of the variations in geography across the different municipalities. Nonetheless, geography is a noteworthy influencer on the decision to stay because it shapes work logistics (e.g., transportation and supplies delivery), and thus, the DTTB’s opportunity and ability to manage patients. Losing the sense of agency to help patients discourage retention:
There was a time that they brought a patient to me in the middle of the night and there was no electricity, no oxygen. The patient was highly distressed, but we could not transport him because number one, he did not want to be transported, and number two, there was no boat [to cross the sea]. (DTTB # 9)
Despite it being stipulated in their deployment contract, there are sometimes no set accommodations and financial aid for living expenses for DTTBs. This is exacerbated by lack of food choices, scarcity of electricity and potable water, and limited transportation (i.e., once a day boat ride). Such unsatisfactory living conditions may discourage retention.
Local social needs
Due to their daily workload, there is evidently less time for DTTBs to spend with their close friends and family. This is exacerbated by the lack of options for leisure and entertainment, potentially discouraging retention.
Because DTTBs are often assigned to areas far from friends and family, they rely on technology to communicate with them. Communication devices/media used by the DTTBs for this purpose include mobile phones, social media applications (e.g., Facebook®ฏ, Twitter®ฏ), and other online telecommunications applications like Viber®ฏ, Messenger®ฏ, Skype®ฏ, and FaceTime®ฏ. Therefore, the availability of a cellphone signal and internet connectivity are among the main considerations of DTTBs on whether to stay in their area after deployment. Having a poor cellphone signal or internet connection may discourage retention.
E. National Environment
Majority of the respondents believe that their wages (86%) and benefit packages (71%) are fair. However, only few respondents report that their work is not affected by recent political conflict in their area of deployment (39%), which could discourage retention (Fig. 3).
Figure 3. Percentage of DTTBs that agree or strongly agree with national factors (n = 102).
Out of all the factors discussed in this study, the DTTBs considered good compensation as one of the most important in their decision to be retained. While most of the DTTBs interviewed mentioned that their salary is high considering that being a DTTB is an entry-level profession, some still do not feel that this salary is commensurate to the amount of work that the DTTBs do. Additionally, there are often delays in the processing of salaries of the DTTBs, sometimes up to four months. While this issue has been mentioned several times to the central DOH office, several DTTBs report that no tangible solutions have been made so far.
Furthermore, no executive medical check-ups are given to the DTTBs. This is despite the DTTBs’ mentioning that they think it is essential for them to have these medical consultations, especially since they are exposed to several infectious diseases in the community such as tuberculosis and malaria. The DTTBs also complained that vaccinations are not made available to them.
Universal Health Care (UHC) Act
The Universal Health Care Act seeks to give Filipinos increased access to health-related services by enrolling all Filipino citizens into the National Health Insurance Program of the Philippine Health Insurance Corporation (23). The UHC act was considered as an important factor in the DTTBs’ decision to be retained as this may eventually lead to higher priority for DTTBs and their respective health projects. A former DTTB cited that he may have stayed longer in his area if the UHC act had been implemented while he was still in the program, since this may make it easier to attain the DOH-set health indicators and goals for the community. Other current DTTBs also talked about how the full implementation of the UHC act would facilitate their work and overall experience as DTTBs (e.g., gain more respect from staff, local government officials, etc.), encouraging retention. Another said that being a DTTB allows her to make contributions to the UHC act. Hence, she can impact the Philippine public health system as a DTTB, which makes her want to stay.
Safety and security
Being assured that they are safe while being deployed to the community is one of the top priorities of the DTTBs for retention in the program. However, according to them, there is no existing safety and security protocol from the DOH in instances of social unrest/conflict within their area. This protocol is important, especially since many of the DTTBs are assigned to rural areas with terrorists and/or insurgents. DTTBs are also often caught in between conflicting political parties, which affects their safety and ability to work. Nevertheless, some areas were noted to be free from socio-political unrest. Some also noted the lack of or delayed monitoring of DTTBs in the communities, especially in times of natural disasters which commonly affect the country.
F. International Environment
Opportunities such as higher rates of remuneration, more satisfying working conditions, higher quality of life, a safer working environment, and better educational and career development opportunities were the common reasons as to why DTTBs would prefer to work abroad. However, some DTTBs identify the current Philippine health system to be a great avenue to practice public health, encouraging retention in the program.