Manila (CNN Philippines Life) — On a good day, Miguel* is already in the hospital at 5 a.m., doing rounds of his ward patients. If it’s a bad day, he clocks out at 12 midnight and starts work again at around 3 a.m.

“Uuwi ako ng two to three hours lang — ligo, tulog, bangon, pasok ulit,” he says.

Most days, he’s carrying specimens to the lab, getting blood, extracting blood, putting intravenous therapy, pushing carts to the emergency room, counselling families, filling out forms, shelling out money for patients who have zero cash on them, answering incessant phone calls and text messages of patients, updating his seniors, assisting his seniors, studying for exams, and sometimes, he rests.

Miguel is a first-year resident at the Philippine General Hospital (PGH), the state-owned tertiary hospital and the biggest in the country, established during the American colonization in the restless streets of Ermita, Manila. The neo-classical building receives about 600,000 Filipinos every day from across the Philippines, some even travelling from as far as Mindanao and arriving at the hospital at 4 in the morning, only to be seen for a couple of minutes.

“Tinatanong ko nga, ano ‘tong pinasok ko? Pero iniisip ko na lang ‘yung mga taga surgery. At least lamang ako sa kanila. Two hours [na tulog] at least meron ako,” he says, emphasising that surgical residents do have the worst hours as opposed to other medical specializations because of the number of patients that need attending.

Esther Saguil, a pediatric surgeon and the current Chair of the Outpatient Services of PGH, says that it has been this way even during her time as a resident in general and pediatric surgery from 1992 to 1998.

“In those days, the policy of PGH was ‘admit all.’ So any patient that goes to the ER has to be seen, has to be admitted,” she shares. “We had no sleep at all. There were days where we had no baths.”

This dilemma isn’t unique to PGH; government hospitals in other areas endure the same problem. Jade Javellana, a former emergency department nurse at a provincial hospital in Region XII, describes his everyday work as “hellish,” having to attend to at least 13 to 26 patients from the previous shift and then cater to around the same number for his own shift. This particular hospital is just supposed to cater to a maximum of 200 patients, but they had to cater to around 450 patients everyday.

“I had an experience wherein we were able to revive a patient who arrived in the ER with no pulse, no breathing, and almost flat ECG tracing,” he shares, “but two hours later, the stabilized patient was endorsed to the ward, where she died in less than an hour, because of the lack of nurses to monitor and to take care of her in the ward.”

Salaries of government health workers

With the hours that our government health workers need to put in, it is then hoped that they at least be compensated properly. During Saguil’s time as a resident in 1992, they were only paid ₱1,000 per month, as a sort of allowance. This changed in 1994, under Fidel V. Ramos’ administration, when the Magna Carta for Public Health Workers was established, which promised the health workers the following:

“a. To promote and improve the social and economic well-being of the health workers, their living and working conditions and terms of employment b. To develop their skills and capabilities in order that they will be more responsive and better equipped to deliver health projects and programs; c. To encourage those with proper qualifications and excellent abilities and remain in government service.”

The Magna Carta also includes the implementation of salary grades as well as additional compensations, such as hazard allowance, subsistence allowance, longevity pay, laundry allowance, and remote assignment allowance. By 1994, Saguil and her co-residents started receiving around ₱7,000 per month.

Salaries of public health workers have steadily increased in the succeeding years. On March 15 this year, President Duterte issued amendments to Executive Order 201, which scheduled the fourth tranche of adjustments under the salary standardization law on Jan. 1, 2019. Today, a resident like Miguel who is classified as a Medical Officer falls under Salary Grade 21, receiving at least ₱57,805 every month. Medical Specialists II and III (usually medical fellows and consultants) can also earn at least ₱73,811 and ₱83,406, respectively.

Meanwhile, a Nurse II at PGH earns ₱30,531. Miko Abat, a bedside nurse at PGH, says that this is typically enough for him. “Pinakamalaking pasahod ‘yung sa government nurses sa Pilipinas. Well-compensated naman,” he says, “pero sobrang dami lang talaga ng pasyente namin.”

While the salaries of government workers seem to be adequate, there are still limited plantilla positions provided by the government, which inhibits hospitals to take in more permanent staff and instead, hire contractual workers.

Javellana was a job-order nurse at the provincial hospital. Prior to being part of the contractual pool, he was considered a volunteer nurse, working 12 hours per shift for four to five times a week, while only receiving an allowance of ₱1,000 per month. “Some of my colleagues had been volunteer nurses for four years and received nothing from the government on their first few years,” he shares.

He only got promoted into a Job-Order nurse on his 11th month and received a stipend of ₱600 per 12-hour shift. A year later, he received ₱832.50 per 12-hour shift in addition to ₱5,000 PhilHealth shares. “The salary was tolerable,” he says, “however, the work itself was not.”

Universal Health Care Law in motion

According to the latest data of the Department of Health’s Bureau of Health and Facilities, there are 428 government-run hospitals while there are 808 private hospitals in the Philippines. Another report shows that for a population of around 100 million people, the country only has 98,155 hospital beds, with 49,372 in public hospitals and 48,783 in private facilities. The hospital bed density rate in the country is also the fourth lowest in the ASEAN region, following Myanmar, Laos, and Cambodia.

Considering that 50 percent of Filipinos still consider themselves poor and with the Philippines ranking third in the number of population that live below the poverty line in Southeast Asia, it is expected that Filipinos run to government hospitals rather than private ones, exacerbating the number of patients that these government facilities serve.

On February, President Duterte signed the Universal Health Care Law (UHCL) to the rejoice of many. The bill will “expand the coverage of PhilHealth to all Filipinos both home and abroad, whether as indirect or direct contributors. PhilHealth coverage will also cover free diagnostic services, consultation fees, and medical tests.”

Department of Health Undersecretary Rolando Domingo explains that this simply means that when care is delivered — whether the patient is hospitalized or is in the outpatient department — everything will be reimbursed. He does warn, however, that Filipinos should temper their expectations.

“When you hear it, it's like all of your healthcare needs will be given,” he says. “But there's no Universal Health Care in the whole world that will give you everything that you will need because resources are not unlimited.”

The recurring complaints from health workers on the overwhelming number of patients is one that the UHCL aims to resolve. With the ₱257 billion that the government has allocated for the new law, Domingo says that this will completely change the way healthcare is delivered. Besides the health insurance being made available to everybody, the law also prioritizes setting up primary healthcare services.

“Most Filipinos don't really see doctors unless there's something severe, something that's really terribly bothering them, before they go to the hospital,” he says. “And then they go directly to the hospital, which leads also to congestion of our hospitals kasi people don't go to the primary and secondary care level eh. Diba lahat ng Pilipino gusto, espesyalista? Punta agad sa cardiologist, punta agad sa pulmonologist when they have a cough and cold.”

When a primary care setting is in place, Filipinos will have the opportunity to regularly consult for diseases and not only be seen when conditions are worse. The primary care physician will then refer if you have to go to the secondary or tertiary hospital. This aims to decongest the hospitals and also ensure that everybody will receive care in a timely manner and in a way that's appropriate to the level of care that they need.

“The working conditions will be better for everybody and the outcomes should be better for the hospitals. Instead of having one nurse for 30 patients, we should be having one for every 10 to 15 patients,” he explains.

Jose Jonas Del Rosario, a physician and the public affairs coordinator of PGH, says the UHCL is a welcome change in the health system but that there is a need for more permanent staff. “We have to be ready. We have to appeal. It's not that easy to ask for plantilla positions,” he says. “The UHCL has to be properly funded and implemented. The IRR [Implementing Rules and Regulations] should be well-written, well-drafted — hindi ningas kugon. It has to diba? Kailangan niyan ma-maintain, ma-sustain.”

Saguil also adds that the UHCL certainly is a “god-send,” relaying stories of how most doctors in government hospitals do shell out their own money to help their patients. “When we had sweldo, that sweldo was used to help the patient,” she says. “Even patients who can go home ... You give them money just so they can go home.”

“Kung hindi ka kaalyado, you might not be getting the number of health workers that you need just because you're not aligned with the provincial governor.” — Dr. Van Philip Baton on the UHCL being implemented by local government units

However, a looming issue that comes with the UHCL is its implementation by local governments. The UHCL has mandated the Local Health Boards of Local Government Units to be the ones to propose yearly budget allocations for the operation and maintenance of health facilities. Moreover, Section 21 of the UHCL states that “all income derives from PhilHealth payments shall accrue to the Special Health Fund used exclusively for the improvement of the LGU health system.” This means that the LGUs have the power to determine how the funds will be used, which can, essentially, shape how the new law is implemented.

Van Philip Baton, a doctor stationed at the Department of Health (DOH) in Cebu, underscores that giving more local funding to the provincial government can be problematic, as there can be too much space for politicization.

“Personally speaking, mahirap kasi [kung] ibigay mo to somebody who's more a politician rather than a policy maker on the ground kasi isa sa mga fears na iniisip namin is that gamitin ‘tong political tool,” he says. “Kung hindi ka kaalyado, you might not be getting the number of health workers that you need just because you're not aligned with the provincial governor.”

For policy makers in the regional and national level, Baton says it may be easier to manage the fund because you only have to talk to one person — the governor. The danger lies in the idea that just because a governor is amenable, then the mayors are also given the support. “Baka in reality is that hanggang usap lang kay governor pero selective pa rin ang pag-implement ng program because nga may political color ang mga pag-iimplement ng programs — ‘yun ‘yung fear namin,” he shares.

“We even see that in the municipal level na may mga barangay na may consistent support from the city while other barangays that are not allied with the current mayor, eh kawawa din. Kulang ‘yung improvement, kulang ng tao, hindi nabibigyan ng support.”

Respect for government doctors, nurses

It has become clear that in order for the UHCL to work, there needs to be proper cooperation and coordination among the local government units, the policy makers, and the health workers.

Undersecretary Domingo also stresses that UHCL needs the help of the people it is trying to serve; that there should be a shift in the health-seeking behavior of Filipinos for the law to be effective.

“Gusto namin top of mind lagi kung may nararamdaman, ‘I'll go to my primary care physician. I'll go to my primary care worker.’ And then siya ‘yung parang mag-dedecide kung kailangan ka i-refer,” he says. “It's going to be a complete change so challenge ‘yan sa patients, and challenge din ‘yan sa side ng doctors kasi maninibago sila.”

Domingo also hopes that through the new health care law, Filipinos will be more empowered to see a doctor and to be free from the fear of the possible repercussions of health concerns. “Ngayon, takot na takot ‘yung mga tao, kasi magastos.” he says. “With the UHCL, ‘pag nagkasakit ang Pilipino, hindi siya kailangan magpili between bebenta niya ba ang kalabaw niya o maghihintay ba siya ng another six months.”

He adds: “We want protection from poverty na hindi pwede ‘yung health problem ang magiging dahilan because every year until now, one million Filipinos go into poverty every year just because a family member gets sick.”

While healthcare is a right and one that every Filipino should demand from its State, Saguil also hopes that patients can be more understanding of public health workers who are often on the receiving end of complaints. In PGH, patients would even text the 8888 hotline or the Citizen’s Complaint Hotline that is meant for government malpractices such as red tape, graft, and corruption.

Abat, the nurse, says that he’s seen this happen. “Minsan, makapagreklamo lang eh. Parang sumama lang ‘yung loob, text agad ‘yun sa 8888,” he says. “Ang ginagawa naman ng 8888, kinaklaro kung totoo. Kadalasan naman talaga, reklamo lang.”

“With the UHCL, ‘pag nagkasakit ang Pilipino, hindi siya kailangan magpili between bebenta niya ba ang kalabaw niya o maghihintay ba siya ng another six months.” — DOH Undersecretary Rolando Domingo

A year ago, videos and photos of sleeping nurses in a public hospital in Metro Manila made rounds on social media, which started an online discussion on the amount of tasks our health workers have to deal with as well as the glaring gap in our healthcare system. Broadcaster Ramon Tulfo also famously took a video while spewing expletives to a PGH physician for not immediately attending to a child his staff member bumped in a street.

Saguil, being the chair of the outpatient department, can attest that nurses and doctors indeed have a lot of fear that they’ll be seen on social media. “That's become a source of major stress,” she says. “I now have nurses who have post-traumatic stress disorders because of that.”

Del Rosario adds that as the UHCL is on its way, patients do need to understand the volume of work government health workers have to face on a daily basis on top of the huge, often understated responsibility of dealing with actual lives. “Eto, you're like in a war zone in a way,” he says. “You end up assuming so many responsibilities outside of being a doctor … But in the end, you do come out of the hospital a more complete physician. Ginawa mo na lahat eh.”

But at what cost?

“‘Yung humanity ko talaga minsan, question mark na,” says Miguel. “May patient [ako] na sobrang poor prognosis. Then, nag-text sakin ‘yung family na namatay ‘yung patient. Tapos tinignan ko lang cellphone ko then [kausap ko na ‘yung] next patient, ‘Hello, magandang umaga po.’ Ganon lang.”

*Name has been changed to protect his privacy.