The Continuing Challenge of Maldistribution of Human Resources for Health
Authors: Antonio Carl Abelardo T. 
Published: May 2022

In 2006, a seminal report from the World Health Organization1 provided an all-encompassing definition of health workers as “all people engaged in actions whose primary intent is to enhance health,” whether involved in direct service provision (e.g., physicians, nurses, midwives) or administrative/support functions (e.g., administrative professional or driver in a healthcare facility), and with or without compensation (e.g., volunteer health workers, family caregivers). Because of limitations on data availability and measurement, however, technical and academic discussions about health workers, or more formally, human resources for health (HRH), focus on those under the formal sector.2 By and large, HRH is considered a vital pillar of a functioning health system3 because the health sector is a labor-intensive industry4 that relies on a substantial number of highly skilled staff to provide services to target populations, and consequently, the attainment of national and global health targets (e.g., Sustainable Development Goals).
One challenge confronting HRH management is the issue of geographical imbalance, which means that health workers are attracted to work and settle in urban more than rural areas for a variety of individual, organizational, institutional, economic, political, and cultural factors.5,6 In the Philippine context, the Department of Health (DOH) reported in 2018 that there still exists a maldistribution of HRH in the country, particularly in “hardship” posts where municipalities could not entice, nor retain, HRH.7 For example, a separate analysis of institution-based HRH data in 2017 showed that the National Capital Region had significantly more physicians, nurses, and medical technologists than the Autonomous Region of Muslim Mindanao.8
The paper by Tejero et al.9 in this issue of Acta Medica Philippina adds further evidence to the underlying reasons for the geographical imbalance of HRH in the country. Based on interviews with officials and health workers from 76 rural municipalities across the Philippines, the researchers found that, in general, while local government units attempted to implement strategies to help recruit and retain health workers in their areas, such a response has mainly been inadequate and has failed to bridge the HRH gap confronting their locality.
At its core, the financial obligations tied to the recruitment and retention process appear to be a significant driver of this situation since most rural municipalities are dependent on their share of national revenues by way of the Internal Revenue Allotment (IRA), which in turn is based on population (50%), land area (25%), and equal sharing (25%).10 That is to say, rural municipalities can only commit so much financial resources in their annual budget to fund the salary of health workers, given the other equally important social and development programs that need to be implemented. Even the impact of the expected increase in IRA based on the Mandanas Doctrine promulgated by the Supreme Court in 2019 revising the computation of national revenues may be modest at best since some programs, projects, and activities previously supported by the national government will have to be assumed again by local government units.11
The devolution of health services following the promulgation of the Local Government Code of 199112 with its promise of creating a governance structure that is more responsive to the needs of communities has resulted in a paradox whereby local government units are constrained in their strategies and initiatives by, among other things, the financial resources that are available at their disposal.
To this end, two important points need to be considered by local government units to address the issue of the geographical imbalance of HRH. First, augmentation of available human resources for health through national-level initiatives (e.g., DOH HRH Deployment Program 8, Medical Scholarship, and Return Service Program 13) as well as private sector support (e.g., project-specific HRH for the tuberculosis control program 14) should be maximized, but with a clear intent that, as we have argued in past publications, these be regarded as temporary measures to rectify the issue in the short- to intermediate-term.14–18 Second, and more importantly, there is a need to explore, mobilize, and maximize non-financial incentives (e.g., housing) and extrabudgetary sources (e.g., share from the feed paid by social health insurance), as more long-term tactics.1,17
Unless and until a viable fiscal environment is put in place, coupled with implementation of a comprehensive policy and framework across the phases of the working lifespan1 , the challenge of HRH maldistribution will continue to persist.

Carl Abelardo T. Antonio, MD, MPH Department of Health Policy and Administration College of Public Health University of the Philippines Manila, Manila, Philippines Department of Applied Social Sciences The Hong Kong Polytechnic University, Kowloon Hong Kong SAR, China

REFERENCES

World Health Organization. The World Health Report 2006: Working together for health [Internet]. Geneva: World Health Organization; 2006 [cited 2022 May 4]. Available from https://apps.who.int/iris/handle/10665/43432
Al-Sawai A, Al-Shishtawy MM. Health workforce planning: an overview and suggested approach in Oman. Sultan Qaboos Univ Med J. 2015 Feb; 15(1):e27-33.
World Health Organization. The World Health Report 2000. Health systems: improving performance [Internet]. Geneva: World Health Organization; 2000 [cited 2022 May 4]. Available from https://apps.who.int/iris/handle/10665/42281
Buchan J. What difference does (“good”) HRM make? Hum Resour Health. 2004 Jun 7; 2(1):6. doi: 10.1186/1478-4491-2-6.
Zurn P, Dal Poz MR, Stilwell B, Adams O. Imbalance in the health workforce. Hum Resour Health. 2004 Sep 17; 2(1):13. doi: 10.1186/1478-4491-2-13.
Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 2006 May 27; 4:12. doi: 10.1186/1478-4491-4-12.
Department of Health. National objectives for health Philippines 2017-2022 [Internet]. Manila, Philippines: Department of Health; 2018 [cited 2022 May 4]. Available from https://doh.gov.ph/sites/default/files/health_magazine/NOH-2017-2022-030619-1%281%29_0.pdf
Dayrit MM, Lagrada LP, Picazo OF, Pons MC & Villaverde MC. The Philippines health system review [Internet]. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018 [cited 2022 May 4]. Available from https://apps.who.int/iris/handle/10665/274579.
Tejero LS, Leyva EA, Abad PB, Montorio D, Santos M. Production, recruitment, and retention of health workers in rural areas in the Philippines. Acta Med Philipp. 2022; 56(8):31-42.
Congressional Policy and Budget Research Department. Facts in figures, FF2012-03 [Internet]. Quezon City: House of Representatives; 2012 [cited 2022 May 4]. Available from https://cpbrd.congress.gov.ph/images/PDF%20Attachments/Facts%20in%20Figures/03-FnF%20IRA.pdf

Manasan RG. Fiscal sustainability, equity, and allocative efficiency in the light of the 2019 Supreme Court ruling on the LGUs’ share in national taxes, DP 2020-18 [Internet]. Quezon City: Philippine Institute for Development Studies; 2020 [cited 2022 May 4]. Available from https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps2018.pdf
Congress of the Philippines. Republic Act No. 7160, Local Government Code of 1991 [Internet]. Metro Manila: Congress of the Philippines; 1991 Oct 10 [cited 2022 May 5]. Available from https://www.officialgazette.gov.ph/downloads/1991/10oct/19911010-RA-7160-CCA.pdf
Congress of the Philippines. Republic Act No. 11509, Doktor Para sa Bayan Act [Internet]. Metro Manila: Congress of the Philippines; 2020 Dec 23 [cited 2022 May 4]. Available from https://www.officialgazette.gov.ph/downloads/2020/12dec/20201223-RA-11509-RRD.pdf
Antonio CT, Guevarra JP, Medina PN, Roxas EA, Cavinta LL, Manalo JA, et al. Facilitators and barriers to the implementation of selected local tuberculosis control programs in the Province of Laguna, Philippines. Philipp J Sci. 2021 Dec; 150(6A):1501-1506.
Lawas ND, Faraon EA, Mabunga SY, Antonio CT, Tobias EM, Javier RS. An evaluation of the Medical Pool Placement and Utilization Program (MedPool PUP) of the Philippine Department of Health. Acta Med Philipp. 2016; 50(3):186–193. doi: 10.47895/amp.v50i3.826
Medina PN, Bardelosa DD, Lara AB, Avelino MD, Agbon AG, Cengca RM, et al. A historical perspective of mandatory service policy in the Philippines: a document analysis. Phil J Health Res Dev. 2018; 22(3):1–12.
Antonio CT, Guevarra JP, Medina PN, Avelino MD, Agbon AG, Sepe DC, et al. Components of compulsory service program for health professionals in low-and middle-income countries: A scoping review. Perspect Public Health.2020;140(1):54–61. doi: 10.1177/1757913919839432.
Guevarra JP, Medina PN, Avelino MD, Cengca MM, Ting ML, Agbon AG, et al. Perception of program administrators and students on the implementation of return service agreement in the Philippines. Acta Med Philipp. 2020;54(3):289–95. doi: 10.47895/amp.v54i3.1666.