ORIGINAL ARTICLE

Important but Neglected:

A Qualitative Study on the Lived Experiences
of Barangay Health Workers in the Philippines
Kenneth Y. Hartigan-Go, MD, Melissa Louise M. Prieto and Sheena A. Valenzuela, MPM

School of Government, Ateneo de Manila University

ABSTRACT

Background and Objective. Within a decentralized health system, barangay health workers (BHWs) are often the first
point of contact for Filipinos seeking care. Despite their importance, BHWs are neglected in the health value chain.
The study seeks to examine the lived experiences of BHWs, particularly their journey in navigating their roles within
the community and the health system that encompasses their day-to-day realities, challenges, motivations, and the
meanings they derive from their work.

Methods. The study draws on seven focus group discussions (FGDs) with BHWs (n=50), residents (n=7), and local
government officials and health workers (n=7) of San Miguel, Bulacan. The qualitative data collected were analyzed
using thematic analysis.

Results. Findings show that BHWs perform many roles, which are not limited to health and are dependent on orders
from their superiors. Guidelines are vague in appointing BHWs, with personal connections valued more than technical
qualifications. Their accreditation is hardly conferred any significance. There is also a lack of formal and structured
training. The informality of these processes leads to an absence of quality assurance on rendered health services. The
non-provision of incentives and benefits stipulated in RA 7883 also places their health and lives at risk. Furthermore,
BHW’s commitment to serve is used to excuse the inadequacy of their compensation and excessive workload.

Conclusion. BHWs take on diverse roles, from community organizers to healthcare providers, and are confronted
with significant challenges encompassing politicization, inadequate training, and insufficient compensation. The study
concludes with policy recommendations to improve the conditions of the neglected BHWs, with particular attention
to coordinating, capacitating, compensating, career pathing, and connecting them to the health system.

Keywords: barangay health workers, community health workers, universal health care, health systems, Philippines

INTRODUCTION

Health in the Philippines is inequitable. For many, basic

health care services remain out of reach.1-3 This is especially
lived by Filipinos in rural and far-flung areas, who are most
impacted by the maldistribution of health facilities.4-6 Nearly
half of the Filipino population are unable to access primary care
facilities within 30 minutes.7 This persistent health inequity
is a solemnly recognized yet unsolved issue in the country.
The most recent and most comprehensive intervention to
address this is the enactment of the Universal Health Care
(UHC) Act in 2019. The UHC Act aims for every Filipino
to have “equitable access to quality and affordable health
Corresponding author: Melissa Louise M. Prieto care goods and services.”8 To reach this goal, strengthening
School of Government
primary health care is paramount.9-12 Considered as the
Ateneo de Manila University
Loyola Heights, Quezon City 1108, Philippines cornerstone of UHC, the importance of primary health care
Email: [email protected] in UHC is jointly vouched by the Department of Health and

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Lived Experiences of BHWs

World Health Organization, with primary health dubbed with potential—or even confirmed— carriers of the virus. Yet
as “the fairest and most affordable path to universal health despite risking their lives, many report not receiving reciprocal
coverage.”13 At the front lines of implementing primary care from the state, unable to receive the promised hazard pay
health care are community health workers (CHWs). in exchange for their service. According to BHW Partylist
CHWs refer to trained health workers with minimal Representative Angelica Co, BHWs are only provided hazard
to no formal medical training, tasked to provide patient- pay when there are excess funds from the cash assistance.36
centered care and promote health. They act as essential This starkly demonstrates how BHWs are relegated to the
cadres in the delivery of health services, especially in low- least priority despite their essential contribution.
and middle-income countries.14-21 The 1978 Alma Ata As such, this study intends to examine the lived
Declaration of Primary Health Care recommended their experiences of BHWs. Lived experiences refer to one’s
increased participation in primary health care, deploying embodied experiences of themselves and the world.38 The
them at the household level to connect community members study specifically seeks to explore the journey of barangay
to health facilities and services.22-24 The Philippines was one health workers in navigating their roles within the community
of the first countries who adhered to this recommendation.25 and the health system, encompassing their day-to-day
In the 1990s, the Philippines moved toward a realities, challenges, motivations, and the meanings they
decentralized system through the enactment of Republic Act derive from their work. These are complemented by insights
No. 7160 or the Local Government Code. The code ushered from individuals in their lifeworld, including community
in the devolution of health services: the DOH overseeing members and local government officials. The present study
the overall performance of the health system and the local seeks to contribute to a deeper understanding of how BHWs
government units in charge of direct delivery of health perceive and make sense of their role, and bring to light
services. It also underscored the importance of first-level the overlooked conditions and contributions of BHWs in
health facilities, such as rural health units and barangay health the Philippines.
stations.26-31 CHWs often act as the first point of contact with
health systems in these decentralized health systems.32 In the Methods
Philippines, the CHW initiative features barangay health
workers (BHWs).29,32 Research Approach and Paradigm
The Republic Act 7883 defines barangay health workers The study employs a qualitative research design to gain
as those who have “undergone training programs under any a comprehensive understanding of the subject of inquiry.39
accredited government and non-government organization It specifically adopts the phenomenological approach.
and who voluntarily renders primary health care services Defined as the reflective study of pre-reflective experience,40
in the community after having been accredited to function phenomenology seeks to “fully describe a lived experience.”41
as such by the local health board in accordance with the The study is underpinned by the constructivist paradigm,
guidelines promulgated by the Department of Health which allows for in-depth exploration of phenomena.42
(DOH).”33 BHWs act as bridges between the community Constructivism primarily aims to understand why and how
and the health system and are the first part of contact for phenomena occur and how people make meaning out of
patients in local health centers.34,35 They also serve as the them.43 The approach and paradigm are chosen since the
key source of information in rural and far-flung areas and present study centers on lived experiences.
in fact are crucial in delivering health services in these
disadvantaged communities.19,21,36 Furthermore, BHWs are Research Locale
tapped to fulfill the role of health navigators under the UHC The study was conducted in San Miguel, Bulacan. San
system. The Department of Health seeks to train BHWs to Miguel is located in the third district of Bulacan, with a land
be primary care providers in primary, promotive, curative, area of 23,140 square kilometers. Its recorded population in
rehabilitative, and palliative care as part of the initiative to 2020 is 172,073.44 The landlocked municipality is politically
strengthen province-wide and city-wide health systems.37 subdivided into 49 barangays. All barangays had BHWs,
Yet despite their integral role to the health system and the reporting either to the barangay or the Municipal Health
pursuit of universal health coverage, BHWs are considerably Office located in Poblacion. The focus group discussions
neglected in the health value chain. They are treated as (FGDs) with BHWs covered all barangays, broken down
volunteers rather than regular workers, thereby only earning into five separate sessions (Table 1).
compensation in the form of honoraria or allowances. The
amount received by BHWs are unstandardized, inadequate, Data Collection
and often delayed.35 This neglect has been most pronounced The study involved three groups of participants: BHWs,
during the COVID-19 pandemic. Mobilized as frontliners residents, and local government officials and health workers
in the COVID-19 response and tasked with monitoring the of San Miguel, Bulacan. Seven FGDs were conducted
health status of community members and conducting contact from October 6 to October 26, 2022 in a university located
tracing, BHWs constantly risked their health by interacting at Poblacion, involving a total of 64 participants (Table 2).

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 Lived Experiences of BHWs

Table 1. Distribution of FGD Sessions according to Barangays Table 2. Distribution of FGDs according to Participant Group
No. of No. of No. of No. of
Barangays Group Description
participants FGDs Participants FGDs
Cluster A 10 1 BHWs Registered BHWs with at 50 5
Bulualto least one year of service
Pulong Duhat Residents Residents with at least 7 1
Bantog one dealing with BHWs
Sacdalan
Bariton Local government Barangay captains, 7 1
King Kabayo officials and barangay kagawad on
Pinambaran health workers health, rural health
Cambio midwives, rural health
Sapang unit members
Buga Total 64 7
Cluster B 10 1
Bagong Pag-asa
Salacot This is deemed sufficient to reach data saturation as it is
Ilog-Bulo
Bagong Silang
within the recommended four-to-eight focus group range,
Mandile found to be most applicable for studies with relatively
Batasan Matanda homogenous populations and defined objectives.45 The
Batasan Bata study also adhered to the recommended size of focus groups
San Agustin
Salangan
of between six to twelve participants, expected to be small
Sta. Rita Matanda enough to be conducive for sharing while large enough to
Cluster C 11 1 allow for diversity.46
San Vicente The study employed purposive sampling, intentionally
San Jose selecting participants according to their ability to elucidate a
Poblacion* specific phenomenon.47 Participants of the present study were
Tigpalas
Sta. Rita Bata chosen according to their experience and knowledge related
Paliwasan to BHWs. The recruitment of participants was done through
Biclat prior arrangements with the Municipal Health Officer of
San Juan San Miguel.
Tibagan
Labne FGD guides were developed for each group of
Cluster D 10 1
participants. The FGD questions followed a two-part
Balite structure, with the first part focusing on the lived experiences
Camias of BHWs. Researchers asked the participants to walk them
Buliran through the day-to-day experiences of BHWs. The questions
Santa Ines
Tartaro
also covered how they learned about the job, the appointment
Masalipit process, training, and accreditation. The guide also covered
Balaong questions on compensation, work-related challenges, and
Pulong Bayabas personal difficulties faced by BHWs. Meanwhile, the
Pacalag
Magmarale
second part tackles the insights of participants on policy
recommendations intended to improve the conditions
Cluster E 9 1
Bardias of BHWs. These include exploring their roles as health
Santa Lucia navigators, probing the voluntary nature of their work, and
Partida dissecting their workload.
Lambakin The FGDs adhered to an iterative process, which
Calumpang
Maligaya entailed reviewing data after each FGD session and making
Malibay adjustments to the discussion guide. This process involved
Sibul modifying certain topics based on newly gathered insights
Biak-na-Bato and broadening the scope to investigate emerging points of
Total 50 5 interest. Follow-up questions that drew out detailed responses
*There were two participants from Poblacion, which was the site of the were also integrated to enhance the depth and direction of
FGD. the discussions in the subsequent sessions. Throughout the
Note: There was at least one participant from each barangay of San study, the researchers declare no characteristics or conditions
Miguel, Bulacan. that influenced the conduct or outcomes of the findings.
The research team maintains rigor and objectivity and raises
no conflicts of interest.

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Lived Experiences of BHWs

Table 3. Sex and Age among Barangay Health Workers Table 4. Educational Attainment and Years of Service among
Characteristics n (%) Barangay Health Workers of San Miguel, Bulacan
(n=50)
Sex
Female 50 (100) Educational attainment n ()
Male 0 (0) No formal education 0 (0)
Intersex/Others 0 (0) Elementary level 1 (2)
Prefer not to say 0 (0) Elementary graduate 3 (6)
Age group (years) High school level 14 (28)
15 - 19 0 (0) High school graduate 18 (36)
20 - 29 0 (0) College level 11 (22)
30 - 39 4 (8) College graduate 3 (6)
40 - 49 18 (36) Prefer not to say 0 (0)
50 - 59 19 (38) Years of service (years)
60 and above 9 (18) 1-5 6 (12)
Prefer not to say 0 (0) 6 - 10 15 (30)
11 - 15 13 (26)
16 - 20 5 (10)
Data Processing 21 - 25 5 (10)
The sessions were also audio-recorded with the written 26 - 30 1 (2)
and verbal consent of the participants. The audio-recordings 31 - 35 1 (2)
were transcribed thereafter, with the transcripts cross-checked 36 and above 4 (8)
against the recordings to ensure accuracy. The recordings Prefer not to say 0 (0)
were promptly destroyed after transcription. Additionally, the
transcripts did not mention any names or identifying details,
using identification codes in its place. All data were only Results
accessible by members of the research team who had sworn
to confidentiality. Excerpts used in the final report were Demographic Characteristics
similarly de-identified to ensure that they cannot be traced All BHWs in the study identified as female at birth
to the participants. (n = 50, 100%). This is aligned with the number of BHWs
nationwide. As of November 2, 2022, the recorded number
Data Analysis of BHWs is 232,243. The overwhelming majority of them
Thematic analysis was used to analyze the qualitative are female, comprising 229,219. In stark contrast, only 3,024
data gathered, which identifies patterns of meaning or themes are male.49 When this gender imbalance was pointed out, the
across a data set, allowing researchers to make sense of shared participants recounted knowing around three male BHWs,
experiences.48 The researchers extracted the recurring themes but acknowledged that most were female.
from the transcripts, conducting a preliminary coding through In terms of age, the majority of BHW participants (n
open reading. The transcripts then went through several = 19, 38%) are between 50 to 59 years old. In the national
rounds of coding to refine the identified themes. The themes BHW registry, it was reported that the majority of BHWs
were finalized through consensus among the team members were 60 years old and above, closely followed by the ages of
to minimize subjectivities. To verify the trustworthiness of 50 to 59 (Table 3).49
the data, triangulation was employed by situating the findings Thirty-six percent (36%) (n = 18) of the participants
in the existing literature. The researchers also maintained answered high school graduation as their highest educational
an audit trail through the use of memos in their individual attainment, echoing the national data. Finally, most
fieldnotes, which were collated after every FGD session. participants have been in service for 6 to 10 years (n = 15,
30%). Notably, four participants (8%) have more than 35
Ethical Considerations years of experience (Table 4).
Ethical approval for the study was obtained from the
University Research Ethics Committee (UREC) of Ateneo The Journey of a Barangay Health Worker
de Manila University. The researchers also obtained written This study maps the journey of a BHW in San Miguel,
informed consent from BHWs prior to conducting the FGDs. Bulacan. It delves into the role they play in their community
The participants were assured confidentiality and anonymity. and in the health system as a whole. The present research also
Furthermore, it was clarified that their participation in the looks at the processes that BHW undergo, from appointment
study is purely voluntary, and they are free to withdraw their to receiving remuneration, and the challenges they experience.
participation at any time. Table 5 compiles illustrative quotes for all five themes.

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 Lived Experiences of BHWs

Table 5. Summary of Themes and Supplementary Quotes Furthermore, BHWs are critical actors in the
Theme Quotes COVID-19 response. A BHW shared, “We go to the patients
Performance of We go to the patients to deliver medicine. We are to deliver medicine. We are called even at nighttime to inform
multiple roles called even at nighttime to inform us when someone us when someone tests positive for COVID-19 so we can get
tests positive for COVID-19 so we can get their data their data and provide them to the contact tracer.” The work of
and provide them to the contact tracer. (BHW)
BHWs mandates them to interact with potential – and even
Political nature If the barangay captain does not want you, even if confirmed – carriers of the virus. Some BHWs shared how
of appointment you’re qualified, you will inevitably be removed. (BHW)
they contracted the virus and infected their family members,
Limited impact It was needed at first. However, due to the pandemic, one of which died as a result. Aside from monitoring
of accreditation there were no training and seminars held. We were
renewed as long as we have volunteer experience.
and providing medicine to COVID-positive patients,
(BHW) BHWs were also tasked to manage social assistance given
Minimal conduct We are not trained to reach [BHW] competencies yet
to residents. Furthermore, the pandemic underscored how
of training because there are no policies in place. (BHW) BHWs are expected to be available 24/7.
Inadequacy of The little amount they receive is not commensurate BHWs also assist community members in gaining and
compensation with their contribution to the community. (LGU) using PhilHealth coverage. Some even pay out of their own
pockets to acquire the member’s data records of residents.
However, many BHWs have no coverage of their own.
Roles Those who do are covered not because they are BHWs,
The Implementing Rules and Regulations of RA but because they are senior citizens or beneficiaries of the
7883 outlines the general duties and responsibilities as a Pantawid Pamilyang Pilipino Program (4Ps). Some BHWs
community organizer, educator, and health care services shared how their PhilHealth is covered by local government
provider, but also acknowledges that the work of BHWs officials, but state how these coverages are coterminous. One
varies from community to community, depending on the BHW recounted how they got PhilHealth coverage initially,
agreement between the BHW and the community leaders. but had to pay for it themselves after a year. This elicited a
Notably, there were BHWs who were initially unaware sense of helplessness for many of the BHWs. As a participant
of the roles and responsibilities before joining: expressed, “I think to myself, if I get sick, who will assist me?”
Before I became a BHW, I had no idea what a Furthermore, BHWs are sought by residents who need
BHW is and what they do. I had no experience. Those guidance in accessing healthcare facilities and services.
who are sick will come to you. I asked myself if I were BHWs not only provide directions but also handle the
performing the roles of a doctor, nurse, or midwife. transportation of patients to the facilities and even accompany
Sometimes, people would call me, ask for my help and them throughout the entire process. Nevertheless, BHWs
assistance. (BHW) acknowledge that they sometimes fall short in answering the
patients’ questions, referring them instead to the hospital.
Upon taking on the role, BHWs find themselves They however expressed willingness to act as navigators of
performing many tasks. They handle pregnancy, providing the health system when capacitated.
information on family planning and conducting prenatal and It is also noteworthy how community members rely on
postnatal checkups. BHWs are also involved in vaccination BHWs even in terms of finances. BHWs remarked how a
drives. Their roles are mainly supportive, involving record- typical issue faced by residents is their inability to shoulder
keeping and assisting the midwives who administer the the costs of healthcare services. In these instances, they turn
vaccines. They also make announcements and follow up on to BHWs for assistance:
those who do not show up. Community members also rely on us for finances.
For BHWs, persistence is a virtue. Many recount They approach us when they cannot pay for check-ups. We
how they have to relentlessly remind residents, not only to seek the help of councilors and other municipality officers
vaccinate but to partake in health activities – family planning, or handle their requirements in getting a certificate of
prenatal care for pregnant women, and general maintenance indigency. (BHW 1)
of medicine for the residents. However, some BHWs face For example, they’ll say, “We have no money to pay
difficulties in convincing those who are hesitant to take for my child’s hospitalization.” Since I like my job, I help
the vaccine, stating “We feel like we are not in the position to them by bringing them to the hospital and looking for
explain because we are not knowledgeable enough.” people who can provide help. For those who are about to
BHWs are also involved in disaster and calamity give birth but lack finances, we provide them money to
responses. However, their roles are limited to relief operations purchase necessities for raising a child. (BHW 2)
and record-keeping. BHWs monitor disaster-prone areas,
especially flood-prone areas that carry the risk of leptospirosis. Residents are aware of the financial situation of BHWs.
They also document the aftermath of disasters, reporting From the responses, it is clear that they do not expect BHWs
damages incurred on buildings. to shell out money themselves, but rather reach out to

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Lived Experiences of BHWs

authorities who may help them or assist them in acquiring appointed me as BHW, but I don’t have any background
requirements to waive or reduce the costs. To make this on what BHWs or mother leaders do. I just asked them
happen, BHWs are expected to tap into their networks in to include me. (BHW)
the community, particularly their connections with local
authorities. The role of personal relationships in appointing BHWs is
BHWs are also pivotal in census taking, keeping records an open secret in the community. Notably, BHW participants
of the various illnesses in households. They also keep a who gained their position through ties with local officials
record of those who are pregnant, high-risk, senior citizens, shared how they had no knowledge about the work of BHWs
and residents who have recently passed away. These data are prior to being appointed.
critical to the work of midwives: Personal relationships with former BHWs also hold
BHWs have the information we need, such as the weight in appointments. Several participants shared how
schedule of vaccination and who needs to be vaccinated. they eventually “replaced” their relatives who were formerly
We have good communication. They were especially BHWs:
critical during the pandemic. We couldn’t have created My mother-in-law used to be a BHW. Since
our report if not for the data they gather, since they are she’s quite old, she had me accompany her during
the ones most familiar with their barangay. (Midwife) house-to-house visits and other tasks. After one year
of accompanying her, the midwife told me that my
Evidently, the roles expected of BHWs are not limited mother-in-law should retire and I should take her place.
to health. Residents recount how BHWs even sometimes (BHW)
handle marital disputes. BHWs do virtually anything and
everything. As one barangay captain stated, “BHWs are all- BHWs describe the appointment process as
around. They do everything we ask them to do.” BHWs are well “napopolitika”– politicized. They acknowledge that the length
aware of this set-up: of their stay depends on their relationship with the barangay
As volunteers, we accept whatever work is given captain. Participants shared how barangay captains tend to
to us. Because we are just volunteers. (BHW) remove BHWs and replace them with their supporters. As
one BHW spelled out, “If the barangay captain does not want
The multiple roles of BHWs may be attributed to its you, even if you’re qualified, you will inevitably be removed.”
ambiguity, being highly dependent on orders from the top. This is validated by the response of a barangay captain
BHWs accept whatever work is handed to them, viewing participant, who explained, “If the BHW outrightly goes against
themselves as “the lowest member of the health team,” equating me during elections, I will not appoint them because I cannot work
their role to that of a health aide or even a servant. properly with someone who does not believe in me. If they believe
in me, they will not speak against me during the campaign period.
Appointment I prefer appointing someone who I know can help me and believes
According to RA 7883, BHW applicants must apply in me. That ensures we have a good relationship. How can I work
at the Municipal or City Health Board or the BHW with someone who does not believe in me?”
Registration and Accreditation Committee, who will evaluate During some cases where there is threat of replacement,
their application and interview them when necessary. In the midwife gets involved. One BHW recounted how the
reality however, this process is not met. In San Miguel, midwife disapproved of her appointment, preferring the
most barangay health workers do not even apply. Rather, the BHW she replaced, “When we met the midwife, she did not like
majority of BHWs are appointed by the barangay captain. us. She preferred the BHWs before us. She did not know us and did
Once elected, barangay captains appoint their own BHWs: not want to accept us.” She shared how the municipal health
When the barangay captain won, he appointed me. officer, together with the barangay captain, had to intervene
I was then the solo parent president of our barangay. and vouch for them.
The barangay captain made me a BHW chairman once Meanwhile, some dismissals were prevented by midwives
he was elected. But I had no idea then what BHWs do. themselves:
(BHW) When the new barangay captain assumed the role,
he insisted on removing three of us remaining BHWs.
Barangay captains do not follow specific guidelines in But we were protected at the municipal and provincial
selecting their appointees. This demonstrates the informal level. We retained our roles despite the new barangay
nature of the process, underscored further by BHWs who are captain. We were stationed at the RHU instead. (BHW)
appointed due to their familial ties with the barangay captain:
My grandfather ran for barangay captain. I Nevertheless, the influence of the midwife is limited.
have no background in being a BHW or a mother They can only retain the BHW in the municipality and the
leader. I simply asked him to include me in [BHWs]. region, but not in the barangay. As a result, some BHWs
The councilor is also my uncle. When they won, they do not receive honoraria at the barangay level.

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 Lived Experiences of BHWs

To lessen the likelihood of replacement, BHWs were deciding their renewal, deciding based on their performance,
advised to remain apolitical. One BHW recounted, “The which are primarily gleaned from the submitted reports by
midwife advised us to remain silent over the candidate we will the BHWs.
vote for. Just vote on the ballot on the day of the election. Don’t Notably, there are instances where BHWs are accredited
join political campaigns because it will be taken against you. but not appointed. BHWs cite politicization as the culprit.
That’s why I lasted for 30 years, I followed her advice.” This Despite being accredited, the barangay captain can choose
lends further credence to the politicized notion of BHW not to appoint the BHW at the barangay level. In these cases,
appointments. the MHO usually intervenes.
As there are no formal guidelines in appointing
BHWs, appointments tend to be arbitrary. After one year Training
of volunteering, appointees automatically become BHWs. RA 7883 requires BHWs to undertake training
They are not required to take a qualifying exam or undergo programs under any accredited government and non-
an interview. The only requirement, as surfaced in the FGDs, government organization. However, similar to the application
is to volunteer for a year. According to the participants, there and accreditation process, this is not fulfilled. Participants
is the assumption that BHWs already know everything revealed that they did not have training prior to assuming
they need to know after one year of volunteering. the role. This is acknowledged by local government officials.
Furthermore, there are no technical qualifications to A barangay captain shared how there are newly appointed
become a BHW. Some BHWs cite willingness to volunteer BHWs who do not know how to perform their roles at first:
as the only qualification. Most participants emphasized the During the beginning, they did not know how to
importance of attitude, to which skills are only secondary. do tasks as simple as taking blood pressure. They are not
One barangay captain narrated what they look for in a BHW, perfect upon appointment and admittedly fall short in
stressing the significance of trust, “In selecting a BHW, the first several tasks. (BHW)
qualification is trustworthiness. Someone who will obey me – not
in wrongdoings, of course, but I look for someone who is willing Even once they assume the role, BHWs rarely receive
to volunteer and serve.” They further noted how skills can be formal training. Instead, they primarily receive on-the-job
learned over time, justifying the perceived preeminence of training. Many of them gain experience by shadowing and
attitude over skills. assisting the midwife. Some senior BHWs also volunteer to
guide newer BHWs. The reliance on on-the-job training over
Accreditation formal training is also acknowledged by local government
RA 7883 states that registered BHWs who have actively officials, with one recounting, “BHWs learn how to do their
rendered voluntary primary health care services in their work in the process, through the conduct of meetings, lectures,
locality for at least three years are qualified for accreditation. and seminars. Over time, they are trained under the guidance of
The application for accreditation is reviewed by either the local officials, midwives, and workers in the rural health unit.”
Municipal or City Health Board or its duly constituted Newer BHWs especially receive minimal formal
Barangay Health Worker Registration and Accreditation training: “They reason that it’s expensive and outside the budget.
Committee (BHW-RAC). In practice, BHWs are almost We get our training instead when we are stationed at the health
always automatically accredited. One BHW participant center. We gain actual training in assisting in the national
recounted the accreditation process in their barangay: immunization program, administering first aid during accidents,
We collect the names of each BHW. Then we seek and taking blood pressure of those who are pregnant.”
the signatures of the midwife, BHN, MHO, and mayor. The amount of supplementary training also varies among
We then forward the documents to the provincial office BHWs. Some BHWs recounted receiving additional training
in Malolos, which is automatically forwarded to the for diseases like tuberculosis and dengue, but admit that these
region. Afterwards, we are accredited. (BHW) were not regularly given. They also shared how BHWs hold
an annual conference where they receive refresher courses,
Broadly however, most BHW participants were unfamiliar with the most recent one garnering nearly 360 attendees. For
with the accreditation process. Many admit that they do not the most part however, BHWs rely on whatever training is
know who conducts accreditation. They are only familiar with given to them. When they do seek specific training, these
the yearly renewal of their accreditation status, which requires requests are often unaccommodated, citing lack of budget.
BHWs to have undertaken at least one training approved by This leads to a sense of resignation. When asked what
the MHO. However, this requirement was waived due to training they would like to receive, the participants merely
the COVID-19 pandemic. A BHW shared, “It was needed reiterated that they depend on whatever is given to them.
at first. However, due to the pandemic, there were no training Alarmingly, some BHWs reported how they were not trained
and seminars held. We were renewed as long as we have volunteer to respond to the pandemic despite serving as frontliners.
experience. The strictest requirement was having at least one year Nevertheless, many BHWs express wanting to receive
of volunteer experience.” The midwife is the main authority in training of various nature. One BHW shared how they want

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Lived Experiences of BHWs

to receive first aid training, reasoning “Many of us take patients Even midwives and barangay captains recognize how the
to the hospital and accompany them in the ambulance.” Another BHW’s meager pay is not proportionate with the services
BHW underscored the importance of training for those they render:
who are involved in health delivery. Furthermore, training We really need them. [...] We hope that they get an
makes BHWs feel qualified in their roles. When asked how increase in their payment. (Midwife)
they know they are qualified to fill the BHW position, the The little amount they receive is not commensurate
participants cite the training programs and seminars they with their contribution to the community. (Barangay
attended. captain)
The Technical Education and Skills Development
Authority (TESDA) offers a training program for BHWs Despite their meager remuneration, BHWs spend
called Barangay Health Services NC II. Those who have out-of-pocket for various expenses related to their work,
completed the course and the corresponding assessments such as photocopying materials, load, and transportation.
are deemed competent to become a barangay health worker. BHWs are thus unable to generate savings, and are often
However, while most participants are aware of the existence pushed to borrow money from family members, friends, and
of these competencies, with some expressing that they want microfinancing schemes to meet their household expenses. By
to attain them, they admit that they have not reached these. itself, being a BHW is not seen as a viable source of income.
According to a participant, “We are not trained to reach these BHWs typically have other working family members, such as
competencies yet because there are no policies in place.” They also their spouses or children. Furthermore, BHWs are not full-
shared how no one prepares programs for them to attain time workers. Most of them take on part-time jobs, primarily
these competencies. in the food and service industry. From the responses, the
most common sideline of BHWs is direct selling. Some
Compensation participants reported how their role as BHWs actually helped
Since BHWs are volunteers, they only receive them in direct selling by creating and sustaining a network
compensation in the form of honoraria. Moreover, they of clientele. Midwives and local government officials are also
are only eligible to receive incentives after one year of generally supportive of the BHWs’ part-time work.
volunteering. Presently, their compensation depends on the BHWs also find it hard to rely on their compensation
internal revenue allotment (IRA) of the barangay, and not all because of delays in payment. In fact, some participants
barangays are created equal. As a result, the amount BHWs recounted that they have to regularly remind the units for
receive is inconsistent across barangays. This variability their compensation. BHW participants also expressed
emerged as a point of concern for the participants. One feelings of resignation when their remuneration gets delayed,
BHW complained about receiving different amounts despite chalking it up to their voluntary status:
doing the same work. They told us that we were just volunteers. We should
The compensation received by BHWs come from three not wait for compensation. (BHW)
different levels. BHWs in San Miguel receive monthly They said that we were only helpers, volunteers, so
remuneration from their barangay, with the amount ranging we must be patient. (BHW)
from 800 to 1,000 pesos.They also receive 1,000 pesos quarterly
from their municipality and 3,500 pesos from the provincial BHW participants also raised the issue of mandatory
office. However, BHWs have to physically go to the offices to retirement for BHWs at the age of 65. They expressed feeling
pick up their payments, spending for their own transportation. unappreciated by the lack of retirement pay for BHWs:
For some, the expenses can cost up to a fifth of the payment We implore the government to pay attention to
they receive, stating “We receive 1000 pesos quarterly from the us BHWs. Currently, once we turn 65, we are auto-
municipal office, spending 200 pesos for transportation.” During matically removed from being BHW without receiving
the peak of the pandemic, this arrangement was temporarily anything. There isn’t any form of compensation to show
suspended in adherence to safety protocols, with the barangay appreciation for our lengthy years of service. We are just
treasurer collecting the payments from the municipal office nonchalantly removed. That’s painful to us. (BHW)
and bringing them to the barangay center where the BHWs
can more easily acquire them. However, after the restrictions Finally, BHWs intimated their desire to be regular
were eased, the old arrangement was brought back. Barangay government employees instead of volunteers, with fixed
captains are aware of the inconvenience of this set-up, but salaries and employee benefits. They are also willing to
claim that it is out of their control, as the decision on how to have salary deductions in exchange for PhilHealth and
distribute compensation lies with the officials at the municipal Government Service Insurance System (GSIS) coverage.
and provincial level. However, this must come with an increase in compensation.
Furthermore, BHWs grapple with the inadequacy of The regularization of BHWs and increase in their
their remuneration. All BHW participants agree that they compensation are similarly supported by local government
receive very little compensation despite their heavy workload. officials and midwives.

8
 Lived Experiences of BHWs

Discussion Furthermore, participants report not receiving the

incentives and benefits stated in RA 7883. According to
BHWs perform various roles as community organizers, the Act, “Volunteer barangay health workers in rural and
educators, and healthcare providers, although their urban areas, exposed to situations, conditions, or factors
responsibilities may vary across communities based on in the work environment or place where foreseeable but
agreements with local officials. Some BHWs enter the role unavoidable danger or risks exist which adversely endanger
despite having no prior knowledge of their duties and soon his health or life and/or increase the risk of producing
find themselves assisting in a wide range of activities, from adverse effect on his person in the exercise of his duties, to
family planning to disaster relief and pandemic response. be validated by the proper authorities, shall be entitled to
Despite their vital contributions to the community and the hazard allowance in an amount to be determined by the
health system, BHWs often face challenges such as the local health board and the local peace and order council of
threat of removal due to politicization, inadequate training, the LGU concerned.”33 However, despite promises from the
and insufficient compensation. They have expressed desire national and local government, BHWs do not receive these
for improved conditions, including better remuneration, hazard allowances. The absence of hazard pay makes BHWs
provision of formal training, and regular employment. vulnerable to health risks. This peril becomes heightened
during the COVID-19 pandemic as BHWs interact with
Diverse Interpretation of RA 7883 Exposes BHWs potential carriers of the virus. BHWs are composed mostly
and the Community to Vulnerabilities of older adults, mainly female senior citizens53, making them
RA 7883 or the BHWs’ Benefits and Incentives Act is even more vulnerable. Moreover, in the absence of financial
the most recent reform involving BHWs. The Act is part of assistance, participants shared how they had to pay for their
participatory strategies employed under the Primary Health own expenses when they and their families contracted the
Care Approach, aimed at making health services more virus. This demonstrates that the failure to adhere to RA
accessible.50 However, the interpretation of the Act varies 7883 puts the health and lives of BHWs at risk.
across geographical areas, owing to the decentralization
of the health system. While the DOH sets the agenda Politicization of BHWs Disrupts the Delivery of
for the national program, LGUs are responsible for its Health Care
implementation.51 Despite being part of the local health workforce, BHWs
The Local Government Code designates BHW appoint- are atypically and heavily politicized. They are aware of the
ment to be at the barangay level, providing the barangay importance of political positioning in their recruitment and
captain with the appointing power, whereas accreditation is continuous participation in the BHW program. BHWs feel
done under the municipality and the province. This set-up the need to align themselves politically with elected officials
results in conflicting interpretation and implementation of to maintain their position.52 Among BHWs of San Miguel,
RA 7883, as evidenced by the case of San Miguel, Bulacan. there is a similar acknowledgement that one must not openly
Majority of BHWs are appointed without adhering to go against the barangay captain to keep their jobs. This is
basic qualifications set out in the Act, with little to no aligned with previous literature, where involvement with
consideration to their credentials. As a result, BHWs may the “wrong” politician – that is, the politician who does not
be perceived as accountable to the political leader who win – becomes a disadvantage for the BHW.35 In the present
appointed them rather than the community they serve. With study, the main recourse of BHWs was to remain uninvolved
proper implementation, accreditation may serve as a helpful with any candidate during the election period. There is an
tool in legitimizing the role of BHWs. Moreover, it can understanding that being apolitical is necessary to remain
provide them with job security, acting as a buffer against the BHWs.
influence of local politics.52 The politicization of BHWs is illustrated by the preference
The lack of standardized training also emerged as a point for personal connections over technical qualifications in
of concern. While RA 7883 mandates BHWs to undergo BHW appointments. It is worth noting that merit-based
training programs under accredited organizations, BHWs of appointments do occur. Some BHWs are appointed based
San Miguel are not trained before filling the position. As of on their previous volunteer experience in community
writing, there is currently no standardized training program activities or in assisting BHWs.35 BHW participants in
that BHW aspirants and appointees go through. Moreover, the present study similarly shared how they were recruited
the implementation of training programs depends on local to become volunteers themselves after assisting BHWs in
governments and their prioritization. While TESDA released their work. However, there remains a personal aspect, as
the Barangay Health Services NC II, it remains unimple- these participants are often personally related to the BHWs
mented in the municipality. The noncompliance with the they assisted, replacing them when they become unable to
appointment, accreditation, and training requirements stipu- do their jobs often due to sickness or old age. Furthermore,
lated in RA 7883 results in the absence of quality assurance appointments based on merit are scarce, with the majority
on health services rendered by BHWs to the community. being political in nature.

9
Lived Experiences of BHWs

Previous literature warns against the politicization of is often used to excuse the inadequacy of their compensation.
BHWs and its adverse effect on the broader participation Despite the consensus among all participant groups that
of the community. The perception of BHWs as political the remuneration BHWs receive is severely lacking, BHWs
appointees is found to discourage community members themselves are willing to overlook their meager compensation.
from volunteering themselves. Politicization also allegedly They believe that their social relationships with their fellow
causes an erosion of trust between BHWs and community BHWs and the broader community compensate for the
members as a result of frequent replacement of volunteers.35 absence of financial incentives.35 In fact, “honorarium,
However, this runs contrary to the findings of the present incentives, and annual benefits” only ranked sixth among the
study, wherein BHWs continue to enjoy a high level of motivations of BHWs, with “ability to help the community”
trust and appreciation among residents. Residents view the ranking first.54 However, in viewing compensation as
BHW role as extremely helpful to the community and have secondary and even optional, there is a tendency to reduce
even considered becoming BHWs themselves. Residents the gravity of the financial struggles of BHWs. As such, calls
also recognize the difficulty of fulfilling the BHW role, to raise their compensation may be diluted.
demonstrating considerable respect for BHWs. Despite The same pattern can be observed when it comes to the
being aware of the politicized appointment of BHWs, this workload of BHWs. Another consensus among participants
is not thought to interfere with their perceived altruistic is that BHWs take on an excessive amount of work. Unlike
motivations and the rigor of their work. with compensation however, there is lesser demand to
A critical consequence of the politicization of BHWs address this issue. While some BHWs expressed wanting
however is their periodic replacement. In the aftermath of local to reduce their workload, the dominant sentiment is its
elections, BHWs who do not support the new administration docile acceptance as an irrevocable part of their job. In fact,
are often dismissed and replaced with the allies of the elected BHWs are considered indispensable because of their ability
official.35,52 This frequent turnover causes a massive strain on to handle whatever work is handed to them and regardless of
government resources. The training and resources invested in how much. Furthermore, while local government officials and
the replaced BHWs are wasted when their services end with health workers recognize the shortage of midwives, nurses,
the new administration. Despite the already limited budget and doctors, there is scant attention paid to the understaffing
and human resources, more training needs to be conducted of BHWs. The DOH’s recommendation of 1 BHW per 20
for new BHWs. Furthermore, the frequent replacement of households is not followed in practice.54,55 BHWs of San
BHWs negatively impacts their integration in the health Miguel typically deal with 200 to 300 households. Even the
system, resulting in disrupted rapport between BHWs and lowest number of households a BHW handles is in the range
the community – an essential component of BHW work.35 of 50 to 70.
The politicization of BHWs affects the effectiveness and BHWs are perceived as heroes or even martyrs, praised
sustainability of the BHW program, which may result in for doing the work that many reasonably decline. As one local
fragmented delivery of care. official participant articulated, “No registered nurse or degree
holder will volunteer as a BHW, knowing the compensation
Reliance on the Benevolence of BHWs and the amount of work. Only those who are motivated by
Perpetuates their Exploitation volunteerism will take on the role.” However, dependence on
The desire to serve their community motivates BHWs to volunteerism creates instabilities. As volunteers, BHWs
become and remain volunteers. The participants commonly have weak accountability and can hypothetically opt out of
cite their willingness to help as their driving force to remain doing their responsibilities at any point in time. Furthermore,
BHWs. Notably, many of them described their work using the invoking volunteerism only creates more overlooked and
same phrase “mahirap pero masarap” – difficult but rewarding. overworked BHWs. Relying on their benevolence without
They shared how they gain fulfillment from being of service improving their conditions takes advantage of BHWs. Hence,
to others. This is a sentiment that can be traced in previous the outcome is not only a fragile system but an exploitative
studies, where BHWs are primarily motivated by care and one.
their desire to contribute to their communities. This often BHWs are indispensable members of the health
compels them to cover the travel costs and purchase medicine workforce. They are the first point of contact for many Filipino
and even rice for residents with insufficient resources.35,52 households and form the backbone of primary health care
Their goodwill does not go unnoticed. BHWs have delivery.32,34,35 If BHWs decide to collectively boycott work,
considerable social capital, enjoying a great deal of respect it is likely that the Philippine health system will collapse.
and appreciation from local government officials, health Yet despite their importance, the struggles of BHWs remain
workers, and residents alike. The role of BHWs is described overlooked and unaddressed. BHWs grapple with informal
as a form of martyrdom taken up by those willing to make and politicized processes, meager compensation, exposure to
sacrifices for the sake of the community. However, extolling multiple risks and hazards, and unreasonable workload.35,52,53
the benevolence of BHWs risks overlooking the realities of Despite their essential contributions to the Philippine health
their exploitation. For instance, BHWs’ commitment to serve system, BHWs have received limited scholarly attention. The

10
 Lived Experiences of BHWs

present study seeks to contribute in bridging this research Author Disclosure

gap by shedding light on their lived experiences, particularly All authors declared no conflicts of interest.
in the context of policy inconsistencies and politicization.
Funding Source
Limitations This study was funded by AIA Philippines (formerly
The present study carries certain limitations. Firstly, the Philam Foundation).
research is geographically limited to one municipality, which
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