Abstract

Background

Despite advances in medicine and public health, glaring inequalities in access to

health care and health outcomes within and between countries persist and have
even widened in some countries, including the Philippines. A major contributor is
the mismanagement of human resources for health, including doctors, nurses, and
community health-care workers. 60% of Filipinos die without seeing a doctor, and
the Philippines has a shortage of trained doctors. Furthermore, doctors in the
Philippines are distributed unevenly and emigration is high. Poor medical
education partly causes the mismatch between competencies of health
professionals and the health needs of the population. Such mismatch leads to
mismanagement of human resources for health and reduces access to the health-
care system. We aimed to gain insights from current medical students about the
present situation and future direction of medical education in the Philippines.
Methods

In response to the 2010 Lancet Commission Health professionals for a new century,

we organised a 3 day workshop that covered the current state of medical
education and human resources for health in the Philippines, and existing and
emerging global and national health challenges. 47 medical students from several
medical schools in the Philippines were selected through an open application
process. The sessions, which included interactive lectures and field visits,
culminated in small group discussions about the present state of medical
education in the Philippines and the participants' recommendations for scale-up.
Findings

The participants came up with three types of recommendation. First, reforms in

human resources for health, from recruitment and training to certification and
deployment. Second, reforms in the different components of medical education:
framework, content, and method. And third, reforms of the different levels of
physician training: medical school, health system, and broader societal
determinants, such as the living and working conditions of doctors. Some specific
changes suggested include: early, prolonged exposure to the community; inclusion
of more social science, public health, and leadership and management subjects in
the curriculum; and provision of environments conducive to interprofessional
learning. The students also proposed institutional reforms such as including
students in the design of the curriculum, and social accountability as a measure of
success of medical schools, instead of traditional licensure exam pass rates.
Interpretation

Medical education needs to change, as more medical graduates aspire to work

abroad or in urban centres, or become specialised. However, the overall approach
to and management of human resources for health in the country should also be
reformed, not just the content and method of medical education. Scale-up of
medical education will need the involvement of the Filipino Government, the
Department of Health, medical schools, and even medical students. The
Philippines should commit to transforming medical education, which is an
important step towards production of new health leaders for national and global
health equity.
Funding

International Federation of Medical Students' Associations.

Introduction. The COVID-19 pandemic forced educational institutions to adapt to a full

online learning environment. Medical schools in particular were disrupted by this shift
since the majority of the learning objectives, skills, and necessary competencies are
learned through classroom and hospital face-to-face activities.

Objective. The purpose of this paper is to describe the experiences of a medical school

in the country as it navigated the sudden shift to full online learning vis-à-vis a
framework on the barriers and solutions to online learning.

Method. This is a descriptive paper written from the perspective and observations of an

administrator who participated in crafting the immediate response of the school to the
sudden shift to online delivery and who worked with the stakeholders of the Ateneo
School of Medicine and Public Health (ASMPH).

Results. To address concerns on time, skills and infrastructure, the school reprioritized
its learning objectives for the remainder of the school year. It conducted in-service
sessions for faculty while also immediately setting up a learning management system and
a technical support team that was available on demand. Strategies employed included a
deliberate switch to asynchronous learning, curation of content and creativity in delivery
and assessment, and the reshaping of the management and public health activities into
the online platform. To manage attitudes and provide institutional support, the school
worked collaboratively with stakeholders and transformed its traditional support
services of campus ministry, counselling, formation, and physical and mental health to be
readily available online.

Conclusion. We described the experience of ASMPH when medical schools were forced
to completely shift to online delivery of their programs because of the pandemic. We
identified the barriers and solutions of online learning in medical education. The unique
context of the ASMPH for having a dual degree in medicine and management; having an
inter-disciplinal, non-departmentalized set-up at each year level; and, possessing the
traditions of Jesuit education were instrumental in the school’s ability to navigate this
sudden shift.

In March 2020, the coronavirus disease 2019 (COVID-19) pandemic

forced medical schools in the Philippines to stop face-to-face learning
activities and abruptly shift to an online curriculum. This study aimed to
identify barriers to online learning from the perspective of medical
students in a developing country.

Methods

The authors sent out an electronic survey to medical students in the

Philippines from 11 to 24 May 2020. Using a combination of multiple-
choice, Likert scale, and open-ended questions, the following data were
obtained: demographics, medical school information, access to
technological resources, study habits, living conditions, self-assessment
of capacity for and perceived barriers to online learning, and proposed
interventions. Descriptive statistics were calculated. Responses were
compared between student subgroups using nonparametric tests.

Results

Among 3670 medical students, 93% owned a smartphone and 83% had a
laptop or desktop computer. To access online resources, 79% had a
postpaid internet subscription while 19% used prepaid mobile data.
Under prevailing conditions, only 1505 students (41%) considered
themselves physically and mentally capable of engaging in online
learning. Barriers were classified under five categories: technological,
individual, domestic, institutional, and community barriers.

Discussion

Medical students in the Philippines confronted several interrelated

barriers as they tried to adapt to online learning. Most frequently
encountered were difficulty adjusting learning styles, having to perform
responsibilities at home, and poor communication between educators
and learners. By implementing student-centered interventions, medical
schools and educators play a significant role in addressing these
challenges during the COVID-19 pandemic and beyond.

Supplementary Information

The online version contains supplementary material available at

10.1007/s40670-021-01231-z.

Keywords: COVID-19, Online learning, Philippines, Undergraduate

medical education
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Background

The coronavirus disease 2019 (COVID-19) pandemic disrupted

undergraduate medical education worldwide. During the early part of
2020, when little was known about the disease and no effective
treatment or vaccine was available, medical schools in different
countries had to suspend classroom teaching and remove students from
their clinical placements [1]. These drastic measures intended to ensure
safety of learners and educators [2], curb viral transmission in higher
education institutions and hospitals [3], conserve personal protective
equipment for essential staff [4], and reduce the teaching load of
physicians deployed at the pandemic’s frontlines [5]. To sustain medical
education, it became necessary for medical schools to pivot to online
learning—also called e-learning, web-based learning, or internet-based
learning [6, 7]—as their primary means of curriculum delivery. In a short
span of time, medical educators had to adapt and innovate, designing
online learning experiences to substitute for lost hours that would have
been spent in the classroom [8], laboratory [9], or patient’s bedside [10].

Howlett defined online learning as “the use of electronic technology and

media to deliver, support, and enhance both learning and teaching and
involves communication between learners and teachers utilizing online
content” [11]. The advantages of using online learning in medical
education include improved accessibility of information, ease of
standardizing and updating content, cost-effectiveness, accountability,
and enhancement of the learning process, wherein students are
motivated to be active learners [7, 12]. Online learning can provide
students with foundational knowledge and confidence before exposure
to real or standardized patients [13]; it has been used effectively to teach
evidence-based medicine [14] and to facilitate interprofessional
education [15]. A recent systematic review suggested that online
learning for undergraduate health professions was equivalent and
possibly even superior to traditional methods of curriculum delivery
[16]. The high risk of bias among several included studies, however,
precluded the authors from drawing definitive conclusions.

In low- and middle-income countries, online learning has the potential to

(1) address faculty shortage, expanding the reach of medical educators
and improving their efficiency; (2) improve access to health professions’
training, increasing the number of health workers and encouraging their
retention in regional units; and (3) facilitate collaboration with
institutions that have more resources [17]. Notwithstanding, in survey
studies during the COVID-19 pandemic in India [18], Pakistan [19], Nepal
[20], Jordan [21], and Libya [22], the majority of medical students had a
negative perception or expressed dissatisfaction towards online
learning.
In the Philippines, a low-middle-income country in Southeast Asia,
classes in all levels were suspended in mid-March of 2020, after the
government had put the country’s largest island Luzon and other major
cities under lockdown [23]. Halfway into the second semester, medical
schools had to cease all face-to-face learning activities. Medical students
were removed from clinics, wards, intensive care units, and emergency
departments. Local and international electives were cancelled. The
national internship program was likewise suspended, and the physician
licensure exam postponed indefinitely.

Forced to abruptly transition to an online curriculum, each medical

school crafted its own guidelines on learning activities, revised
assessment measures, and set promotion policies. Consequently, the
learning experiences of students varied among medical schools
nationwide. In an open letter posted on social media, the student
network of the Association of Philippine Medical Colleges called for the
suspension of online learning and termination of the ongoing semester,
citing difficulties that the students had encountered, particularly poor
internet connection, limited access to gadgets, and lack of study space at
home [24].

The utilization of and capacity for online learning in Philippine medical

schools had not been described before. In this paper, we aimed to
comprehensively identify and describe the challenges to online learning
from the perspective of medical students during the COVID-19 pandemic.
Regmi and Jones previously examined papers on e-learning in health
sciences education and categorized barriers under four themes: poor
motivation and expectations, resource-intensiveness, not being suitable
for all disciplines or contents, and lack of information technology skills
[25]. Focusing on developing countries, Frehywot et al. cited inadequate
infrastructure, lack of face-to-face interaction, inadequate technical
support staff, financial costs of maintaining the platform, and time
commitment required from teachers as major challenges [17]. From the
standpoint of managers and educators, also important were resistance to
change [26] and lack of institutional strategies and support [27]. It must
be pointed out that these studies evaluated online learning as part of
planned curricular changes or under controlled circumstances.

We hypothesized that during the COVID-19 pandemic, medical students

in the Philippines faced socioeconomic and cultural barriers, in addition
to limited access to technological resources. It is crucial to have targeted
interventions that address these challenges in low- and middle-income
countries, where the need to continuously train skilled health workers is
also greatest [28].

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Methods

We conducted a nationwide cross-sectional study among medical

students in the Philippines from May 11 to 24, 2020, through an
electronic survey in Google Forms (Google LLC, Mountain View,
California). At that time, online classes had been ongoing for 8 weeks,
and most medical schools were nearing the end of their academic year.
Face-to-face learning activities would remain suspended in all medical
schools for the rest of year 2020. During the study period, the Philippines
reported an average of 210–246 new confirmed COVID-19 cases per day,
reaching a peak 7-day average of 4477 new cases in August 16 [29].
Based on World Bank data [30], the country had an estimated population
of 108 million in 2019.

Philippine Medical Education

The Doctor of Medicine program in the Philippines takes 4 years [31].

The first 2 years consist mainly of didactic teaching, when students learn
basic or foundational sciences. Clinical placements usually begin in third
year, although  clinical sciences may be introduced through lectures, case
presentations, simulation activities, and patient encounters as early as
first year. During the fourth year, medical students complete 12 months
of clinical clerkship, with required rotations in internal medicine,
pediatrics, surgery, and obstetrics-gynecology. Other courses that must
be integrated in the curriculum include history of medicine, research,
medical informatics, legal medicine, medical jurisprudence, bioethics,
leadership and management, and interprofessional education.

There is marked variability in medical curricula throughout the country

[32]. Medical schools may implement a curriculum that is subject- or
discipline-based, organ- or problem-based (i.e., integrated), community-
based, or any other innovative curriculum. Regardless, students must
attain the learning outcomes that the Commission on Higher Education
set for the Doctor of Medicine program [31]. To obtain a medical license,
graduates must undergo 1 year of internship and then pass a written
examination that covers 12 subjects.

Survey Instrument

We initially conducted a focus group discussion with medical students

from the University of the Philippines, searched official school websites
for announcements on changes being implemented in Philippine medical
schools due to the COVID-19 crisis, and reviewed relevant literature.
Using these background data, we developed a 23-item questionnaire
(see Supplementary Material A) that collected demographics, medical
school information, access to technological resources, study habits,
current living conditions, and views on online learning.

Using a 4-point Likert scale (strongly disagree, disagree somewhat, agree

somewhat, strongly agree), we asked the participants: (1) whether they
considered themselves physically and mentally capable of studying
online for the rest of the semester; (2) whether medical schools should
give a passing grade to all their students (i.e., mass promotion); (3)
whether they had enough time and resources for online learning; and (4,
5) whether the resources of their schools and the skills of their educators
were adequate. We listed ten barriers to online learning and asked
respondents to select how frequently they have encountered each
barrier. In open-ended questions, we probed for any additional barriers
that the students may have faced, and asked for their proposed
interventions.

The primary investigator (REB) drafted the survey instrument. It was

pilot tested among medical students (NRIA, MBCB, RECM, LGTR, JJS, and
CJST) and revised several times, incorporating critical reviews from
medical educators (CAC and JCBR). The research unit of the Department
of Anatomy provided a technical review for face validity. The study
protocol was submitted to the University of the Philippines Manila
Research Ethics Board, which granted a certificate of exemption
(UPMREB 2020-281-EX).

We distributed the survey link through social media (Twitter, Facebook,

Instagram) and the Association of Philippine Medical Colleges Student
Network. We contacted organizations to share the link among students
in their respective schools. Our survey was open to students from first to
fourth year levels. Participation was voluntary, anonymity was
guaranteed, and consent was obtained.

Data Analysis

At the end of the data collection period, de-identified data were exported
to Stata/IC 16.1 for Mac (Stata Corp, College Station, Texas). We stratified
the data based on demographics and medical school information,
calculating the frequencies and percentages of categorical variables. In
the self-assessment of capacity for online learning, the responses were
converted to their numeric equivalents from 1 to 4, and these were used
to get the mean and median responses for each subgroup. We analyzed
differences between subgroups using Kruskal-Wallis test, with post hoc
analysis using Dunn’s multiple nonparametric pairwise tests. A P value < 
0.05 was considered statistically significant. For the rest of the Likert
scale questions and the list of barriers to online learning, we computed
the frequencies and percentages of responses.

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Results

Survey Respondents

We received a total of 3813 responses. We removed 75 (2%) that were

duplicate entries based on email addresses or student numbers, and 68
(2%) that were deemed invalid because of missing information or
because respondents were not medical students. Hence, we included
3670 responses (96%) in the data analysis. This represented 15% of the
estimated 25,000 medical students in the Philippines.

The exact number and distribution of medical students enrolled for

academic years 2019–2020 were not available at the time of study
completion. In lieu of this, we compared our nonrandom study sample
with the total population of first-time examinees of the physician
licensure exam [33] in the last 5 years (see Table Table1).1). Our sample
had a higher percentage of students enrolled in public medical schools
(16% vs. 14%, p = 0.001). The representation of the different regions also
differed (p < 0.001). Of the 55 medical schools recognized by the
Commission on Higher Education, 54 (98%) were represented in this
survey. The median number of respondents per institution was 42
(range 1–293), with 23 schools having 50 respondents or more.

I was 13 years old when I watched my uncle as the Department of Health spokesperson
on Philippine television during the 2003 SARS outbreak, and I decided in that moment
that I wanted to be a medical doctor. At such a tender age, I had no conception of the
challenges ahead, but I chose to take the path anyway, both with excitement and a
deep sense of courage.
The Philippine education system, including medical education, is heavily influenced by
the American system of education. This is primarily due to periods of foreign
occupation, with the United States leaving the most remarkable impression. In this
system, it is a requirement that, in order to pursue higher education (i.e., postgraduate
studies such as law or medicine), a student must be able to complete elementary
education, high school, and an undergraduate or bachelor’s degree program. The
duration of a bachelor’s degree program is a minimum of 4 years. A high school
graduate who would later like to pursue medical education may actually choose any
degree program for undergraduate studies; for example, he or she may choose a
health-related course (e.g., BS Nursing, BS Occupational Therapy, BS Speech
Pathology) or a non-health related course (e.g., Culinary, Engineering, Music) as a pre-
medical course. Those who have completed a non-health related course will need to
add Biology, Chemistry, Physics, and Math units to be eligible for medical school.
I was 17 when I began my Bachelor of Sciences in Public Health as a pre-medical
course in the University of the Philippines-Manila. I chose Public Health as an
undergraduate course with only the knowledge that it would help me achieve my
ultimate goal. Later, after immersing myself in 4 years of Public Health, I realized that it
has given me gifts other than the competencies I needed to enter medical school. It has
granted me insight and the passion and patience required for research.
I describe myself as an average student, as there are a lot of brilliant others who
perform exceptionally in class, but I truly believe I am lucky. Being competitive is a
requirement since the admission process of medical schools is a rigorous competition.
Generally, the criteria for selection include the student’s grades in the undergraduate
course, the results of the National Medical Admission Test (NMAT), and a final interview
with a panel from the admissions committee. The NMAT is a set of tests that measure a
student’s aptitude in the Maths and Sciences. The NMAT scores required by medical
schools vary; for example, at the University of the Philippines College of Medicine and
the Ateneo School of Medicine and Public Health, the minimum score is a 90th
percentile, while the minimum score is a 85th percentile at the University of Santo
Tomas. At the medical school I attend, the NMAT requirement is a minimum of a 45th
percentile, but this relatively low requirement does not reduce the level of competition.
In order to beat thousands of applicants for the prized slot, the NMAT score should be
greater than or at the level of the 99th percentile. Lastly, an individual needs to convince
the panel interviewers that he or she deserves the opportunity to be educated and that
he or she will one day be useful to society in prolonging life and promoting health. The
interview stage is key; some applicants have very high grades and NMAT score but still
do not make the cut because they fail the interview process. Alas, the average but lucky
student is not accepted to a medical school, such as the Pamantasan ng Lungsod ng
Maynila College of Medicine.
To date, there are about 38 medical schools in the Philippines. Out of the ten best
performing medical schools in the Philippine Physician Licensure Exam (2016), only 3
out of 10 are public medical schools, and the rest are private institutions. The tuition and
other fees are exorbitantly high: the private medical education of a course costs more
than that in public medical schools. Studying in a public institution, my tuition and other
fees amount to about Php 160,000/year (about USD3200), while my friends who attend
private schools pay about Php 300,000/year (about USD 6,000). Additionally, there are
other costs such as condominium or dormitory rent, food, and living allowances for the
entire duration of medical school. Despite the high medical school fees, Philippine
medical education is cheaper compared to other countries; for example, in the United
States, the cost of attendance ranges from USD 50,000 to over USD 70,000. Because
Philippine medical education is relatively affordable, a considerable number of foreign
students from India, Nepal, Africa, and other parts of the world are enrolled in mostly
private medical institutions for training.
The duration of a proper medical school is typically 5 years. In the first and second year,
students are taught basic medical sciences, and on the third year, clinical and
diagnostic approaches are emphasized. The last 2 years are spent on a clerkship and
internship, which include practical years of intensive hospital training. After the
internship, the medical student becomes eligible to take the Physician Licensure
Examination (PLE). The PLE is administered twice a year, in the months of September
and March. Every time it is conducted, about 3,000 students take the examination,
yielding about 6,000 medical doctors every year. Despite the large number of doctors
produced annually, many medical and healthcare positions in rural and geographically
isolated and disadvantaged areas (GIDAs) remain vacant since work opportunities in
the urban setting and abroad appear more attractive and profitable. As a result of this
undersupply of medical doctors in rural areas, the delivery of healthcare is delayed as
sick patients endure long travels to other municipalities or to the provincial capital to
seek consult.
New medical doctors are given many opportunities for training and practice. The
duration of the residency training programs duration from 3 to 5 years, and further
specialization entails longer years of education. According to the Philippine Health
Systems Review in 2011, the most common tracks taken by doctors are Internal
Medicine (17.5% of all physicians), Pediatrics (15.5%), OB-Gynecology (12.5%), and
Surgery (10.6%). For those who do not want to pursue further training immediately, they
can choose to do moonlighting. Moonlighting is the practice of medicine as licensed
physicians with direct financial compensation. This provides avenues to reduce the
debts incurred during medical school, augment the doctor’s income, and provide
experiences and insight that could not be realized within the walls of a hospital.
I believe one of the most serious issues regarding the health workforce is that the
meager compensation for doctor, nurses, and other allied medical professionals is not
commensurate with the cost of education and workload. Although the salaries of
medical doctors are higher than the national capital’s minimum wage of Php 12,500
(USD 250), these are not sufficient to pay the debts incurred during the study of
medicine as well as the needs of doctors and their families. Presently, a junior resident
in a government hospital earns only about Php 30,000 (USD 600) per month, while a
more senior resident earns more or less Php 40,000 (USD 800).
This mismatch in wage and the labor offered by the physician prompts immigration to
higher-income countries. Other reasons for migration include professional and career
development and the attraction to higher living standards. These result in a large
shortage of 1 doctor for each population of 28,493, which is far below the WHO
recommendation of 1 doctor for each population of 1,000. According to the Philippines
Health Systems Review (2011), from 1997 to 2008, there is a total 3,678 physicians
who work overseas, and of these, 66.3% have migrated permanently. Also, according to
Dr. Alberto Romualdez (2008) from the University of the Philippines College of Medicine
(UPCM), 90% of the graduates of the class of 1960 and 88% of those from the class of
1965 have left the country.
In order to address the issue on the dispersion of Filipino doctors, the University of the
Philippines College of Medicine (UPCM) implemented the Return Service Agreement
(RSA) in 2011. It is a contract that requires all students to render 3 years of return
service in a health-related public or private institution in the country after completion of
the medical program and obtaining the licenses. This strategy is not a definitive solution
but will delay the migration of physicians while the next batches are still undergoing
training.
It is also worth mentioning the Department of Health’s (DOH) Doctors to the Barrios
Program (DTTB) as a strategy to address the shortage of doctors in remote areas in the
country. This 2-year deployment of medical doctors to rural areas was launched in
1993, but monitoring and evaluation of the program showed that very few doctors chose
to remain for an extended period and/or be absorbed by their Local Government Unit
(LGU). Several factors affect the retention of doctors in the community, which include
DOH and LGU support, family issues, and career advancement opportunities. In order
to make this program more attractive to volunteer doctors, the compensation was
increased to Php 54,000 (USD 1,080) as of 2014. Hopefully more doctors will volunteer
to join this program and cater to the needs of the poor and underserved.
With regard to the reduction of the cost of medical education, the current president of
the Philippines, Rodrigo Duterte, recently approved free tuition fees but only to state
universities in the Philippines. Presently, Senate Bill 526, which was filed by Senator
Antonio Trillianes, is waiting to be passed. The bill aims to increase the basic pay of
Filipino doctors to no lower than Salary Grade 27 or 73,937 (USD 1,586). Unless the
government offers decent wages, salaries, and other incentives, the diaspora of medical
professionals will continue to threaten the workforce, which will severely affect the
delivery of healthcare.
As a third-year medical student, I understand that the journey is far from over. I have a
long way ahead—a lot of lessons to learn, skills to develop, and experiences to gain.
Despite the difficulties of the medical program, and the gaps and failures of the
Philippine healthcare system, I feel confident and positive that our contributions to
healthcare can indeed make the world a better place.