The continuing and massive exodus of Philippine nurses and doctors to other countries all over the world is now taking a heavy toll on the countryâ€™s already inadequate health-care system. If not addressed, health experts warn, the countryâ€™s health-care system could collapse.
By Carlos H. Conde
Published: Oct. 17, 2004
The pediatric ward (left) and the labor room (right) of the Cruzado Community Hospital in Pikit, North Cotabato. Photos by Gene Boyd Lumawag
PIKIT, North Cotabato â€“ For the past eight years, Mary Jane Maximo has been ministering to the people of this small town in North Cotabato, southern Philippines. As the head nurse at the only private hospital here, she has seen the violence and felt the pain that have visited this place, such as the extreme poverty made worse by the governmentâ€™s war against Muslim insurgents in 2003 that devastated the town.
Before the year ends, Maximo, a 29-year-old mother of one child, will leave the Cruzado Community Hospital and head for Saudi Arabia, where she would earn five times more than sheâ€™s making now. Sheâ€™s among the thousands of Filipino nurses â€“ and doctors — who seek jobs abroad every year, leaving behind poorly manned hospitals and clinics across the Philippines.
This exodus, officials said, is now taking a heavy toll on the countryâ€™s already inadequate health-care system. If not addressed, the countryâ€™s health-care system could collapse, they warn.
â€œIt can get to you sometimes,â€ Maximo said of her job. â€œBut I have tried for years to resist the temptation to quit,â€ she said. â€œI became a nurse because I thought I could be of help,â€ she added. â€œI still think I can be of help, but there are days now when I am convinced that my life could get better.â€
The lure of better pay abroad and better lives for their families back home has become so strong that even licensed medical doctors are studying to become nurses. Dr. Edwin Cruzado, the owner of the Cruzado Community Hospital here, is one of them. Although he did not say that he would abandon his hospital soon and seek a nursing job abroad, Cruzado said his parents and relatives have been trying to persuade him to do just that.
If Cruzado and Maximo do leave, as well as the other nurses in the 10-bed hospital who are also planning on leaving, the hospital will most likely be closed down. And if it continues to operate, its owners will face the possibility that they might not find the people to run it: “I wouldn’t know where to find replacements,” Cruzado said.
â€œItâ€™s a national crisis,â€ said Dr. Bu Castro, president of the Philippine Medical Association. He said the country’s health-care system would “certainly collapse” if the trend continues.
Castro said his group has studied the phenomenon and found out that the most vulnerable areas in this crisis are the rural areas, where most of the countryâ€™s poor live and where health care is, in many instances, nonexistent. Castroâ€™s group also found out that 80 percent of doctors in community hospitals in the rural areas are studying to become nurses.
Statistics show that every year, between 5,000 and 8,000 nurses leave for abroad, around 2,000 of them former doctors. Castro said the case of doctors turning into nurses is particularly worrisome because medical schools only produce an average of 1,000 doctors a year. Considering that the doctor-to-population ratio here is a low 1 to 26,000, the situation is alarming, Castro said. (The ideal ratio is 1 doctor for every 6,000 citizens.)
Worse, the number of Filipinos taking up medical courses is declining fast â€“ down by 20 percent last year. Several medical schools have, in fact, closed down, Castro said.
On the other hand, the enrollment for nursing courses has shot up, from about 20,000 in 1999 to more than 40,000 last year, according to the Philippine Nurses Association (PNA). In 1999, there were 186 nursing schools; this year, there are 329 such schools. The demand was such that even computer schools have started offering nursing courses.
Only about half of the nurses who graduate end up passing the licensure exam and fewer still end up being hired abroad. This means, thousands of nurses still remain in the Philippines. The problem is, they are not inclined to seek employment in hospitals and clinics here because of the low pay, according to Ruth Padilla, the president of the PNA. They either find other jobs or wait until they get hired abroad.
The average salary of a nurse in the provinces is about $120, sometimes lower. In contrast, a Filipino nurse in the U.S. could earn between $3,000 to $4,000 a month. The average salary a doctor in the Philippines gets is between $300 to $800 a month.
â€œHow can you not think of leaving when you have a very low salary?â€ said Maximo, the rural nurse, who gets about $100 a month.
The rate of migration is such that a congressman proposed a law requiring nurses and doctors to practice in the Philippines for two years before they are allowed to work abroad. Early this week, some 6,000 doctors signed a covenant pledging to stay and practice in the Philippines before they consider leaving for abroad.
Then thereâ€™s the huge demand. According to Padilla, Filipino nurses are probably the most sought after in the world, owing to their better communication skills and their â€œcaring ways.â€ Most of these nurses go to the Middle East, although demand in Europe and the U.S. has been increasing. According to one estimate, the U.S. would need as many as one million foreign nurses up to the year 2020.
But Padilla said there is actually no shortage of nurses and doctors in the Philippines. â€œWhat we have is a shortage of skilled nurses and doctors, and those who are committed enough to go to the rural areas,â€ she said.
In a paper he prepared last year, former Health Secretary Jaime Galvez-Tan, who is now the executive director of the National Institutes of Health at the University of the Philippines in Manila, warned of a â€œworsening of the health crisis already plaguing our country.â€ Very soon, he said, â€œthe Philippines will be bled dry of nurses.â€ He called the situation a â€œbrain hemorrhage,â€ not a brain drain.
Two years ago, the World Health Organization warned that the migration of nurses from Third World countries would affect the health care system of these countries. â€œIf the world’s public health community does not correct this trend,â€ said Dr. Gro Harlem Brundtland, the WHOâ€™s director-general, â€œthe ability of many health systems to function will be seriously jeopardized.â€
This is already happening in the Philippines, officials and health experts said. Various studies and reports have indicated a sharp decrease in the number of nurses, especially in the rural areas, while health services in these areas have deteriorated.
And because hospitals are forced to hire new graduates, the lack of experience can affect the quality of health care. When his wife gave birth last month, JB Deveza, a student in Cagayan de Oro City in the southern Philippines, thought that they would only stay in the hospital for three or four days. But a slip-up by a young nurse who was new on the job forced Deveza and his wife to stay two days longer, thus paying more.
â€œIt was absolutely unnecessary but we had to suffer because of the incompetence of the nurse,â€ Deveza said, adding that a more experienced nurse would have spared them the trouble.
Padilla, the president of the nursesâ€™ association, said things like this are bound to happen. Worse, sheâ€™s worried that because of the huge demand for nurses, some schools might take shortcuts, resulting in mediocrity, which could affect the competitiveness of Filipino nurses.
Across the country, particularly in the countryside, most public health clinics â€“ if there are any – only have midwives, who act both as doctor and nurse. In clinics and hospitals in towns and small cities, the turnover of doctors and nurses is so fast that administrators are complaining not only about the cost of training new nurses but also about the poor quality of service that frequent turnovers create.
Dr. Jojo Carabeo, the president of the Health Alliance for Democracy, said recently that the turnover of nurses has been â€œso rapid due to migration that many nurses only work in hospitals as trainees for a period of three to six months and leave soon thereafter. Thus many hospitals are perpetually staffed by trainees.â€
New nurses often just stay within this period to gain the required credentials to apply abroad, virtually turning hospitals and clinics into nothing but training facilities. “The mass production of nurses this year is massive, so many hospitals end up with no nurses,” said Cruzado, the owner and administrator of the hospital in Pikit.
Government to blame
Health experts put the blame squarely on the government for this predicament. â€œSalaries of nurses have not been raised and because of the fiscal crisis, government hospitals canâ€™t hire more,â€ said Padilla. There is no incentive for nurses to remain in the country, she said.
Galvez-Tan, the former health secretary, said in his paper that the Philippines â€œwill never be able to compete with the salary scales and better opportunitiesâ€ in other countries. But, he added, the government cannot tolerate this trend.
â€œIt is high time that the present administration implement actions to address this health threatening situations,â€ Galvez-Tan said. He suggested, among others, that the Arroyo administration initiate â€œhigh-levelâ€ bilateral negotiations with countries that import Filipino nurses and doctors, and to lobby for representation in the World Trade Organization â€œto regulate and monitor the trading of medical and nursing services.â€
Castro, the medical association president, said the government should give more attention to doctors and nurses at home. â€œTalk to them, assure them that the government is doing something for them,â€ he said.
Beyond the low pay and the lack of government attention are deeper reasons for the migration: the contractualization of labor and the governmentâ€™s policy of using migrant workers to prop up a weak economy.
In a recent paper titled â€œHealth Professionals Migration and its Impact on the Philippines,â€ Antonio Tujan Jr. of Ibon Foundation said the increase in the migration of nurses and labor in general â€œis only a by-product of contractualization of labor and services in many sectors of the economy as a result of globalization.â€ On one hand, he pointed out,â€ it reduces the relative cost of labor for the affected enterprises, while on the other hand it creates new wealth for the service contractors and labor contractors which take a share of the savings in labor costs through their fees.â€
Tujan traced labor migration to the governmentâ€™s labor-export policy that began during the Marcos years. â€œThis policy has an avowed objective to earning foreign exchange and easing the unemployment situation. Additionally, the government earns billions of pesos in various fees and insurance premiums required of contract workers,â€ Tujan wrote.
Indeed, economists have said that if not for the more than $7 billion in remittances these overseas Filipino workers send back home every year, the Philippine economy would have sunk a long time ago.
And as long as the economy remains weak, as long as it does not industrialize, as long as it fails to create jobs locally, Filipino workers can expect a perpetuation of this labor-export policy. Bulatlat