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