The 1978 Declaration of Alma Ata on primary health care (PHC) revolutionized the world’s interpretation of health with the core principles of universal access to care, equity, community participation, intersectoral collaboration and appropriate use of resources [1]. Moving forward, reforms towards Universal Health Coverage are hinged on strong primary care systems to provide essential health services to all.
The Philippines has a long history of PHC having adopted the approach in 1981 as a national strategy. This strategy relies heavily on the community through barangay health stations (BHS) that serve a population of 5,000 and rural health units (RHUs)/city health offices (CHOs) that serve a population of 20,000 [2]. The devolution of health services in 1991 mandated the management of primary care facilities at the barangay, city, or municipal levels to local governments units (LGU) [3]. The DOH, on the other hand, sets the standards for primary care facilities, including their staffing. In addition to formal cadres of health workers under the primary care facility (e.g., physicians, nurses, and midwives), Barangay Health Worker (BHW) complement health services at the community level, acting as the first point of contact between the healthcare system and the rest of the community [4].
In 2019, building upon successes in the past 30 years of health reforms, the Government of the Philippines signed the Universal Health Care (UHC) Law (Republic Act 11223) which provides a strong agenda for effective health workforce management in the country [5]. The UHC Law highlights the importance of the primary care approach and provides for the formulation and implementation of human resources for health (HRH) policies and plans that generate, recruit, retrain, regulate, retain, and reassess the health workforce based on population health needs [5]. UHC ensures that everyone has access to well-trained, culturally sensitive, and competent health workers. The best strategy for achieving this is by strengthening multidisciplinary teams at the primary health care level [6, 7, 8]. Key in this endeavour is the availability of competent and well-motivated health workers at the community level [9]. The Philippines, however, faces several HRH challenges. These challenges include a shortage of health workers, maldistribution, and an urban bias that causes most rural areas to be severely understaffed. Some health workers are employed on a contractual basis, either by the government or development partners. This has negative consequences on retention and biases service provision towards specific disease programs [10].
The HRH shortages and inequities in the Philippines translate to disparities in the provision of quality of health care services, impacting critical PHC services such as Tuberculosis (TB) and family planning (FP) [11]. TB remains one of the leading causes of morbidity and mortality despite sustained investments on the prevention, control and management by the government and partners. In 2016, the World Health Organization (WHO) reported that there were 260,000 projected cases in the country with 28,000 dying per year [11]. The report further highlighted the emergence of multidrug-resistant TB and extensively drug-resistant TB across population groups have significantly increased. In addition, the 2017 Philippines National Demographic and Health Survey indicated the low uptake of FP services noting that one in every five married Filipinas wishing to postpone their next birth or stop childbearing are not using contraceptive [12]. This is despite provisions in the Responsible Parenthood and Reproductive Health Law (Republic Act No. 10354) guaranteeing universal access to FP information in all public health facilities with emphasis in the primary care level facilities [13].
The UHC Law echoes the need for evidence-based planning for HRH at all levels of care with an emphasis on primary care. Evidence- based HRH planning provides the information necessary for mobilizing adequate resources based on these needs. Further, it recognizes that having adequate staffing in health facilities requires critical consideration for HRH planning beyond the usual workforce to population ratios. [10, 14, 15, 16].
In response to this need to conduct evidence-based planning, the Philippine Department of Health (DOH), with support from the United States Agency for International Development (USAID) funded Human Resources for Health 2030 (HRH2030) Philippines Project implemented by Chemonics International, in 2019 used the World Health Organization’s (WHO) Workload Indicators of Staffing Need (WISN) methodology with a focus on the four most prevalent cadres namely nurses, midwives, physicians and medical technologists in primary care health facilities in selected regions of the country. While the DOH and other stakeholder conducted workforce analysis studies in the past using population and health worker densities, this study was the first in the Philippines to adopt the WISN methodology step by step to provide evidence for staffing requirements for the country’s context. The WISN methodology offers an objective and scientific method to estimate health workforce requirements based on actual workloads, looking at both the health service and non-health service activities that are conducted by health workers using actual service statistics from the facility [17, 18, 19, 20, 21]. The WISN study allowed the DOH to conduct a thorough analysis of the workload of physicians, nurses, midwives, and medical technologists at BHS, RHUs/CHOs. The study resulted in the identification of staffing needs, as well as minimum and maximum staffing standards, for these cadres to carry out PHC and ultimately contribute to achieving UHC.