Clinical courage in rural Asia: a Philippine perspective

Dear Editor 

We read with great interest the article ‘Investigating clinical courage: an international survey of rural doctors’¹. The study offers valuable insights into how rural doctors act with courage in difficult and uncertain situations. Being familiar with the rural health landscape in the Philippines through experience, we would like to share three key reflections that highlight how the concept of clinical courage² speaks directly to our local experience.

First, the study’s concept of ‘responsiveness to community’ reflects a deeply Asian and Filipino way of being. In many parts of the Philippines, values like pakikipagkapwa (sharing identity with others) and bayanihan (community cooperation) guide how rural doctors see their roles. When a rural doctor takes action, even when unsure or lacking resources, they are not only being clinically courageous, but also living out cultural values that prioritize collective care. For example, recent research affirms that community doctors are often the only frontline providers addressing the complex needs of children with disabilities in rural areas, from health care to legal support, underscoring the critical protective role they play in underserved communities³.

Second, the study shows that doctors who score highly in clinical courage are more likely to stay in rural areas. This is very important for countries like the Philippines that try to place doctors in far-flung communities through programs like Doctors to the Barrios (DTTB). These programs often struggle with keeping doctors for the long term⁴. For instance, the Department of Health in Bicol recently deployed 14 doctors to rural health units in the region under the DTTB program to provide health care in far-flung areas, participate in health education, assist in community development, and reduce the burden on secondary/tertiary facilities⁵. A related study found that doctors who joined the DTTB program out of a return service obligation were significantly less satisfied than those driven by a desire to serve or an interest in public health, highlighting the role of motivation in shaping rural commitment⁶. Another study confirmed that individual beliefs, working conditions, career development, infrastructure, and local social needs all interact to influence DTTB retention, and that national policies and program implementation also play a key role⁷.

Encouragingly, there is strong evidence of the DTTB program’s impact: recent findings show that it improves key public health outcomes, including increased use of modern contraceptives and reduced child underweight prevalence in poor municipalities⁸. Furthermore, cost-effectiveness analysis shows that DTTB provides good value for money from both societal and healthcare perspectives, with favorable cost per QALY and life saved compared to WHO thresholds, even while likely underestimating the program's full benefit⁹. These studies remind us that clinical courage must be understood within a broader system of support, motivation, and measurable community benefit.

Third, the study notes that ‘functioning within the health service context’ was not linked to any demographic group. While this may seem like a neutral result, it actually shows that many rural doctors, no matter their background, are working in systems that do not always support them. In the Philippines, rural doctors often face poor infrastructure, unclear roles, and limited resources¹⁰. Still, they continue to show courage by planning carefully, leaning on colleagues when possible, and acting for their patients. Clinical courage is influenced by the relationships rural doctors have with their communities, patients, healthcare team members, and other colleagues and health leaders. Rural doctors can collectively learn, use, and strengthen clinical courage, supporting its development in new members¹¹. However, the study also shows that collegial support was one of the lowest scoring areas. This is a warning sign for us in Asia. Many rural doctors feel isolated. Building strong networks of support, especially in remote areas, must be part of how we foster clinical courage in the future.

In conclusion, this study on clinical courage is not only useful for global health researchers, but especially important for countries like the Philippines. It helps us see that courage in rural medicine is not just about individual bravery; it is about community, culture, and care. We hope this work leads to more efforts that support, retain, and empower rural doctors across Asia.

Alvenio G. Mozol Jr. and Jesus Roland M. Gatpolintan, De La Salle University, Malate, Manila, Philippines