Medical Interns Catalyze a Solid Waste Management Program in a Rural Community

Elizabeth Paterno
Associate Professor in Community Medicine
Department of Family and Community Medicine
College of Medicine
University of the Philippines (UP)
Manila, Philippines

Context:

The UP College of Medicine (UPCM), with the Community Medicine faculty of the Department of Family
and Community Medicine as its lead group, has been engaged in implementing Community Based Health
Programs (CBHP) since the early 1990s with the mission “to train health manpower specifically oriented
towards the communities by using the Primary Health Care Approach.” Its main objective is to provide
learning opportunities for both the faculty and medical students in the principles and practice of community
medicine, and in the process assist communities attain increasing capacity in their own health care and
community development. Its main principles are embodied in the Alma Ata Declaration which defines
Primary Health Care.

The UP-CBHP is a partnership among the University, the Local Government Unit and the Community
where planning, implementation and evaluation of health work are done with the active and genuine
participation of the community. The CBHP uses community organizing and indigenous health manpower
development as base strategies, while aiming for comprehensive community development. The most recent
CBHP of the UPCM was started in Sto. Tomas, Batangas, a municipality in Southern Luzon, in March
1999. Here, medical interns live in the communities for 6 weeks, guided by the Community Medicine
faculty of the UPCM.

During their 6-weeks immersion in the villages or barangays (as villages are called in the Philippines),
interns, with their preceptors, provide guidance and support to the BHWs in carrying out their roles as
social mobilizers/community organizers, health educators and health care providers. The BHWs are
primarily tasked with leading the community in terms of health promotion and disease prevention. In doing
these, interns conduct the following activities with the BHWs:

 Development, implementation and monitoring of the barangay health plan made by the BHWs in
consultation with the community
 Establishing partnerships with different groups and organizations within and outside the barangays
 Health skills and facilitation training of the BHWs, while assisting them in providing curative health
care to the community
 Organizing and conducting health education activities with the members of the community (e.g.
mothers’ class, fathers’ class, youth class, health class with the parents waiting for their children in the
day-care center, health class with parents attending a PTA meeting, health class within the center
during an immunization day).
 Conducting community researches where these are needed

There are also efforts in strengthening the Local (Municipal) Health Board and the Municipal-wide
organization of Village Health Workers. All these are aimed to make devolution of health services work
through enhancing community participation in governance and program management.

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Objective:

The objective of this paper is to describe, through the example of a particular barangay, the process
whereby medical interns rotating in the CBHP learn the principles and practice of community medicine and
community development. Specifically, the paper aims to

1. briefly describe the physical characteristics and demography of Sto. Tomas, Batangas and
Barangay Sta. Cruz;
2. relate the series of activities carried out by the medical interns that led to the establishment of the
solid waste management program in Barangay Sta. Cruz;
3. describe the Solid Waste Management Program and its effects in Sta. Cruz; and
4. offer an academic discussion of the practice of Community Medicine that was exemplified in the
Sta. Cruz experience.

A Brief Description of the Program Area:

Sto. Tomas is a municipality composed of 30 barangays, with a total population of around 70,000. It is
located 60 km south of Metro Manila, in the northeasthern portion of the province of Batangas. The UPCM
staff and medical students travel 1-2 hours by bus to reach the town center from the UP College of
Medicine. Sto. Tomas is bounded in the north by the town of Calamba, Laguna, in the northeast by Los
Baños and Alaminos, in the west by Tanauan and Malvar and in the south by Lipa City. Though only about
30% of the 30 barangays remain rural and agricultural, these comprise 75% of the total land area of Sto.
Tomas. Coconut trees occupy most of the agricultural land. Since the municipality is a part of the
CALABARZON Growth Area, Sto.Tomas aims to develop itself into the industrial and commercial center
of this part of Batangas and it now houses the First Industrial Park of the province.

Barangay Sta. Cruz is one of the rural barangays of Sto. Tomas, situated at the foot of Mt. Malipunyo. It is
one of the farthest of the villages from the town center of Sto. Tomas. Natives often refer to it as Sulok,
implying it to be the farthest corner of the municipality. No direct public transportation going to Sta. Cruz
is available from the Sto. Tomas town center, and one has to ride for an hour or so in a bus or a jeepney that
passes through several municipalities to get to the city of Lipa where one can finally take a 15-20 minute
jeepney ride to Sta. Cruz. With a private vehicle, however, Sta. Cruz is reached from the town center via
the Maharlika Highway and cemented barangay roads in 30 minutes. A large part of its land area is
uninhabited and covered with coconut trees and other vegetations. The latest population count is 1900, with
434 families in 6 geographical divisions called puroks. The primary source of income of the community is
agriculture and livestock raising. Around a third of the population is made up of laborers or white-collar
workers in factories and other offices in Sto. Tomas and Lipa City. A few are overseas workers. Literacy is
high with more than 50% of the population having finished secondary school. The average annual income
is around P48,000 (US$850) for a family of five.

Interventions:

In September of 2001, a team of interns, guided by their preceptor, conducted a workshop with the health
workers of several contiguous barangays to determine what the BHWs perceived to be the priority health
problems in their communities. In this workshop, the BHWs were asked to define and visualize a picture of
a healthy community. With this picture in mind, the BHWs were once again asked what their barangays
needed to achieve such a picture. For the BHWs of Barangay Sta. Cruz, poor garbage management was the
main obstacle to attain this picture. This was verified when the interns did a series of focus group
discussions among the population of Sta. Cruz. The most common response to the question of what was the
priority health need of the barangay was cleanliness and sanitation. The next group of interns, together with
the BHWs of Sta. Cruz then conducted another survey to ascertain the community’s baseline knowledge,
practices and attitudes regarding solid waste management, as well as their willingness to participate in a
waste management program. Though the survey showed that less than 50% of the surveyed population
perceived garbage to be a major problem in the community, more than 80% of the respondents were willing
to participate in any phase of a waste management program.

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As a result, the next batch of interns did extensive literature search and familiarized themselves with the
Philippine Solid Waste Management Act, documents of experiences of communities in other parts of the
country and the world with successful waste management programs, and other related materials. They
simplified these documents, translated them into the vernacular and conducted study sessions on the subject
with the BHWs and the Barangay Council. This led to the formation of the Local Solid Waste Management
Board (LSWMB) of the barangay, which included the Barangay Captain and the BHWs among its
members.

These study sessions were supplemented by the attendance of the LSWMB in the Earth Day 2002
Celebrations held in the Palace of the Philippine President (Malacaňang Palace) in Manila on April 22,
2002. It was hosted by the Mother Earth, Unlimited (a non-government environmental organization) and
the government Eco-Waste Management Office. Invitation to and attendance in this forum was facilitated
by an intern. In this forum, the LSWMB of Sta. Cruz listened to barangay leaders from other communities
and pioneers in zero waste management in the country share their experiences in successful waste
management. Products of waste recycling that communities made and sold were also displayed that day,
showcasing samples of Filipino creativity in zero waste management.

In June, 2002, a team of third year medical students of the UPCM, in fulfillment of their requirements in a
community diagnosis course in Community Medicine, made a study on the character of the solid waste
produced daily by the community of Sta. Cruz, in an effort to help guide the community plan out its own
program. During the meeting where the students reported the results of the survey to the LSWMB, the
members of the board verbalized their request for the UPCM team to invite an expert to the community to
guide them in the planning and implementation of their own waste management program, as well as to
inspire the rest of the community in participating in the program.

In July, therefore the interns rotating in the barangay at the time invited a speaker from the Mother Earth,
Unlimited to give a talk to the community. They likewise assisted the BHWs and the LSWMB in preparing
for the event. It was agreed that the event be held at the local elementary school, and the local PTA
organization the venue for inviting the community to participate. As part of these preparation efforts, the
interns and the BHWs conducted waste management lectures for the elementary school students and
encouraged them to invite their parents to the event. Letters were likewise sent out by the PTA. As a result
of these efforts, a good number of the community population came to listen to the speaker from Mother
Earth.

Outcomes:

The last activity mentioned above proved to be the turning point of the program. As a result of the seminar,
the organization of women, headed by the wife of the Barangay Captain decided to take on the
responsibility of implementing the waste management program in the community, with the blessing of the
LSWMB. Since all the BHWs were women, they were (and still are) all members of the revitalized
women’s organization that was up to that point inactive since its formation by the local representatives of
the Department of Social Welfare and Development in 2000. The organization renamed itself BIGKIS, an
acronym for Bisig at Galing ng Kababaihan para sa Iisang Sambayanan (roughly translated as “arms and
talents of women for a united community”). From this point on, the program progressed with minimal, if at
all, help from the UPCM team.

In a series of meetings, BIGKIS planned out activities for the implementation of the waste management
program in the community, fully aware that there were no funds available for these activities, and that they
would rely fully on community contributions and voluntary labor. Firstly, members of the BIGKIS made
field trips to several communities in nearby provinces with successful waste management programs. Their
link with Mother Earth made these field trips possible. After these field trips, they elected and trained
speakers from among themselves to do house-to-house information dissemination regarding the projected
activities for the waste management program. The emphasis was on waste segregation and backyard
composting of biodegradable waste materials. They also announced that they would be collecting the non-
biodegradable materials for recycling or sale to recycling groups. An old unused chapel in the community

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was ‘borrowed,’ cleaned and converted into a Materials Recovery Facility where they would gather the
non-biodegradable waste in separate small corals. The conversion of the chapel was done through the
contribution of labor and scrap wood and bamboo materials from the community members. Soon, the
women, using borrowed vehicles (usually color-coded jeepneys unable to ply their routes in Lipa City)
were collecting the non-biodegradable materials, and were also soon selling them, starting a modest fund
for the BIGKIS. The remarkable thing was that the program was started and implemented with no start-up
funds.

In December, 2002, Barangay Sta. Cruz formally introduced its program to the municipality of Sto. Tomas.
The barangay was decorated with Christmas ornaments made from recycled waste materials, notable of
which was a big colorful lantern made of tetrapack juice containers. It was the first solid waste
management program in the municipality and the Mayor proudly inaugurated the program. In his speech
for the occasion, he challenged the other communities to follow Sta. Cruz’s example. In appreciation of
Sta. Cruz’s efforts, the Mayor awarded P50,000 to the community. This was only the first of many awards
that the community received from thereon.

Linkage with Mother Earth, Unlimited was maintained by BIGKIS. Through Mother Earth, Sta. Cruz
became known to the circle of ecological organizations throughout the country. Communities that want to
start a waste management program but have no funds to start it with are sent to Sta. Cruz to learn from the
experience of BIGKIS.

With the institutionalization of the solid waste management program in Sta. Cruz, BIGKIS soon started
other projects, this time to help augment the income of its members. With the funds that they earned from
awards and the sale of recyclable wastes, the women arranged for training seminars in income generating
projects for themselves. As a result, the women created fashionable bangles that were sold as gifts during
the Christmas season. Making give-away gifts for weddings was also made possible by these training
seminars and this remains to be one of the collective income-generating activities of BIGKIS. They have
also opened short-term credit lines for their individual members to engage in income generating activities,
like selling snacks that they themselves cooked, bags made of used tetrapack containers, and school
supplies. Recently, BIGKIS has gone into producing and selling soap.

Last July, 2004, Sta. Cruz placed 5 th in the national search for the model barangay, earning them a right to
once again grace the grounds of the Malacaňang Palace. This happened after Sta. Cruz was nominated by
the Municipality of Sto. Tomas to represent them in the provincial search for the model barangay. Winning
this, Sta. Cruz was then nominated by Batangas to represent the province in the regional search for the
model barangay, which in turn nominated Sta. Cruz to represent Region IV in the national search. With
this award, Sta. Cruz received another P65,000.

Barangay Sta. Cruz has become the model for the rest of the barangays of Sto. Tomas to emulate. It has
given the interns and Community medicine faculty members who were involved in the initiation of the
project valuable lessons in community organizing and development as integral elements in the practice of
community medicine. It continues to serve as a guide for UPCM staff and interns immersed and working in
the other barangays of Sto. Tomas.

Discussion:

“Community Medicine is that branch of medical science which is concerned with the health needs and
conditions, and with dealing with these by appropriate methods and interventions, of population groups of
known size and composition. This system of health care is different from that which is present in most
affluent industrialized nations, which is based on an individual doctor/patient relationship, whereas in most
developing countries community medicine predominates because of the scarcity of personnel and financial
resources….. the future pattern [of Community Medicine] consists of a complex, highly organized and
multidisciplinary system in which the university is used as a social instrument to achieve social, as well as
health objectives. In fact, socioeconomic development, in which health is included, becomes the major
objective.”

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The Community Medicine faculty of the UPCM has been guided by the above definition of Community
Medicine. It was lifted from a Rockefeller publication of the proceedings of an international conference of
Community Medicine practitioners held in Bellagio, Italy in April, 1978, “The Future of Academic
Community Medicine in Developing Countries,” edited by Willoughby Lathem, M.D. This definition is in
line with the principles embodied in the Alma Ata Declaration on Primary Health Care. While working to
improve the health status of the community, comprehensive community development, directed and
implemented by the community people themselves is the long term goal. The Community Medicine faculty
believes that without improvements in the socio-economic status of the people, very little improvement in
health can be achieved.

Students can only be made familiar, at best, with these principles if they are lectured or even discussed in a
classroom setting. Students learn community medicine best when they live the principles as they are made
to work in and with the communities. As the community begins to experience the benefits from working
with the program, students, as well as the faculty guiding them, gain important lessons in community health
work. In their immersion, however, students need to be oriented not to take a commanding role but merely
to act as catalyzers and facilitators to assist the community in whatever stage the interns enter the program,
whether it is in the identification of the community’s priority needs, or in the design and implementation of
a program to answer these needs. Here, the role of the faculty preceptor is vital to ensure the continuity of
the program and provide correct guidance to the interns.

Some of the lessons that the UPCM staff learned from the experience in Barangay Sta. Cruz echo
guidelines that experts in community organizing and development teach us. The late Minda Quesada, a
community health nurse advocated that health care providers be guided by six principles in doing
community work and organizing. These are the principles of felt needs, leadership, participation,
communication, structure and evaluation. Three of these principles were observed in the program in Sta.
Cruz and were probably the main reasons of its success.

1. Principle of Felt Needs. Felt needs are problems / issues the people recognize. These are
differentiated from needs which health providers and do-gooder groups or agencies have determined
based on their perceptions….. [the] task is therefore to discover what these felt needs are and to
channel these….. into organization and action (Quesada, 1972). People are inclined to participate in
programs that they perceive will benefit them or will solve problems they personally experience and
see. Problems in community work arise when the students, sometimes together with their preceptors,
fail to identify the felt needs of the people. In the worst case, students fail to consult the community or
the BHWs at the very least, and embark on projects or researches based on their own perception of the
community’s health needs, or some other bases like national campaigns or campaigns by private
organizations, whether these are relevant to the community’s needs at the moment or not. This happens
when guidance by the faculty is weak. Community people fail to ‘own’ the project or program,
participation becomes difficult and the program results in frustration for all concerned. In Barangay
Sta. Cruz, the BHWs identified cleanliness and the garbage situation as the priority health problem in
the community. This perception was echoed by other community members as verified in various focus
groups organized by the interns. This was definitely a factor in the success of the program.

2. Principle of Leadership. Leadership is a key to successful community organizing. It is important that

the leader is accepted, well respected, has a charisma or influence to a number of people, is
democratic, has a track record of working for the common good, and demonstrated capability of
making things work (Quesada, 1972). The UPCM came into Sto. Tomas as a partner of the Local
Government Unit (LGU) and was therefore obliged to enter the communities as partners of the
barangay councils who are elected by the community every three years. BHWs are likewise chosen by
the Barangay local government head or the Barangay Captain. The UPCM has therefore no hand in the
choice of leaders. Sometimes, even when the felt needs are correctly identified, inadequacies in the
management and facilitation skills or commitment of the BHWs and the Barangay leaders to serve
their communities result in weak, short-lived programs where very few community people participate
and are benefited. In a situation like this, the community eventually begins to feel the burden of having
to host teams of interns, even when they continue to assist in the curative work of the BHWs. In Sta.
Cruz’s case, the Barangay Captain is well respected by the community, and possesses most of the

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 characteristics described above. His wife, a dentist by profession, is an even stronger willed but equally
respected leader. Through sheer will and good example, she led the BIGKIS and the entire community
through its successive achievements, often giving up hours of her dental practice to attend to the
program. The BHWs of Sta. Cruz, likewise are among the most respected members of the community
and recognized leaders in their respective puroks. Their commitment to their work impressed many
interns who immersed in their barangay.

3. Principle of Participation. Genuine Community Organizing aims to enable people to be in control in

the management of projects or programs designed to address their problems, in which they were
involved in the decision-making process (Quesada). Participation of the community people in all the
aspects of the program was clearly illustrated in the implementation of the Solid Waste Management
Program of Sta. Cruz. There was and continues to be a strong sense of ownership of the program by
the community people. As soon as the leaders of the community showed the ability to manage the
program and lead it to its objectives, the UPCM staff took a backseat and maintained minimal presence
in the community.

Program objectives primarily based on felt needs of communities may result in program designs that do not
cover all the aspects of work that health professionals perceive to be important for a comprehensive health
program and local health systems development. However, the experience of Sta. Cruz has shown that once
a community learns the merits of collective action and achieves a certain level of success in attaining an
objective, albeit a narrow objective as far as health is concerned, other objectives will be easier to achieve.
Success has driven the people of Sta. Cruz to aspire for more success.

References:

1. The Municipal Development Plan of Sto. Tomas, Batangas, 1996-2005

2. Manahan, S.E., et al. “A Preliminary Study on the Perceived Roles and Needs in Health
Management of Residents in Barangay Santa Cruz and Barangay San Isidro Sur, Santo Tomas,
Batangas,” September 2001.
3. Galivo, F., et al. “A Descriptive Study of the Knowledge, Practices and Attitudes Regarding Zero
Waste among Residents of Barangay San Isidro Sur and Barangay Sta. Cruz in Sto. Tomas,
Batangas,” January 2002.
4. Yap, V., et. al. “Implementation of the Zero Waste Management Program in Barangay Sta. Cruz,
Sto. Tomas, Batangas,” April 30, 2002.
5. Barrion, A. F., et al. “Waste Characterization Study in Barangay Sta. Cruz, Sto. Tomas,
Batangas,” June 17, 2002
6. Robrigado, P., et al., “Implementation of the Zero Waste Management Program in Barangay Sta.
Cruz, Sto. Tomas, Batangas (Progress Report),” July 22, 2002
7. Pulmones, Marie Ann, “Bigkis, an Interview,” March, 2004
8. Lathem, Willoughby, M.D., ed. The Future of Academic Community Medicine in Developing
Countries. The Rockefeller Foundation, USA, 1979.
9. Castro-Palaganas, Erlinda. Health Care Practice in the Community, First Ed. Educational
Publishing House, Manila, 2003.

Note: References 1-7 are unpublished documents. References 2-7 are reports written by interns and
medical students, submitted in partial fulfillment of their requirements in Community Medicine.

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