Special Report
Poor Pay, Working Conditions
are Driving Health Professionals Abroad
Last of three parts
A paper by Dr. Jaime
Galvez-Tan, former Vice-Chancellor
for Research of the
University of the Philippines-Manila and executive director of the
National Institutes of Health-Philippines,
entitled “The Brain Drain Phenomenon and Its Implications to Health”
revealed that since 1994, more than 100,000 nurses have left the country
to work abroad. And while the ideal nurse to patient ratio is 1:4, the
ratio in government hospitals has increased from 1:50 to 1:100.
BY
AUBREY SC MAKILAN
Bulatlat
 |
Before the devolution of health services,
deserving health workers in the municipal health posts and district or
provincial hospitals were granted scholarships by the (Department of
Health) DoH for graduate studies in hospital administration, public health
or other fields to prepare them for higher positions. Devolution has
drastically reduced the number of public health care providers enjoying
the scholarship because very few local government units can afford the
cost of staff development now. |
DOCTORS AS PATIENTS:
Physicians and other health workers protest sick state of Philippine
public health
PHOTO COURTESY OF COUNCIL FOR
HEALTH AND DEVELOPMENT
The Local Government
Code of 1991 provides for every local government unit to design and
implement its own organizational structure and staffing pattern. The
chief executive of every local government unit is responsible for human
resource development in his unit, taking into consideration its service
requirements and financial capability and subject to the minimum standards
and guidelines prescribed by the Civil Service Commission. The chief
executive may employ emergency or casual employees or laborers paid on a
daily wage or piecework basis. The compensation of the local officials and
personnel is determined by the local legislative body.
Under this setting, the selection,
promotion and tenure of devolved health personnel are now under the local
appointing powers.
But not all devolved health workers
remained receptive at the time.
To appease devolved workers, the Magna
Carta for Health Workers or Republic Act (RA) 7305 was passed in 1992. It
mandates a host of benefits, including hazard pay, laundry allowance,
subsistence allowance, holiday pay, and even remote allowance or
medico-legal allowance, for government doctors, nurses, midwives,
dentists, barangay health workers, and sanitation inspectors at the
national and local levels.
The DoH instituted the Doctor to the
Barrios Program, which supplied temporary and contractual doctors to
remote areas. The program began deploying physicians to 271 municipalities
lacking doctors in May 1993. But only 198 of these municipalities received
doctors. Worse, only about a third of the physicians deployed remained
after their two-year duty due to the potential of receiving better pay and
benefits abroad.
To supplement the local health force, the
Barangay Health Workers’ Benefit and Incentives Act of 1995 provided for
training volunteer workers as well as minimal incentives to convince them
to help run barangay health stations. These volunteers assist in clerical
tasks and minor health procedures, such as weighing and measuring
patients. However, these workers do not effectively cater to the
increasing health needs of the growing population.
The Asian Development
Bank (ADB) reported in January this year that over 50 percent of IRA is
used for personnel services. Local revenue collection accounts for less
than 10 percent of total expenditures. On the other hand, even if local
government regulations allow the allotment of 45 percent of the IRA for
hiring regular workers, the contractualization
of non-technical health
workforce has been the
practice.
In government
hospitals, the security and janitorial services have been mostly
contractualized, along with nurses and nursing aides. Even if health
workers in the LGUs have security of tenure, this may not be so in
practice. Governors and mayors are elected every three years. The Health
Alliance for Democracy (HEAD), an organization of health workers and
professionals, cited reports of health workers being eased out or forced
to resign due to the perception that they were sympathetic to a political
party opposed to the incumbent administration.
“Despite delayed benefits and uncertainty
of tenure, health workers continue to perform under hazardous working
conditions,” said Emma Manuel, president of the Alliance of Health Workers
(AHW), an alliance of unions of health workers.
Overworked and underpaid
The international
standard for the ideal ratio of nurses to patients in hospitals is 1:4.
But even at the
premier state hospital in the country, the Philippine General Hospital (PGH),
said Dr. Jaime Galvez Tan, former Vice Chancellor for Research of the
University of the Philippines-Manila and executive director of the
National Institutes of Health-Philippines, the ratio of nurses to patients
averages from
1:15 up to
1:25.
In Davao del Sur and in most other
hospitals, the ratio would even reach
1:50 up to 1:100.
“So how can you take care of 25 patients,
much more the 300?” Tan lamented. “It may be too late by the time you
could attend to the last patient.”
Aside from patient
overload, nurses and doctors also work extended duty hours.
Work in a hospital
with a 100-bed capacity in urban centers is supposed to be 40 hours per
week. However, medical workers such as doctors and nurses work 56 hours a
week as they are required to work 16 hours straight whenever there is no
reliever. Even health workers assigned at the emergency room, laboratory
and other hazardous and stressful departments in hospitals are not exempt.
In the Don
Susano Rodriguez Memorial Medical
Center, integrated as the psychiatry department of the Bicol
Medical Center in Naga
City, Albay, a nurse has to attend
to more than 300 in-house mentally-ill patients.
“Before it was almost impossible to think
that hospitals will be closed due to a shortage of health workers but it
is happening now,” said Tan.
Aside from these discouraging conditions,
Manuel said that unimplemented laws also disappoint them. She cited the
Nursing Law of 2002 which mandates that an entry-level nurse should get
about P13,300 a month. Unfortunately, in the provinces, there are nurses
who receive as low as P2,000 a month. Ironically, government hospitals pay
more than private hospitals. Nurses in public hospitals receive at least
P9,000 while those working in private hospitals are paid as low as P4,000
a month.
Although several laws
and executive orders had been passed to uplift the conditions of health
workers, the necessary funds were not amply provided.
Exodus
The Philippines is
one of the leading
producers and exporters of doctors and nurses.
Ironically, many
LGUs find it difficult to hire physicians, nurses, and medical
technicians.
The PGH loses 300 to 500 nurses every
year, it was learned. Midwives who are in the front-line in providing
health services are also seeking jobs as caregivers in other countries.
HEAD called the mass exodus of nurses as
the government-sponsored “brain drain.”
Tan’s paper “The Brain Drain Phenomenon
and Its Implications to Health” revealed that since 1994, more than
100,000 nurses have left the country to work abroad.
Tan said in his report that the Philippine
Overseas Employment Administration (POEA) has reported that only 84,150
nurses left the country from 1994 to 2004.
“This data,” he said, “is understated
considering that U.S.-based hospitals have been directly recruiting nurses
by the thousands in the Philippines, bypassing the POEA system. “POEA
statistics from 1998-2004,” Tan said, “do not also include rehired nurses
or those renewing their contracts with the same employer.”
From 2000-2004, more than 50,000 have left
for at least 32 countries, with the United States, United Kingdom, Saudi
Arabia, Ireland, and Singapore as the major countries that received the
bulk of nurses. “While the Philippines traditionally produce a surplus of
nurses for export since the 1960’s, the large exodus of nurses in the last
four years has been unparalleled in nurse migration history,” said Tan.
In 2001, the Philippine Overseas
Employment Administration (POEA) likewise reported that 13,536 Filipino
nurses went overseas, almost double the previous year’s figure of 7,683
nurses. The 2001 figure is the highest ever recorded. The same year, only
4,430 students passed the board examination. Thus, the country is
exporting more nurses than it can train.
The U.S. and the UK offer the best working
conditions for Filipino nurses. Although Filipino nurses are required to
take the Commission of Graduates of Foreign Nursing Schools (CGFNS) and
the National Council Licensure Examination (NCLEX) to work in the U.S.,
successful applicants are given migrant visa status, which includes their
spouse and children, and a work contract with remuneration of at least
US$4,000 a month. Some hospitals even offer subsidized housing grants.
Meanwhile in the UK, only an English proficiency examination or TOEFL
(Test of English as a Foreign Language) is required and a work contract
equivalent to US$3,000.
“These remunerations are definitely pull
factors attracting Filipino health workers abroad,” Tan said.
“Despite these alarming figures,” Tan
said, “government agencies send conflicting messages on whether nurses and
doctors are encouraged to go abroad or to stay and serve the country.”
“But definitely, something is wrong with
the Philippine policy on health human resource development,” he said.
“Although there has been no policy,”
Manuel said, “it is very evident that the government has been promoting
overseas employment as a way of generating inflow of foreign currencies to
revive the ailing economy.”
Based on records of the Central Bank of
the Philippines, the country received US$8.5 billion in foreign currency
remittances mainly from overseas Filipino workers (OFWs) this year. This
is eight times the total foreign investments in 2003, which was a mere
US$1 billion.
Equally disturbing
during the past
several years is the phenomenon of doctors, many of whom are already
consultants or specialists, taking up nursing as a second course with the
objective of working abroad. This development
has made rural areas, where 60 percent of
the population lives, even more vulnerable to human resources
deficiencies.
This development, according to HEAD, has
gone beyond a “brain drain”. HEAD refers to this phenomenon as “brain
hemorrhage.”
The country is the second major exporter
of physicians, with India being the first. Tan’s paper showed that at
least 9,000 doctors have become nurses or are about to become nurses and
nursing medics. Out of this, 1,500 have left the country, while another
1,500 have just completed taking the nursing licensure examination. The
6,000 are enrolled in shortened one and a half to three-year nursing
courses offered by nursing schools catering to the needs of doctors
wanting to become nurses. About 80
percent of public health physicians have taken up or are enrolled in
nursing courses, said Tan.
“I lament it because it takes a long time
to train doctors and most of those taking these (nursing courses) are
those who are already specialists,” Tan said. “Never in the history have
we exported tens of thousands of health professionals.”
Meanwhile,
medical schools are getting less popular.
Of the 39 medical schools in the country, three have closed because of a
sudden decline in enrollment. At the same time, medical doctors enroll in
at least 43 nursing schools offering an abbreviated nursing course
tailor-made for medical doctors.
This mass exodus of
nurses and doctors has contributed to the worsening state of health care
delivery in rural areas due to the lack or non-availability of health
professionals.
Although there are still midwives and
barangay health workers, Tan said rural hospitals, in essence, are
considered “closed” since these could only offer first aid and delivery
assistance. For
instance, three hospitals in
Mindanao
and two in Isabela have stopped operations because they have no more
doctors and nurses. The nurse-patient ratio in many government hospitals
has also worsened as a consequence of the brain drain problem in the
country. In Aklan, Nisperos revealed that four hospitals faces fear of
closure also due to lack of health personnel.
Quality of health workers
Tan is worried that during the past four
years, from 2001-2004, the country trained less than 5,000 nurses a year
while 10,000 to 12,000 nurses left the country to work abroad.
Aside from the exodus, Tan is also
concerned regarding the quality of nurses and doctors the country has been
producing.
In the 1970’s, there were only 40 nursing
schools. By the 1990s, the number of schools reached 170. By June 2003,
there were 251 nursing schools and by April 2004, 370 nursing schools.
There has been a 47 percent increase nationwide and an 84 percent increase
in Metro Manila in the number of nursing schools since June 2003.
However, the increase in nursing schools
was not equivalent to the increase in number of qualified nurses who pass
the national nurse licensure examinations.
Based on Tan’s paper, around 80 to 90
percent of nursing graduates passed the licensure examinations during the
70s and 80s. But since 1994, the passing mark has been below 61 percent.
From 2001-2003, passers reached a low of 44 to 53 percent.
Tan’s paper noted that unlike before when
passers reached 22,000 to 25,000 a year, the last four years only
registered an average of 5,200 passing nursing graduates. This year,
12,843 out of the 26,000 examinees did not pass the exam this June.
But these exams only comprise the
theoretical training of the nurses or doctors, Tan said.
“The skills are never measured in a board
exam,” he said. “So what has happened now when everyone is now feeling the
impact in the hospital?”
Last November 2004, the Commission on
Higher Education (CHED) ordered the closure of 23 nursing schools,
including, most prominently, the AMA School of Nursing in Makati.
Following an appeal by the owner to the government, the CHED's decision
was overruled.
The former chair of CHED, Fr. Rolando dela Rosa, tried to implement
tighter screening processes to reduce the number of diploma mills among
nursing schools. But far from being successful, Fr. de la Rosa was forced
to resign.
The Magna Carta should have overseen and
regulated the production and deployment of health workers. Tan, however,
said this has not been done.
There are 14 government agencies involved
in health human resources development policy, planning and management: (1)
the Department of Health (DoH), (2) Department of Science and Technology
(DOST), (3) Professional Regulatory Commission (PRC), (4) Commission on
Higher Education (CHED), (5) Technical Education and Skills Development
Authority (TESDA), (6) Department of Labor (DOLE), (7) Philippine Overseas
Employment Administration (POEA), (8) Overseas Workers Welfare
Administration (OWWA), (9) Philippine Health Insurance Corporation (PhilHealth),
(10) Philippine Institute of Traditional and Alternative Health Care (PITAHC),
(11) Department of Trade and Industry (DTI), (12) Department of Finance (DOF),
(13) National Economic and Development Authority and the (14) Department
of Foreign Affairs .
Tan, however said, none of these agencies
is taking the lead in national health human resources development.
In PGH, Tan admitted that since the
shortage in health workers, the hospital has admitted nurses with a 75
percent passing rate compared to the 85 percent cut off before. The PGH
used to accept only the top 10 percent of the graduates of nursing
schools. The PGH offers a contract of two years. But nurses who decide to
work abroad suddenly leave, said Tan.
“These trends in the health sector are
already signs of the health system’s collapse,” warned Tan.
“If we do not do anything about it, in
three to five years, we will see that day (collapse) happen.” Bulatlat
SPECIAL REPORT
Public
Health System: On the Death Bed
First of three parts
BY AUBREY SC MAKILAN
Devolution and Corporatization of Health Services
The solution
or the problem?
Second of three parts
BY AUBREY SC MAKILAN
Related article:
The Price of
Devolution
Deployment of Filipino
Nurses
1994 – 2004 |
Year |
Volume |
1994 |
6,699 |
1995 |
7,584 |
1996 |
4,734 |
1997 |
4,242 |
1998 |
4,591 |
1999 |
5,413 |
2000 |
7,683 |
2001 |
13,536 |
2002 |
11,911 |
2003 |
8,968 |
2004 |
8,789 |
Total |
84,150 |
Source: POEA, 2004 |
Nursing Board Performance |
YEAR |
Number
of Examinees |
Number
of Passers |
Passing
Rate |
1994 |
41,459 |
25,477 |
61.45 |
1995 |
38,689 |
22,532 |
58.24 |
1996 |
25,163 |
13,643 |
54.22 |
1997 |
19,546 |
9,776 |
50.02 |
1998 |
17,101 |
9,541 |
55.79 |
1999 |
13,152 |
6,558 |
49.86 |
2000 |
9,351 |
4,600 |
49.20 |
2001 |
8,281 |
4,430 |
53.50 |
2002 |
9,453 |
4,231 |
44.75 |
2003 |
15,624 |
7,528 |
48.18 |
2004 |
25,325 |
12,581 |
49.68 |
Source:
Professional Regulation Commission, 2005 |
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