why filipino nurses work abroad essay

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Nurse Migration from a Source Country Perspective: Philippine Country Case Study

Fely marilyn e lorenzo, jaime galvez-tan, kriselle icamina, lara javier.

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Address correspondence to Fely Marilyn E. Lorenzo, R.N., Dr.P.H., Institute of Health Policy and Development Studies, National Institutes of Health, University of the Philippines, Manila, 625 Pedro Gil St., 1000 Ermita, Manila, Philippines. Fely Marilyn E. Lorenzo, R.N., Dr.P.H., and Kirselle Icamina, B.S.P.H., are with the Institute of Health Policy and Development Studies, National Institutes of Health, University of the Philippines, Manila, Philippines. Jaime Galvez-Tan, M.D., M.P.H., and Lara Javier are with the College of Medicine, University of the Philippines, Manila, Philippines.

To describe nurse migration patterns in the Philippines and their benefits and costs.

Principal Findings

The Philippines is a job-scarce environment and, even for those with jobs in the health care sector, poor working conditions often motivate nurses to seek employment overseas. The country has also become dependent on labor migration to ease the tight domestic labor market. National opinion has generally focused on the improved quality of life for individual migrants and their families, and on the benefits of remittances to the nation. However, a shortage of highly skilled nurses and the massive retraining of physicians to become nurses elsewhere has created severe problems for the Filipino health system, including the closure of many hospitals. As a result, policy makers are debating the need for new policies to manage migration such that benefits are also returned to the educational institutions and hospitals that are producing the emigrant nurses.

Conclusions and Recommendations

There is new interest in the Philippines in identifying ways to mitigate the costs to the health system of nurse emigration. Many of the policy options being debated involve collaboration with those countries recruiting Filipino nurses. Bilateral agreements are essential for managing migration in such a way that both sending and receiving countries derive benefit from the exchange.

Keywords: Nursing migration, Philippines, health human resources development

This case study provides information on Philippine nurse migration patterns and presents a sending-country perspective on the benefits and costs of this phenomenon. Our aim is to identify strategies that will ensure that international nurse migration is beneficial for both sending and receiving countries.

The Philippines is the largest exporter of nurses worldwide. For many decades, the country has consistently supplied nurses to the United States and Saudi Arabia. In recent years, other markets have emerged and opened for nurses including the United Kingdom, the Netherlands, and Ireland. This case study synthesizes existing information and reports on new findings to establish the magnitude and patterns of nurse migration and explore debates within the country regarding the impact of this phenomenon.

Data from a health worker migration case study commissioned by the International Labor Organization (ILO) was reanalyzed to focus specifically on nurses ( Lorenzo et al. 2005 ). Literature review, records review, and focus groups comprised of health workers from five geographic districts were also conducted. Previous studies on Filipino worker migration were reviewed and integrated with available data from government and other field records to validate study results and make the study more robust. In addition, key informant interviews were conducted with selected stakeholders including professional leaders and policy makers to determine their perceptions of nurse migration, describe current migration management programs, and explore future policy directions for nursing and health human resource development in the Philippines.

Precise figures on nurse migration are difficult to obtain because many of those who seek work overseas are recruited privately and not officially documented by Philippines Overseas Employment Agency (POEA). Moreover, Department of Foreign Affairs data are also incomplete as many people leave as tourists and subsequently become overseas workers. We therefore suspect that the data we present on both migration of all occupations and nurse migration specifically are generally underreported.

CONTEXT OF NURSE MIGRATION

The Philippines has too few jobs for its population. The unemployment rate has steadily increased from 8.4 percent in 1990 to 12.7 percent in 2003 ( BLES 2003 ). Even for those with jobs, conditions are difficult. One out of every five employed workers is underemployed, underpaid, or employed below his/her full potential. As a result, the number of Filipinos working abroad has steadily risen and from 1995 to 2000; overseas deployment of workers increased by 5.32 percent annually. Employment abroad provides work to job-seeking Filipinos and is a major generator of foreign exchange. Remittances from overseas Filipino workers of all occupations have grown from U.S.$290.85 million in 1978 to U.S.$10.7 billion in 2005 ( Tarriela 2006 ). A large portion of this comes from international service providers, with nurses constituting the largest group of professional workers abroad.

Filipino labor migration was originally intended to serve as a temporary measure to ease unemployment. Perceived benefits included stabilizing the country's balance-of-payments position and providing alternative employment for Filipinos. However, dependence on labor migration and international service provision has grown to the point where there are few efforts to address domestic labor problems ( Villalba 2002 ).

Movement of health workers from the Philippines as temporary or permanent migrant workers can be traced back to the 1950s. At that time, the objective of working overseas was generally to obtain more advanced training and return home to improve the quality of Filipino health services. Beginning in the late 1960s, countries in the Middle East and North America began to actively recruit health workers. Many of those who went to North America as students stayed on as migrant workers and were ultimately granted residency status ( Corcega et al. 2000 ). By the late 1990s, in the face of widespread global nursing shortages, recruitment conditions changed and destination countries like the United States made recruitment offers both more attractive and more permanent, creating strong “pull factors.”

There are an estimated 1,600 hospitals in the country, about 60 percent of which are private. The government is the biggest employer of nurses with an estimated 16,000 jobs at the national and government facilities. There is no reliable estimate for the number of nursing positions at small local or private institutions ( DBM 2005 ). Both the conditions and the quality of care provided by the small and private hospitals vary greatly and poor working conditions and low pay at many of these institutions also impact nurse migration by creating “push factors.” As a result, the Philippines has begun to experience massive migration of nurses and other health workers to the point that domestic demand for these workers is not being met.

PATTERNS OF NURSE MIGRATION

Nurse supply and employment.

Nurses now make up the largest group of direct health care providers in the Philippines. While physicians have traditionally dominated the health care system, in recent years nurses have emerged as a strong force, often co-managing health care facilities. Both the domestic and foreign demand for nurses has generated a rapidly growing nursing education sector now made up of about 460 nursing colleges that offer the Bachelor of Science in Nursing (BSN) program and graduate approximately 20,000 nurses annually ( CHED 2006 ). Based on production and domestic demand patterns, the Philippines has a net surplus of registered nurses. However, the country loses its trained and skilled nursing workforce much faster than it can replace them, thereby jeopardizing the integrity and quality of Philippine health services.

The total supply of nurses who were registered at some time, adjusted for deaths and retirement, was 332,206 as of 2003, according to data provided by the Professional Regulations Commission, ( Lorenzo et al. 2005 ). Of these, it is estimated that only 58 percent were employed as nurses either in the Philippines or internationally. There are no data on why the remainder left the profession. As shown in Table 1 , the majority (84.75 percent) of employed nurses were working abroad. Among the 15.25 percent employed in the Philippines, most were employed by government agencies and the rest worked in the private sector or in nursing education institutions ( Corcega et al. 2000 ).

Estimated Number of Employed Filipino Nurses by Work Setting, 2003

Source : Corcega, Lorenzo, and Yabes (2000) .

These figures were calculated based on known positions in the domestic market and recorded deployment abroad.

Additionally, as in many countries, there is geographic mal-distribution of employed nurses, with a strong correlation between place of education and place of employment. The national capital region (NCR), including Metro Manila, consistently contributed the highest number of licensed nurses with 33.4 percent of total licensure examination passers between 2001 and 2003 ( PRC 2005 ). Similarly, doctors tend to practice in large urban areas such as the NCR (21.78 percent) and region IV (11.59 percent), while many rural areas and towns are left unattended. These urban areas have also a disproportionately higher share of health facilities in the country. More remote geographic regions report chronic shortages of nurses, doctors, and other health care workers ( NSO 2005 ).

Doctors who have retrained as nurses (known as “nurse medics”) in order to seek overseas employment are a new and growing phenomenon. While exact numbers are not available, a study on this trend showed that in 2001, approximately 2,000 doctors became nurse medics and by 2003, that number increased to about 3,000 ( Pascual, Marcaida, and Salvador 2003 ). In 2005, approximately 4,000 doctors were enrolled in nursing schools across the country ( Galvez-Tan 2005 ) and in 2004, the Philippines Hospital Association estimated that 80 percent of all public sector physicians were currently or had already retrained as nurses ( PHA 2005 ).

Nurse Outflows and Destination Countries

While the numbers of most health professionals who go abroad has remained relatively constant over the years, nurse migration has fluctuated a fair amount as shown in Figure 1 . We have used data from the Professional Regulation Commission, which we consider the most accurate source, although they acknowledge that because of the multiple entry routes to the United States, data on migration to that country are severely underreported. As noted in the introduction, data on migration, including that from the POEA, are often severely underreported because they cover only certain types of emigrants and because many nurses leave the country using other types of visas, such as student or tourist visas ( Adversario 2003 ). POEA also does not include nurses that have returned to the Philippines or those who renew their contracts with the same employer ( POEA 2005a ). In one example, the U.S. Embassy in Manila reported that about 7,994 nurses were deployed under the temporary H1B and permanent EB3 visas in 2004 ( Philippine Embassy 2005 ). For the same year, however, POEA reported only 373 newly hired nurses deployed to the United States ( POEA 2005b ).

Trends of Deployment Filipino Nurses, 1994–2003

From 1992 to 2003, the major destinations of Filipino emigrant nurses have been Saudi Arabia, the United States, and the United Kingdom. These countries have employed 56.8, 13.14, and 12.25 percent, respectively, of the cumulative total of Filipino nurses sent abroad since 1992 ( POEA 2004 ). These remain the preferred destinations because of perceived advantages in compensation, working conditions, and career opportunities. Other common destinations for deployed Filipino nurses were Libya, United Arab Emirates, Ireland, Singapore, Kuwait, Qatar, and Brunei (POEA 2004). The majority of nurse medics also go to the United States, United Kingdom, and Saudi Arabia (POEA 2004).

Profile of Filipino Nurse Migrants

Data for this section were derived from 48 focus groups held in five localities, both urban and rural, with Filipino health workers, some of whom also plan to leave the country. They reported that nurses leaving the country to work abroad are predominantly female, young (in their early twenties), single, and come from middle income backgrounds. While a few of the migrant nurses have acquired their master's degree, the majority have only basic university education. Many, however, have specialization in ICU, ER, and OR, and they have rendered between 1 and 10 years of service before they migrated ( Lorenzo et al. 2005 ).

According to Pascual, the migrant nurse medics have a slightly different profile. They are also predominantly female, but are older, more likely to be married, and have higher incomes. About 24 percent are single, while 76 percent are married with an average of one to three children and they are 37 years old and older. The nurse medics' income bracket in the Philippines ranges from below U.S.$2,400 to U.S.$9,600 annually. They have specializations in the following areas: internal/general medicine (30 percent), pediatrics (14 percent), family medicine (13 percent), surgery (8 percent), and pathology (6 percent). The remaining 29 percent have other specializations including orthopedics, obstetrics, anesthesiology, and public health. The majority (63 percent) of them had practiced as doctors for more than 10 years. Thirty-four percent have pending applications abroad, while 26 percent have been offered jobs abroad already. More than half (66 percent) plan to leave the country in 6 months to 2 years time. The United States is their top destination country ( Pascual 2003 ).

Reasons for Leaving: Push and Pull Factors

A variety of reasons for migrating have been reported. The focus groups revealed the following perceived push and pull factors for migrating.

Push Factors

Economic : low salary at home, no overtime or hazard pay, poor health insurance coverage.

Job related : work overload or stressful working environment, slow promotion.

Socio-political and economic environment : limited opportunities for employment, decreased health budget, socio-political and economic instability in the Philippines.

Pull Factors

Economic : higher income, better benefits, and compensation package.

Job related : lower nurse to patient ratio, more options in working hours, chance to upgrade nursing skills.

Personal/family related : opportunity for family to migrate, opportunity to travel and learn other cultures, influence from peers and relatives.

Socio-political and economic environment : advanced technology, better socio-political and economic stability.

Focus groups were also conducted among nurse medics who still serve as government doctors in two urban areas in the South. They were employed in provincial and local government unit (LGU) hospitals, were municipal health officers, or were private practitioners. They reported that their career shifts were attributed to the very low compensation and salaries in the Philippines, feeling of hopelessness about the current situation of political instability, graft and corruption in the Philippines, poor working conditions, and the threat of malpractice lawsuits (Galvez-Tan, Fernando, and Virginia 2004). Nurse medics were also drawn to attractive compensation and benefits packages, more job opportunities, career growth, and more socio-political and economic security abroad.

Return Migration

While most health workers who seek employment abroad do not return to the Philippines, particularly those who bring their families, others return en route to another job abroad, and some return permanently. For nurses who return, the reasons identified through the focus groups were personal/family, professional, financial, and contract related. The predominant personal reasons included to get married and/or raise children in the homeland, have vacation, return due to homesickness and depression, and to retrieve family members to join them abroad. Professional reasons included wanting to share expertise and seeking professional stability. Financial/social reasons reported were that they had saved enough money to set up a business and or buy a house and a car. Job-related reasons included expired contracts and plans to retire.

IMPACT OF NURSE MIGRATION

Not surprisingly, results from the focus groups revealed that individual migrants and their families were seen as primary winners of the exodus. Respondents pointed out that if the health workers returned to the country, migration would provide benefits to the country in terms of learning technologies used abroad. The migrant was, however, also seen as contributing to the local economy through remittances and reduction of unemployment. Respondents viewed the Filipino health care system and society in general as the losers in the migration equation.

Migration was perceived to impact nursing in the Philippines negatively by depleting the pool of skilled and experienced health workers thus compromising the quality of care in the health care system. One concern among health services managers is that the loss of more senior nurses requires a continual investment in the training of staff replacements and negatively affects the quality of care. Human resources also become more expensive. One health worker expressed this plainly when he said, “We are the one in need of better service yet we are the losers; those countries with better facilities enjoy better care from health professionals” (translation from Filipino statement) ( Lorenzo et al. 2005 ).

Hard evidence regarding the impact of massive nurse migration is only now beginning to be assembled. The Philippine Hospital Association (PHA) recently reported that 200 hospitals have closed within the past 2 years due to shortages of doctors and nurses, and that 800 hospitals have partially closed for the same reason, ending services in one or two wards ( PHA November 2005 ). Shortages have led to failure to meet accreditation standards, which in turn hinders reimbursement and eventually brings financial crisis. Nurse to patient ratios in provincial and district hospitals are now one nurse to between 40 and 60 patients, which is a striking deterioration from the ratios of one nurse to between 15 and 20 patients that prevailed in the 1990s ( Galvez-Tan 2005 ). While previous ratios were not ideal, the current ratios have become dangerous even for the nurses, adding to the loss of morale and desire to migrate for those still employed in the Philippines.

Further evidence of problems can be observed in coverage data reported by the National Statistics Office. The proportion of Filipinos dying without medical attention has reverted to 1975 levels with 70 percent of deaths unattended during the height of nurse and nurse medics migration in 2002–2003 ( NSO 2005 ). This represents a 10 percent increase in the last decade, and many observers attribute the growth of this problem to the nurse medic phenomenon and the resulting shortage of physicians. Perhaps the most troubling indicator of declining access to health services is the drop in immunization rates among children, which have gone from a high of 69.4 percent in 1993 to 59.9 percent in 2003 ( Galvez Tan 2005 ). While there are undoubtedly multiple factors that impact this decline in immunization rates, the association between the lack of health human resources and immunization coverage is indisputable.

POLICY DEBATE

As a result of the impact of nurse and nurse medic migration, a flurry of policy debate has developed as both proponents and opponents of nurse migration realize that health workforce planning is urgently needed. Three major spheres of policy relate to this topic: the labor and employment sector, the trade sector, the health sector, and within that the nursing community.

The labor ministry provides for the promotion, regulation, and protection of migrant workers. The Philippine government first adopted an international labor migration policy in 1974 as a temporary, stop-gap measure to ease domestic unemployment, poverty, and a struggling financial system. The system has gradually been transformed into the institutionalized management of overseas emigration, culminating in 1995 in the Migrant Workers and Overseas Filipinos Act, or RA 8042, which put in place policies for overseas employment and established a higher standard of protection and promotion of the welfare of migrant workers, their families, and overseas Filipinos in distress ( M.T. Soriano, in OECD 2004 ). That act also, however, foresees moving toward a less regulated international recruitment process, in which the government would eventually have a far smaller role.

Reflecting a generally promigration stance, the Department of Labor and Employment and its attached agencies, the POEA, and Overseas Workers Welfare Administration (OWWA) actively explore better employment opportunities and modes of engagement in overseas labor markets and promote the reintegration of migrants upon their return. Instruments developed to this end include predeparture orientation seminars on the laws, customs, and practices of destination countries; model employment contracts that ensure that the prevailing market conditions are respected and the welfare of overseas workers is protected; a system of accreditation of foreign employers; the establishment of overseas labor offices (POLOs) that provide legal, medical, and psycho-social assistance to Filipino overseas workers; a network of resource centers for the protection and promotion of workers' welfare and interests; and reintegration programs that provide skills training and assist returning migrants to invest their remittances and develop entrepreneurship.

Within this sector, the current migration debates center on two issues. The first issue relates to the impact of deregulation and liberalization of the migration services of recruitment entities. Strong differences of opinion exist as to whether this would be positive for the nation and/or for individual migrants. A second issue revolves around whether or not the government should shift its policy from “managing” the flow of overseas migration, which is reactive, to “promoting” labor migration, which is proactive. Right now, migration policy is implicit and reactive to overseas demand. Promoting labor migration would mean actively seeking out international markets and marketing Filipino human resources in selected markets.

The trade and investment sector of the country has shown interest in developing the Philippines' health sector as a magnet for new revenues in their hospital tourism and medical zones initiatives. There has been debate as to whether this would hurt or benefit the Philippines health system. While this might provide significant incentives for retention of the most qualified health workers, jobs developed in this sector may also draw the remaining nurses and physicians away from the already-depleted public and less-profitable private sector facilities that primarily serve the poor.

The issue of nurse migration is, of course, of great concern to the health policy makers. In the area of health workforce policies, the most serious proposal currently being considered is the Department of Health HRH Masterplan for 2005–2030. The HRH Development Network was established in 2006 in order to implement the Masterplan. The Network is composed of representatives of the executive branch, the legislative branch, the private sector, and civil society groups. Congress is currently considering converting this group into a Commission that would be charged with the following:

Review of the past, current, and future scenarios of the nursing and medical human resources.

Create a database of Filipino health human resources.

Develop a 25-year National Health Human Resources Policy and Development Plan.

Develop a unified HHR policy and a National HHR Policy Research Agenda.

Major objectives being considered include the following:

Rational utilization to make more efficient use of available personnel through geographic redistribution, the use of multiskilled personnel, and closer matching of skills to function.

Rational production to ensure that the number and types of health personnel produced are consistent with the needs of the country.

Public sector personnel compensation and management strategies to improve the productivity and motivation of public sector health care personnel.

The nursing sector has also brought to the table a series of proposals that are being considered as part of the Philippine Nursing Development Plan. These strategies include:

The institution of a national network on Human Resource for Health Development, which would be a multisectoral body involved in health human resources development through policy review and program development.

Exploration of bilateral negotiations with destination countries for recruitment conditions that will benefit both sending and receiving countries. Through bilateral negotiations the Philippines may devise investment mechanisms that could be used to improve domestic postgraduate nursing training, upgrade nursing education, increase nurses' compensation, and establish nursing scholarships. Alternatively, multilateral negotiations may be forged with the guidance of international agencies such as the ILO and WHO.

Forging of North–South hospital-to-hospital partnerships so that local hospitals benefit from compensatory mechanisms for every nurse recruited from them. One proposal is that for each nurse recruited, the cost of postgraduate hospital training (estimated at U.S.$1,000 for 2 years at 2002 prices) would be remitted to the hospital from which the nurse has been recruited, allowing the hospital to then train another nurse to join their staff.

If hospital nurses are hired by foreign counterparts, it is suggested that they be given a 6-month leave to return and train local hospital nurses. Health care organizations should also establish returnee integration programs in order to maximize the potentials for skills and knowledge transfer.

The institution of the National Health Service Act (NHSA) which would compel graduates from state-funded nursing schools to serve locally for the number of years equivalent to their years of study.

Health-related organizations such as the PHA, Philhealth, the Board of Nursing, and the Philippine Nurses' Association (PNA) should work to prevent work-related exploitation domestically.

The Philippines should actively participate in debates moderated by international agencies such as the World Health Organization, the International Council of Nurses, and the ILO.

Nurse leaders are hopeful that these strategies will be incorporated into a draft executive order that the Commission would present to the President.

While the outcome of this process is unfolding, it is encouraging that the health sector has taken the lead to shift the terms of the debate. Labor and trade sector buy-in is still essential, but most policy makers agree that the goal should be to manage migration such that both sending and receiving countries benefit from the exchange ( WHO 2006 ). If the Philippines were able to produce and retain enough nurses to serve its own population, there would be widespread support for additional quality nurse production and migration. Attending to source country needs will also benefit the global health workforce and ensure improved quality of health care services for all.

• Adversario P. “Nurse Exodus Plagues Philippines”. [May 2003];2003 Asia Times Online. Available at http://www.nursing-comments.com .
• Bureau of Labor and Employment Statistics. 2003. Occupational Wage Salary.
• Commission on Higher Education (CHED) 2006. List of Nursing Schools and Permit Status.
• Corcega T, Lorenzo FM, Yabes J, De la Merced B, Vales K. Nurse Supply and Demand in the Philippines. The UPManila Journal. 2000;5(1):1–7. [ Google Scholar ]
• Department of Budget and Management. 2005. Interview of Director Edgardo Macaranas and others.
• Galvez Tan J. “The Challenge of Managing Migration, Retention and Return of Health Professionals”. 2005. Powerpoint Presentation at the Academy for Health Conference, New York.
• Galvez Tan J, Sanchez F, Balanon V. The Philippine Phenomenon of Nursing Medics: Why Filipino Doctors Are Becoming Nurses, Powerpoint presentation October 2004.
• Lorenzo FM, Dela FRJ, Paraso GR, Villegas S, Isaac C, Yabes J, Trinidad F, Fernando G, Atienza J. “Migration of Health Workers: Country Case Study”. The Institute of Health Policy and Development Studies, National Institute of Health, September 2005.
• National Statistics Office (NSO) QUICKSTAT. Databank and Information Services Division, February 2005.
• Pascual H, Marcaida R, Salvador V. “Reasons Why Filipino Doctors Take Up Nursing: A Critical Social Science Perspective”. 2003. Paper Presented During the 1st PHSSA National Research Forum, Kimberly Hotel, Manila, September 17, 2003. Philippine Health Social Science Association, unpublished report.
• Philippine Embassy. RP Embassy to Pursue Continued Deployment of Filipino Nurses in the U.S. Philippine Embassy”. News Release, February 2005.
• Philippine Hospital Association Newsletter, November 2005.
• Philippine Overseas Employment Administration (POEA) 2004. Statistics 1990–2004.
• Philippine Overseas Employment Administration (POEA) 2005a. OFW Deployment by Skill, Country and Sex (1992–2003)
• Philippine Overseas Employment Administration (POEA) 2005b. Statistics 1992–2003, August 2005.
• Professional Regulations Commission (PRC) Nurse Licensure Examinations Performance by School and Date of Examination, 2005.
• Soriano MT. in OECD, 2004 [incomplete reference]
• Tarriela FG. “OFW Remittances: Insights”. Manila Bulletin, April 11, 2006.
• Villalba MAC. “Philippines: Good Practices for the Protection of Filipino Women Migrant Workers in Vulnerable Jobs”. 2002. Working Paper No. 8. Geneva: International Labour Office, February 2002.
• World Health Organization. “Working Together”. 2006. World Health Report.
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Home Issues 14 Philippine Nurse Migration: Asses...

Philippine Nurse Migration: Assessing Vulnerabilities and Accessing Opportunities during the COVID-19 Pandemic

This chapter studies Filipino nurses’ skilled migration, factoring in their lived experiences during the onslaught of the COVID-19 crisis. Anchored in the targets of the Sustainable Development Goals (SDGs), the chapter contributes to the existing literature and policy discussion on nurse mobility in healthcare during a global crisis and on the nexus between migration and development. A key aim is to underscore the particular vulnerabilities of nurses as frontliners in both their host and home countries. Ultimately, the goal is to provide a Policy Comment that takes into consideration the question of ‘brain drain’ while also attempting to address the challenges the country faces as it seeks to promote better conditions for its highly skilled medical workforce and creating a more nuanced understanding of a nurse’s role in public and global health during a pandemic. The qualitative study described in this chapter uses semi-structured, open-ended interviews with Filipino nurses working in different parts of the world to elicit exploratory perspectives and understand respondents’ views on nurse migration and policy.

En este capítulo se estudia la migración de enfermeras filipinas cualificadas, teniendo en cuenta las experiencias que vivieron durante la embestida de la crisis de la COVID-19. Basado en las metas de los Objetivos de Desarrollo Sostenible (ODS ), el capítulo contribuye a la literatura existente y al debate político sobre la movilidad de las enfermeras en el sistema de salud durante una crisis mundial y sobre el nexo entre migración y desarrollo. Un objetivo clave es subrayar las vulnerabilidades particulares de las enfermeras, que se encuentran en primera línea tanto en sus países de acogida como en los de origen. En última instancia, el objetivo es ofrecer un comentario de política que tenga en cuenta la cuestión de la ‘fuga de cerebros’, al mismo tiempo que intenta abordar los retos a los que se enfrenta el país al tratar de promover mejores condiciones para su personal médico altamente cualificado, y crear una comprensión más sutil del papel de una enfermera en la salud pública y mundial durante una pandemia. El estudio cualitativo que se describe en este capítulo utiliza entrevistas semiestructuradas y abiertas con enfermeras filipinas que trabajan en diferentes partes del mundo para obtener perspectivas exploratorias y comprender las opiniones de las personas encuestadas sobre la migración de las enfermeras y las políticas públicas que la acompañan.

Ce chapitre étudie les migrations d’infirmières philippines qualifiées, en tenant compte des expériences qu’elles ont vécues pendant la crise de la COVID-19. S’appuyant sur les Objectifs de développement durable (ODD), ce chapitre contribue au débat politique sur la mobilité des infirmières dans les systèmes de santé et les liens entre migrations et développement. L'un des principaux objectifs est de souligner les vulnérabilités particulières des infirmières, qui sont en première ligne tant dans leur pays d'accueil que dans leur pays d'origine. Le chapitre commente la politique de migration en prenant en compte la ‘fuite des cerveaux’. L’auteure analyse les défis auxquels le pays est confronté, notamment : la volonté de créer de meilleures conditions pour son personnel médical hautement qualifié et la nécessité d’une compréhension plus nuancée du rôle d'une infirmière dans la santé pendant une pandémie. L'étude qualitative s'appuie sur des entretiens semi-structurés et ouverts réalisés auprès d’infirmières philippines travaillant dans différentes parties du monde afin d'explorer ces perspectives et comprendre les points de vue des répondants sur les migrations et les politiques les concernant.

Index terms

Thematic keywords: , geographic keywords: , 1. introduction.

1 This chapter calls for greater attention to be paid to the mobility of nurses in order to assess both source and host countries’ abilities to achieve the United Nations Sustainable Development Goals (SDGs) during a pandemic. Here, I look at complementary targets: SDG 3 on global health and SDG target 10.7 on ‘orderly, safe, regular and responsible migration and mobility of people’ (UN DESA, 2020, para 1). I examine the extent to which healthcare practitioners receive adequate access to healthcare, given the risks experienced by Filipino nurses during the onslaught of COVID-19 as local frontliners and as migrant workers at the heart of the global pandemic. This Policy Comment also delves into issues that nurses encounter related to factors such as mental health, questions of diversity and inclusion, and gender. It recognises the ‘brain drain’ phenomenon (Beine, Docquier and Rapopor, 2008) and ‘high-skill migration’ (Hart, 2006) in the Philippines and its population of nurses.

2 The chapter starts by providing a background on nursing as a global profession and the mobility of Filipino nurses. Integrated into the Comment are interviews with Filipino nurses working in different parts of the world; these were conducted from January to August 2020, online and using questionnaires. The chapter also captures responses from nurses on the frontlines of the pandemic, before concluding with policy recommendations.

2. Background

3 On 1 August 2020, over 80,000 doctors and a million nurses from 80 groups sent a collective note to Philippine President Rodrigo Roa Duterte lamenting that the country was on the brink of defeat in its battle against COVID-19 (Morales, 2020) and underscoring that it was critical to formulate a cohesive and clear action plan (Hallare, 2020). The note called for the national government to return Metro Manila, which had the most infections, to the stricter enhanced community quarantine (ECQ) regime for two weeks. Medical frontliners cautioned that the healthcare system could, without tighter controls, collapse under the continuously escalating number of infections. Following warnings from health workers, the president approved the extension of the quarantine regime (Parrocha, 2020). Effectively, the order to stay at home was back for the Philippine population. During that very month, the number of health workers testing positive for the coronavirus reached 5,008 (Tomacruz, 2020), with most contaminations found among doctors and nurses.

4 According to McLaughlin (2020), the coronavirus pandemic has revealed the fragility and inequity present in systems and societies around the globe, including in the healthcare sector. In the war against the coronavirus, health workers are the frontline soldiers. Arguably, the risk to health workers has been one of the significant vulnerabilities of the healthcare system during the COVID-19 pandemic. Those working in hospitals are handling a massive rush of patients while also usually dealing with a lack of personal protective equipment (PPE) and the worry of acquiring the virus, coupled with an increased workload and less time for rest (ILO, 2020).

5 Nursing has been identified as an ‘indispensable profession, discipline and occupation’ (Thuon Northrup et al., 2004, 55). In developed countries the recruitment of foreign nurses is seen as an appropriate way of catering to the needs of growing, resource-intensive healthcare services coupled with ageing populations (Buchan, 2006). Because of this outward movement of nurses, however, source nations may struggle to meet their own need for health workers (Mackey and Liang, 2012).

6 The World Health Organization’s (WHO) State of the World’s Nursing – 2020 reveals that unless appropriate interventions take place there will be a shortfall of 4.6 million nurses worldwide by 2030 (WHO, 2020b). Over the years, the number of healthcare practitioners in the Philippines has increased. Abrigo and Ortiz (2019) capture this robust growth in their study on healthcare professionals employed in the Philippines, comparing data from 1990, 2010 and 2015 based on the 2012 Philippine Standard Occupational Classification (PSOC) and from the Census of Population (see Table 9.1).

Table 9.1. Number of selected healthcare workers by year (who responded that they were employed in the professions in question)

Source: Abrigo and Ortiz (2019).

7 The 2015 Census of Population, meanwhile, revealed that the Philippines had 488,800 health professionals for a population of over 100 million (2015 census cited in UPPI and DRDF, 2020), while the 2018 National Migration Survey estimated that under 1 per cent of working Filipinos in the Philippines are employed as health professionals (PSA and UPPI, 2019). Within this small demographic, the majority (59 per cent) are nurses, 12 per cent are medical doctors, and 11 per cent are midwives (PSA and UPPI, 2019). If the country fails to invest more in retaining its nursing population, it is looking at a deficiency of 249,843 nurses by 2030 (WHO, 2020b). The Philippine Nurses Association (PNA) has stated that 60 per cent of the 500,000 Filipino registered nurses work in other countries (PNA cited in Malig, 2020). Further, in 2014, according to the Philippine Overseas Employment Administration (POEA), 19,815 nurses emigrated from the country (POEA, 2014).

3. Filipino Nurses, Global Nursing, and Healthcare

8 Filipino nurses are important frontliners in the Philippines and abroad. At the onslaught of the deadly pandemic, the Philippines tried to curb the rise in infections within its borders while also dealing with reports of infections, even casualties, from overseas. Inside the country, the opportunity to react effectively to those in need of medical treatment and support was hampered as a consequence of insufficient numbers of health professionals, while there was also an increasing demand for facilities.

9 The Philippine experience is unique because the country is engaged in a balancing act, simultaneously attempting to manage the healthcare personnel shortfall within its borders while meeting the healthcare needs of the global community. The manner in which the Philippines navigates demands for models that respond to new pandemics and the ecology of global health is worth investigating, especially as it relates to attempts to achieve the SDGs.

3.1. Nursing and the Sustainable Development Goals

10 In 2015, the United Nations General Assembly approved the 2030 Agenda for Sustainable Development, which gives ‘a shared blueprint for peace and prosperity for people and the planet, in the present time and for the future’ (UNOSD, 2015). Nursing has an essential function with regard to Sustainable Development Goal 3: to ensure healthy lives and promote well-being for all at all ages (UNOSD, 2015).

11 The active mobility of nurses, meanwhile correlates with the SDGs’ aims with regard to migration, and in particular Target 10.7, to ‘facilitate orderly, safe, regular and responsible migration and mobility of people, including implementing planned and well-managed migration policies’ (UN DESA, 2020, 1), which is part of SDG 10, ‘to reduce inequality within and among countries’ (UNOSD, 2015). The intersection of nurse migration with sustainable development and human rights, such as the right to movement, is supported by targets set by the international community.

3.2. The State of Global Nursing

12 The revival of interest in nurses’ international migration is a consequence primarily of the global shortage of nurses in recent years (Buchan and Calman, 2004). According to the WHO report on the State of the World’s Nursing – 2020 , the result of the collaborative effort of 191 countries, nursing is the largest category in the health sector, with nurses accounting for 59 per cent of all health workers. In the period 2013–18, nurse numbers grew by 4.7 million worldwide (WHO, 2020b). Given nurse-to-population ratios, however, this increase is marginal and barely matches the pace of population increase, resulting in just a small increase in these ratios.

13 The global nursing workforce currently stands at 27.9 million, with 19.3 million of these considered professional nurses (WHO, 2020b). Around 6.0 million (22 per cent) are associate professional nurses, and 2.6 million (9 per cent) do not fall into either of these two categories (WHO, 2020b).

14 These figures reveal that worldwide nursing numbers are not proportionate to the demands of universal healthcare or to the targets regarding inequality reduction set out in the SDGs. The shortfall in the number of nurses worldwide fell slightly from around 6.6 million in 2016 to 5.9 million in 2018 (WHO, 2020b). Around 5.3 million of that shortfall, however, involves low-income and lower-middle-income countries (WHO, 2020b). Figure 9.1 shows the diversity of densities of nursing personnel to populations, revealing major shortages in countries in Africa, the eastern Mediterranean, Southeast Asia and Latin America.

Figure 9.1 Density of nursing personnel per 10,000 population in 2018

Source: WHO (2020b, 3).

15 In its report Human Resources for Health: Overcoming the Crisis (2004), the Joint Learning Initiative explains that providing a supportive climate and sharpening human resources for health is vital to efforts to shape ‘sustainable health systems’ globally and to combat healthcare disasters in the world’s most vulnerable countries (Joint Learning Initiative, 2004). The World Health Report 2006: Working Together for Health (WHO, 2006) underscores this message and encourages efforts to understand what motivates the mobility of health professionals and the effect that this mobility has on society.

16 According to a study carried out by the Institute for Immigration Research of George Mason University (Hohn et al, 2016), 13 to 15 per cent of working nurses in the United States are foreign-born, which indicates how crucial immigrants are for the long-term performance of the healthcare market (Hohn et al., 2016). The same report predicts a shortfall of more than one million new and replacement nurses by 2022. The US Bureau of Labor Statistics, meanwhile, suggests that another 372,000 registered nurses will be needed by 2028 (Smiley, 2020).

17 The Philippines is the second most populous country in Southeast Asia. Despite this, many of the country’s registered nurses remain either unemployed or ‘mis-employed’ (Dabu, 2019). In 2017, the Philippine Statistics Authority reported that, with 90,308 practising nurses in private and public hospitals, the healthcare system fell short of the target nurse-to-patient ratio (see Table 9.2). In the Philippines, the target ratio in government institutions is 1:60, as revealed by the Philippine Nurses Association (Cortez, 2020). This is some way from the Department of Health’s (DOH) ideal ratio of 1:12 (Cortez, 2020).

Table 9.2 Population of nurses in the Philippines

* Human resource development

Source: UP COVID-19 Pandemic Response Team, 2020.

18 An irony of the Philippine health sector is that even with the numbers of health professionals the country trains each year, there are not enough staff to cater to the needs of the growing population (UPPI and DRDF, 2020). Even before the COVID-19 pandemic, the Philippines suffered from an estimated shortfall of 23,000 nurses according to the Private Hospitals Association of the Philippines (PHAP, cited in Maru, 2020). The Philippine situation runs contrary to the WHO’s Global Code of Practice on the International Recruitment of Health Personnel (hereafter, WHO Code), which frowns upon recruiting health personnel from countries that have a shortage (WHO, 2010). With its lack of nursing personnel, the Philippines is ill-placed to encourage the mobility of its healthcare human resources.

3.3 Filipino Nurses and Their Migration

19 The presence of Filipino nurses in the United States, writes Dr Catherine Choy in her book Empire of Care: Nursing and Migration in Filipino American History (2003), can be mapped back to the point at which the Philippines became a US territory, when new professions such as nursing were introduced to the country in time making the Philippines ‘the leading exporter of nurses in the world’ (Choy, 2003). Nursing schools sprang up in the Philippines beginning in 1907 and were interlaced with an Americanised medical training that equipped Filipino women to be employed as nurses in the United States, not in the Philippines (Choy, 2003). Today the country is ‘the leading exporter of nurses in the world’ (Lorenzo et al., 2007, 1406).

20 From 2008 to 2012, close to 70,000 Filipino nurses worked abroad according to government data from the Philippine Statistics Authority (cited in McLaughlin, 2020). In 2017, some 145,800 Filipinos worked as registered nurses in the United States according to the Washington-based Migration Policy Institute (cited in Batalova, 2020). According to government data, around 18,500 Filipinos were employed in the UK National Health Service in 2020 (McLaughlin, 2020). Japan has been recruiting nurses from the Philippines to care for its elderly population. Filipino nurses are also present in great numbers in the Gulf States, including Saudi Arabia (McLaughlin, 2020). Spain, meanwhile, announced in early 2020 that it would fast-track Filipino nurses’ entry to relieve its straining healthcare system, especially during the COVID-19 pandemic (Aboy, 2020).

21 Many nurses leave the Philippines unofficially. Many, moreover, are selected via direct recruitment by overseas employers, while others depart on immigrant visas. These three types of mobility are not reflected in the Philippines’ international employment estimates. Hence, the nurse mobility estimates found in Philippine government must be treated with caution (Pang, Lansang and Haines, 2002). The POEA and the Commission on Higher Education estimate that from 2012 to 2016 the country trained an annual total of around 26,000 licensed nurses, while around 18,500 moved overseas each year (Lopez and Jiao, 2020), meaning that the emigration rate for trained nurses was 71 per cent.

22 The Philippines is a preferred source of nurses because of its exceptionally well-educated workforce, which is a result of the Philippine education system and the quality of training the population receive. The country’s overseas population is an enormous source of remittances, which help the national economy greatly, and thus transnational mobility has enjoyed widespread support. Even at the height of the pandemic, Filipinos living abroad sent USD 2.9 billion home (Focus Economics, 2021). Philippines nurses working in Philippine public hospitals and government offices, meanwhile, had to campaign for almost two decades before they secured a pay increase required by law (de Vera, 2020), the pandemic ensuring that the increase was, finally, approved. Budget Secretary Wendel Avisado released Budget Circular No. 2020-4 (Department of Budget and Management, 2020) in July 2020, thus officially bringing Section 32 of Republic Act No. 9173—also known as the Philippine Nursing Act—into effect. This gave nurses a monthly salary equivalent to the government’s Salary Grade 15, of PHP 28,890 (USD 580) to PHP 33,423 (around USD 671) in state-run health institutions. As the COVID-19 pandemic swept through the Philippines, details of the working conditions and pay shortfalls of nurses were discovered and brought to the national attention.

23 With 233 nursing schools, and producing more than 20,000 graduates per year since 1999, the Philippines’ strategy for healthcare migration is reflected in the country actively training a surplus of registered nurses that cannot be absorbed by the local market, with the intention of providing for the international market (Corcega et al., 2002). The number of nursing schools has increased over time, illustrating the country’s approach of creating a workforce for export with the expectation that the results of this tactic will be instrumental to the country’s progress (Ortiga, 2017).

24 As noted in a study commissioned by the International Council of Nurses, the local health system in the Philippines needs to support the growth of nursing as a profession and to address the dilemmas present with regard to work environments and pay (Buchan, 2020). A balance must be achieved between assisting in the provision of global healthcare expertise by the relocation of Filipino health workers and ensuring that no capacity gaps exist in the Philippines itself (Buchan, 2020).

25 Work in a much more advanced society offers many nurses the opportunity to change their lives for the better and to secure the quality of life they aspire to (Xu and Zhang, 2005). Which explains why many nurses consider moving and working overseas as one of their future goals. Over 80 per cent of interviewees of the present study admitted that migration was always a part of their plans (Figure 9.2).

Figure 9.2 Respondents’ answers to the question, ‘Was migrating to another country a plan from the beginning?’

Source: author.

26 In the Philippines as in other source countries, people study nursing with the intention of working abroad, an intention that is not only accepted but is also supported by their families and the government (Dussault, Buchan and Craveiro, 2016). This rationalisation seems to be supported by responses to the question, ‘What was your reason for getting a nursing degree?’

27 One nurse respondent in the UK explained:

Ever since I was a kid, it was always my dream to become a nurse and work abroad. One of the things that motivated me to pursue a nursing degree is my passion for caring for the sick since when I was growing up I […] [saw] my grandparents suffer from different illnesses. Second is the ongoing demand for nurses all over the world and lastly, the endless learning opportunities. Working as a nurse, we have the opportunity to interact with doctors and other medical staff as well as patients daily, which allow[s] us to learn from other people and allows us to improve our interpersonal skills.

Nurse 1, UK

28 Several respondents also mentioned that they were pressured by family members, especially their parents:

‘Nursing was never my choice. It was my mom’s. I just did it for the sake of my parents. I never really liked or loved it at all, even after graduation. Until I was exposed to Emergency Nursing. My perception was changed then [and I] started loving it’ (Nurse 2, UK).

‘My mom and sisters are nurses so [there was ]a bandwagon effect’ (Nurse 3, UK).

‘It was my aunt who was also a nurse who motivates me to become a nurse. Since I was a child, I really wanted to become one to help the sick’ (Nurse 4, US).

‘[It was my] parent’s choice’ (Nurse 1, the Philippines).

‘My mother told me to study nursing’ (Nurse 5, the Philippines).

‘I come from a family of nurses and the nursing profession offers a more stable employment in Europe’ (Nurse 6, Switzerland).

29 The International Centre on Nurse Migration has stated that there are several ‘push’ factors that encourage nurses to leave their home countries, including constrained access to educational and career opportunities, low pay, a lack of resources, limited social benefits, political instability and the absence of safe and secure conditions, that last of these including the incidence of HIV/AIDS (Li, Li and Nie, 2014). ‘Pull’ factors that attract nurses to developed countries include better working conditions, job security and advancement, avenues to improve skills, and travel opportunities. (Aiken et al., 2004). It can be argued that these push and pull factors are reflected in the Philippine migration experience, especially as it relates to nurse mobility.

30 There are more women than men in the diaspora, and this been referred to as the feminisation of migration (Camlin, Snow and Hosegood, 2014). Nurse mobility is no exception to this rule. Around the world 90 per cent of nurses are women (WHO, 2020b). In the Philippines 74.1 per cent of nurses are female and 25.9 per cent are male (2015 figures) (Figure 9.3) (PSA, 2016).

Figure 9.3 Gender of nurses in the Philippines

Source: PSA, 2016.

31 Women can play an active role in migration, particularly among healthcare workers. A majority of the world’s nurses are female (Brush and Sochalski, 2007). Women migrants are, however, particularly vulnerable to the ‘dark side’ of migration. While they may have decided on their own mobility pathways, as reported by the WHO (2019b), a considerable number in the healthcare workforce encounter partiality and discrimination as well as harassment (WHO, 2019b). Migration is highly gendered and understanding female nurse mobility therefore calls for a gender-responsive approach.

3.4. Filipino Nurses during the COVID-19 Pandemic

32 Through the POEA, the government—in its bid to protect healthcare workers—issued Resolution No. 9 on 2 April 2020, stopping nurses from departing the Philippines pending the lifting of the national state of emergency (POEA, 2020). Some days after this memorandum was released, the Department of Foreign Affairs Secretary announced that health workers with an existing overseas contract, signed before 8 March, were allowed to leave (Cheng, 2020). New applications for healthcare positions in other countries were, however, halted. Citing Republic Act 8043 or the Migrant Workers and Overseas Filipinos Act of 1995, Section 5 on the Termination or Ban on Deployment, the Administration argued that it was within its rights to have implemented the ban. The Act states, ‘Notwithstanding the provisions of Section 4 the government, in pursuit of the national interest or when public welfare so requires, may, at any time, terminate or impose a ban on the deployment of migrant workers’ (Republic of the Philippines, 2010). A respondent, Nurse 9 living in the UK, shared that

During the pandemic, a lot of fellow Filipino nurses working here in the UK were affected. Some [even] lost their lives while taking care of COVID-19-positive patients. It was a difficult time for us, knowing that every time we [went] to work we [could] be affected by the virus […]. For some of my colleagues working in intensive care units it is […] challenging and difficult for them to work a 12-hour shift with complete personal protective equipment on and [have] only a specific toilet and water break as well as time for them to have their lunch. For me, working in the post-operative cardiac ward, I would say that I am very lucky in […] that [I] can continue taking care of our patients using our comfortable scrubs. Here in the UK, I still feel lucky despite the fact that we are at great risk of being affected by the virus, because we were able to have free transportation for a short while going to work and even free food during our shift provided by our hospital.

33 The same respondent also related their anxiety and their fear for themselves and their family members, noting that it is their faith that keeps them going.

Emotionally we are very much affected in [the] way that this is our calling and we have no other choice but to work. Going to work with our anxiety levels […] sky[-high] because we are directly taking care of […] COVID-19 patients. We are scared for our [lives] and our family member[s] if we get infected. But on the other side, I believe that this is the only way we can pay back God’s blessings to us and that he will cover us with his mantle of protection.

Nurse 9, UK

34 Over 25 per cent of the Filipinos in the New York–New Jersey region work in the healthcare sector. According to a report produced by the non-profit ProPublica, in this region alone there were 30 deaths in the community of Filipino frontliners between the end of March and early May 2020 (cited in Martin and Yeung, 2020). Al Jazeera, in its documentary ‘Filipino Nurses: New York’s Frontliners’, reported that at the peak of the outbreak Filipino nurses were fighting to protect Americans on the front lines of New York’s COVID-19 disaster, with some risking their lives (Al Jazeera, 2020).

35 Nurse 10, living in the UK, made a parallel assertion:

When COVID-19 peaked here in the UK, Filipino nurses were placed ahead of all the frontliners. We were sent to the ICU and placed in the COVID-19 wards with no proper PPE. If you look into the statistics and reports, the highest cases of frontliners that died during the peak of the pandemic were Filipinos. Because of the resilience of our race, we still continue to provide high-quality care to our patients in spite of the fact that our lives are at risk. We need to think about the welfare of our patients before our own.

36 In California, with the highest concentration of Filipinos and Filipino-Americans in the world, 20 per cent of all nurses are Filipino, and they have noted a lack of PPE as one of the primary routes to exposure to the virus (McFarling, 2020). Many health workers are too nervous to complain because they fear they could be punished by being given longer shifts, which would increase their risk of exposure (McGannon, 2020).

It affected us in so many ways. We have always been resilient and flexible. However, being in [that] personal protective equipment for hours is no joke. Some of us get pressure sores and end our shift with a terrible headache due to dehydration. Psychologically, very traumatic. As we often say, we feel like we are in a battle without guns, and we can’t see our enemies. It was tough knowing that we can get infected. Especially when we had patients who are also nurses in our hospital. I work in ICU, so I’ve seen the worst COVID-19 can do. Nevertheless, the bond we have with our fellow nurses became stronger than ever. We looked out for each other every time we prepare[d] to enter the COVID-19 zone. And we see to it that we talk to each other in order to release the stress.

Nurse 12, US

37 Frontline medical staff are vulnerable not only to physical but also to psychological consequences of COVID-19 (Adams and Walls, 2020). According to a Lancet study conducted in Wuhan, which is thought to be where the virus emerged, frontline nurses encountered tremendous mental health problems, including the ‘prevalence of burnout, anxiety, depression, and fear’ (Hu, et al., 2020, 6). Caregiving roles such as raising small children, having a family member that has acquired the disease, and financial problems were shown to be correlated with negative mental health effects in research into the social effects on healthcare workers employed during an epidemic of any infectious disease (Kisely et al., 2020). The respondents of the present study shared similar observations:

Nurses are dealing with a lot of emotional stress from working in these times. From wanting to stay at home to keep their families safe and working to keep others safe, nurses are battling with mental and emotional stress in dealing with this pandemic. Many nurses were broken-hearted from working tirelessly for others and get little to no assurance from the company/government they are working [for] about the hazard they are dealing with. The uncertainty that this pandemic has brought to light made the nurses rethink how passionate they are about their profession. Some even contracted the disease and got discriminated against at work. I personally encountered discrimination for working in an area catering to patients with moderate-to-severe cases of COVID-19. Even inside our workplace, we are sometimes denied […] some basic services just because we work in COVID-19 areas and are asked to go back when we are off duty. Nurses’ plans on working abroad had been halted due to restrictions in travel.

Nurse 8, Switzerland

38 The Philippine Department of Health recognised this problem. In response to the growing mental well-being needs of frontline workers and repatriated overseas Filipino workers (OFWs), the Department unveiled its Telemental Health Response programme, a virtual platform that provides psychosocial help (DOH, 2020). Even the University of the Philippines’ Psychosocial Services, with its 100 volunteers, has offered free tele-psychotherapy sessions.

39 Another challenge faced by nurses during this pandemic is discrimination. Nurse 13 (US) shared that ‘most are being bullied and harassed in the community thinking that nurses are carriers of the virus’. Yet another, Nurse 14, said, ‘A lot of nurses were being thrown out of their apartments just because they work inside the hospital’. Meanwhile, the Philippine National Police reported attacks on and discrimination against health workers during the lockdown (Santos, 2020). This prompted the Department of the Interior and Local Government (DILG) to urge all local government units (LGUs) nationwide to pass and enforce anti-discrimination and anti-harassment ordinances to protect frontline workers. Many LGUs responded to this mandate and enacted laws to protect frontliners and overseas Filipino workers, many of them nurses. The country’s Congress also issued House Bill (HB) No. 6817 (Philippine House of Representatives, 2020b), which outlaws discrimination against persons either directly involved in or affected by the COVID-19 pandemic. The bill is currently awaiting its counterpart from the Senate. Once it becomes a law, it will be used to punish those who commit these crimes, with jail sentences of between six months and ten years and fines ranging from PHP 50,000 to PHP 1 million (between 1,000 and 20,000 US dollars). The WHO had already issued a guide to preventing and addressing the social stigma associated with COVID-19 (WHO, 2020c).

40 Nurse 20 (the Philippines) lamented her experience:

Working as a nurse in the Philippines, [one of the] common challenges we’ve encountered [is] working beyond duty hours to complete all necessary paperwork. Sometimes, you offer possible solutions to certain problems encountered in your area that may help in revising old protocols and creating new ones that may benefit the workers and the hospital, but then you get no response or even alternate solutions from the management. Discrimination is one of the challenges any nurse is dealing with at this time of the pandemic.

41 Even prior to the current pandemic research (Gee et al., 2006) had found that daily experiences of prejudice were linked to Filipino Americans’ chronic health conditions. And de Castro, Gilbert and Takeuchi (2008) had discovered that the self-reporting of occupational discrimination was associated with worse health outcomes among Filipino Americans, the authors concluding that it is important to consider the work setting as a specific source of discrimination when studying health disparities.

42 As these words are being written, the WHO-Western Pacific Region COVID-19 Incident Manager, Abdi Mahamud, is expressing concern over the infection rate of 13 per cent in the Philippines (CNN Philippines, 2020). The vulnerabilities of Filipino health frontliners are twofold: they are at risk if they stay in the Philippines but are also exposed if they are deployed abroad.

3.5. The Evolving Role of Nurses in Global Health

43 The WHO, the International Nurses Council and the global campaign Nursing Now emphasise the role of nurses in contributing to national and global health priorities, including the achievement of the SDGs, in their report on the State of the World’s Nursing (WHO, 2020b).

44 In an interview carried out for the present study, Nurse 17 (UK), in affirming the role of nurses, confidently shared , ‘We are pretty much the blood that runs [and keeps] the hospitals alive’. Other respondents also stated that nurses are essential. Nurses ‘care for the sick and the dying’ (Nurse 1, the Philippines) and ‘help the community get better, and provide education on prevention of diseases and spread of infection’ (Nurse 11, UK). All respondents believe in nurses’ vital role in the world as ‘role models of health practices and healthy living’ (Nurse 20, the Philippines). Nurses play a vital role in the community. Regardless of race, age group or cultural diversity nurses have the ability and capability to give the best possible care. Nurse 17 shared, ‘nurses are the caregiver[s] of those who are ill and needing hospitalisations; nurses can be agents of change health-wise by providing people [with] […] information regarding health education and prevention of illness’. Nurse 14 (US) stated emphatically: ‘I believe that our role in the global community always focuses on health promotion and disease prevention. And the primary goal for us nurses is always to protect and promote the health of all people from different age group[s], gender[s], race[s], etc.’.

45 Nurse 15 (UK) said, ‘The role of nurses is crucial, especially in the provision and promotion of the healthcare delivery system to the global community’.

46 The World Health Assembly (WHA) resolution WHA64.7 (WHO, 2011) directs its Member States to support nursing and midwifery through a number of initiatives, such as using nurses’ skills and integrating them into the development of human capital for health policy. Moreover, the framework set by the Global Strategic Directions for Strengthening Nursing and Midwifery 2016–2020 gives the WHO and other actors the platform to ‘develop, implement and evaluate nursing and midwifery accomplishments to ensure accessible, acceptable, quality, and safe nursing and midwifery interventions’ (WHO, 2020a, 12).

47 Recognising the importance of ‘adequate and accessible’ health personnel, the WHA has approved a guide to ensuring secure conditions for people taking part in foreign migration. This WHO Code proposes a series of non-binding guidelines for state and non-state players participating in foreign health worker recruitment (Efendi et al., 2017). Based on principles of fundamental human rights, the Code was created to encapsulate rights to health, including the right to find work abroad (Efendi et al., 2017).

48 Nurse 16, based in the US:

With the pandemic right now, being a nurse has a great impact on the community. We are the frontliners; we are the ones who directly take care of sick patients.

The calling of a nurse is to assess the well-being of individuals, families and the whole community. To be the advocate for all […] patients and to promote justice and equality. To uphold everything mentioned in the ‘Nightingale […] Pledge’ when we took our oath.

A nurse is many things. But for me, the best role of a nurse is being the mediator. You are the only bridge between the patient and the rest of the healthcare team and even to the relatives. The information you relay will be the basis of care plans, therefore expecting good outcomes. Through the nurse, you also protect the patient’s privacy and dignity, ensuring that nobody insignificant to the care of the patient is getting important information.

49 During times of crisis and disaster, nurses are strategically positioned not only to contribute but to lead. With their experience and education as well as their role in society, they can push for partnerships and collaborations and for a new health paradigm that is more efficient, inclusive and responsive.

4. Policy Recommendations and Moving Forward

50 Global health has evolved not only due to the emergence of new diseases but also because of our increasingly interconnected and interdependent world. Recognising that policy is an essential part of the ecosystem of health sciences, the following recommendations are offered to the international community, and to the Philippines.

4.1. Recommendations for the International Community

51 In a study commissioned by the International Council of Nurses (ICN), Buchan (2020) mentions three main factors of concern for national nursing associations (NNAs): The first is maintaining secure minimum staffing levels while nurses are unavailable due to COVID-19 symptoms, and ensuring that personnel and patients are protected. Employers have to ensure that nurses are provided with sufficient protective equipment as well as the right planning and training. A second concern is the shortage of adequate PPE, which has been identified in all countries. The third is ensuring the impartial treatment of staff who report back to work and those on provisional contracts (Buchan, 2020). A further challenge, ensuring ‘ethical’ recruitment, includes guaranteeing that migrants have the same access to working standards and job prospects as locals do. This goal of ensuring ‘ethical’ recruitment is intended to protect migrant professionals’ interests in areas where unions are not so prominent, such as in private clinics, hospitals, or households (Dussault, Buchan and Craveiro, 2016).

52 In an attempt to respond to the needs of nurses worldwide, the State of the World’s Nursing – 2020 lists guidance measures for future nursing staffing policies, including the need for countries with nursing crises to raise investment in order to train and recruit, collectively, at least 5.9 million nurses (WHO, 2020b). Furthermore, countries should improve their ability to collect, analyse and use health workforce data. Nurses’ mobility must be efficiently supervised and handled professionally and ethically. The same report stresses that leadership and governance are essential (WHO, 2020b). Authorities should boost nurses’ participation in decision-making on matters that affect their lives and practice. Actions should, in order to ensure decent work for nurses, be harmonised between those in charge of policy, human resources and standards.

53 Connectedly, the International Covenant on Economic, Social and Cultural Rights, specifically Article 7, contains guidelines for ‘just and favourable’ working standards, such as the ‘right to secure working conditions’ (UNGA, 1966). In the General Comment on the Right to Work, respect for workers’ rights and individuals’ fundamental rights, respect for workers’ physical and mental integrity, and appropriate remuneration are elucidated as the main components of decent work (UNCESCR, 2006). In relation to this, the International Labour Organization’s (ILO) Decent Work Agenda provides four strategic goals: encouraging sustainable jobs, guaranteeing workplace security, promoting dialogue and ensuring social security (ILO, 2016).

54 Ultimately, the aim is for both origin and source countries to benefit while ensuring the protection and rights of health workers moving abroad (ILO, 2009). Bilateral and multilateral guidelines and codes of ethics have been established in collaboration with partner nations to devise and enforce agreements that specifically discuss standards and policies for the nursing profession. There are also reciprocal arrangements that lay down the rules and regulations, as well as the performance criteria, for health staff hired from source by destination countries. There needs to be a consistent review and monitoring of these arrangements, intertwined with a regular assessment of their implementation.

4.2 Recommendation for the Philippines

55 When asked if the Philippine government should do a better job in its response, Nurse 22, based in the US, answered:

Yes. I think the government should step up in its action towards flattening the curve. The community must do its part in preventing the spread of the disease. We must strengthen our campaign towards promoting prevention, starting from our homes. We should all step up in realising that we have to live with the new normal for the next couple of years. The government should start distributing or localising jobs in municipalities so as not to overwhelm cities with people returning for work. The government needs to rebuild the distribution of jobs to promote a safe workplace.

56 The Philippines’ battle against COVID-19 is far from over, and the Department of Health reports that more health personnel will be required for COVID-19 facilities. As a result, the Department began an emergency recruitment campaign to treat COVID-19 incidents. A guaranteed 20 per cent bonus over the government’s minimum wage levels, accommodation, hospitalisation benefits and even compensation of PHP 1 million (USD 20,000) in case of loss of life are all on offer (Lopez and Jiao, 2020).

57 One of the priority measures identified by Philippine President Rodrigo Duterte in his State of the Nation Address (Duterte, 2020) was passing the Advanced Nursing Act, which seeks to modify some aspects of the Philippine Nursing Act of 2002 to create an advanced nursing education program. Senator Bong Go, the bill’s sponsor in the upper chamber, hopes to persuade Filipino nurses to remain in the Philippines rather than work abroad. Senate Bill No. 395 will mandate higher learning institutions approved by the Commission on Higher Education to develop harmonised basic and graduate nursing education programs (House of the Senate, 2019). Lower House Deputy Speaker and Camarines Sur 2nd District Rep. Luis Raymund Villafuerte Jr. provided the lower house version of the bill (House of Representatives, 2020).

58 Nurse 24, who had just returned to the Philippines from the Middle East, recommended that the Balik Scientist programme, an existing programme of the Department of Science and Technology, should ‘allow willing Filipino health professionals to return to share their skills and talents gained from experience with[in] the destination country without risk of job loss’ and that this should also be included in the provisions of bilateral agreements with host countries.

59 Indeed, apart from legislation, there needs to be support given to improving the practice of nursing in the Philippines, support that also includes the strengthening of research and innovation. There also has to be an exchange of best practices and a space in which migrant Philippine health workers can contribute to their home country.

60 Acknowledging the stories of Filipino nurses on active duty in the Philippines and abroad while taking stock of the frameworks created by the UN, WHO, and other agencies advances the need not only for a mapping exercise that tracks geographical nurse mobility but also for becoming conscious of the leaky faucets that disturb the career trajectories of nurses. Measures to ensure that standards are followed, codes are committed to, and concerns are addressed must be implemented in partnership with different sectors, but, more importantly, guarantee that the voices of nurses are heard and valued, as they inform both policy and a more inclusive, safe and secure work environment.

5. Conclusion

61 During the COVID-19 pandemic, the profile of the nursing population from the Philippines has shed light on two issues: the challenges the current health system holds for health workers, in particular nurses, seeking to provide services to the country during a crisis such as the pandemic, and the question of Filipino nurses’ ability to work abroad and their working and life conditions as they navigate the uncertainties and vulnerabilities brought about by a deadly virus.

62 This chapter has attempted to relate the perspectives of nurses themselves in order to understand the impact of migration on their lives through their experiences and to capture their lived realities, hoping to provide solutions that are practical, inclusive and sustainable. These contributions are critical to designing policies for source countries such as the Philippines.

63 Health workers in the Philippines during the COVID-19 outbreak hoped, via their unified call, to convince national governments and receiving nations to look deeper into their daily lives and recognise that improving their conditions, positions and pay would benefit society as a whole.

64 At the height of the health crisis, the government tried to dissuade nurses from leaving the Philippines, especially given the loss of frontline personnel to the disease, a loss that exacerbated the dearth of responders who would be required if the country was to successfully combat this insidious virus. However, as echoed by nurse respondents to the present study, the international migration of nurses can serve as a means of empowerment, and of providing spaces for nurses’ engagement and collaboration. This has the potential to enable their wider participation, particularly in decision-making.

65 Nurse migration and the health ecosystem are multidimensional and complex. The UN, the WHO and local counterparts have attempted to put safeguards in place to ensure the safety and well-being of nurses and other health workers. The challenge of dealing with COVID-19, however, has pressured the global community to reassess its methods. And it is important for host countries to have a better grasp of the needs of its migrant population, especially those on the frontlines. Further, the intersection of the issue of nurse migration with other issues—including those of diversity, inclusion and gender—has to be more closely examined.

66 As is often said, a crisis is a terrible thing to waste. It is hoped that the common experience of dealing with COVID-19 ignites a fire in Filipino nurses, encouraging them to take a more active role in global health and migration policy. And that while the world tries to ‘build back better and stronger’, nurses will be able to take the opportunity to address the leaky faucets that impact their careers, and create an enabling environment in which they themselves will flourish, since doing so will proportionately benefit the global health system and the entire environment of care.

Aboy, S. (2020) ‘Babysitters No More, Filipino Nurses in Spain Find Place on COVID-19 Frontlines’, ABS CBN News , https://news.abs-cbn.com/overseas/04/10/20/babysitters-no-more-filipino-nurses-in-spain-find-place-on-covid-19-frontlines (accessed on 6 May 2020).

Abrigo, M.R.M. and D.A.P. Ortiz (2019) Who Are the Health Workers and Where Are They? Revealed Preferences in Location Decision among Health Care Professionals in the Philippines , Discussion Paper Series No. 2019–32 (Quezon City: Philippine Institute for Development Studies), https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidsdps1932.pdf (accessed on 10 December 2020).

Adams, J.G. and R.M. Walls (2020) ‘Supporting the Health Care Workforce During the COVID-19 Global Epidemic’, JAMA , 323(15), pp. 1439–1440, DOI:10.1001/jama.2020.3972

Aiken, L.H., J. Buchan, J. Sochalski, B. Nichols and M. Powell (2004) ‘Trends in International Nurse Migration’, Health Affairs , 23(3), pp. 69–77, DOI: 10.1377/hlthaff.23.3.69

Al Jazeera (2020) ‘Filipino Nurses: New York’s Frontliners’, Al Jazeera , 16 July, https://www.aljazeera.com/programmes/101east/2020/07/filipino-nurses-york-frontliners-200716112741058.html (accessed on 17 July 2020).

Batalova, J. (2020) ‘Immigrant Health-Care Workers in the United States’, Migration Information Source , 14 May, https://www.migrationpolicy.org/article/immigrant-health-care-workers-united-states-2018 (accessed on 10 December 2020).

Beine, M., F. Docquier and H. Rapopor (2008) ‘Brain Drain and Human Capital Formation in Developing Countries: Winners and Losers’, The Economic Journal , 118, pp. 631–652, http://econweb.umd.edu/~Lafortune/puc-readings/Beine_Docquier_Rapoport_2008.pdf (accessed on 10 January 2021).

Brush B.L. and J. Sochalski (2007) ‘International Nurse Migration’, Policy Politics Nursing Practice , 8(1), pp. 37–46, DOI:10.1177/1527154407301393

Buchan, J. (2020) COVID-19 and the International Supply of Nurses (Geneva: International Council of Nurses), https://www.icn.ch/system/files/documents/2020-07/COVID19_internationalsupplyofnurses_Report_FINAL.pdf (accessed on 9 August 2020).

Buchan J. (2006) ‘The Impact of Global Nursing Migration on Health Services Delivery’, Policy Politics Nursing Practice , 7(3), pp. 16S–25S, DOI: 10.1177/1527154406291520

Buchan, J. and L. Calman (2004) The Global Shortage of Registered Nurses: An Overview of Issues and Actions (Geneva: International Council of Nurses), https://www.researchgate.net/publication/241448495_The_Global_Shortage_of_Registered_Nurses_AnOverview_of_Issues_and_Actions (accessed on 7 June 2021).

Camlin, C.S., R.C. Snow and V. Hosegood (2014) ‘Gendered Patterns of Migration in Rural South Africa’, Population, Space and Place , 20(6), pp. 528–551, DOI:  10.1002/psp.1794

Cheng, W. (2020) ‘Locsin Says Nurses with Existing Contract Abroad May Now Leave’, ABS-CBN News , April 13, https://news.abs-cbn.com/overseas/04/13/20/nurses-with-contracts-abroad-exempted-from-poea-ban-due-to-coronavirus-covid19-luzon-lockdown (accessed on 15 July 2020).

Choy, C.C. (2003) Empire of Care: Nursing and Migration in Filipino American History (Durham, NC: Duke University Press).

CNN Philippines (2020) ‘WHO Works with PH on “Worrisome” COVID-19 Infection Rate of Frontliners’, CNN Philippines, 22 April, https://www.cnn.ph/news/2020/4/22/COVID-19-frontliners-healthcare-workers-coronavirus.html (accessed on 15 July 2020).

Corcega, T.T., et al. (2002) ‘Nurse supply and demand in the Philippines’, The UP Manila Journal, 5(1), pp. 1–7.

Cortez, G.M. (2020) ‘Public-Hospital Staffing Could Be Universal Health Care’s Biggest Hurdle’, Business World , 23 January, https:// www.bworldonline.com/public-hospital-staffing-could-be-universal-health-cares-biggest-hurdle/ (accessed on 29 March 2021).

Dabu, F. (2019) ‘Flight as Fight for Survival’, UP Forum , 28 May, https://up.edu.ph/flight-as-fight-for-survival/ (accessed 20 May 2020).

de Castro, A., C.G. Gilbert and D.T. Takeuchi (2008) ‘Workplace Discrimination and Health Among Filipinos in the United States’, American Journal of Public Health , 98(3), pp. 520–526, DOI: 10.2105/AJPH.2007.110163

Department of Budget and Management (Philippines) (2020) Budget Circular No. 2020–4 , 17 July, https://www.dbm.gov.ph/wp-content/uploads/Issuances/2020/Budget-Circular/BUDGET-CIRCULAR-NO-2020-4.pdf (accessed on 29 March 2021).

de Vera, B.O. (2020) ‘Gov’t Nurses Get Pay Hike 18 Years Overdue’, Inquirer , 19 July, https://newsinfo.inquirer.net/1308840/govt-nurses-get-pay-hike-18-years-overdue?cv=1 (accessed on 11 August 2020).

DOH (Department of Health, Philippines) (2020) Mind Your Mental Health , press release, 9 June,  https://doh.gov.ph/press-release/DOH:-MIND-YOUR-MENTAL-HEALTH;-HEALTH-ORGANIZATIONS-OFFER-REMOTE-CARE-SERVICES (accessed on 10 August 2020).

Dussault G., J. Buchan and I. Craveiro (2016) Migration of Nurses and Doctors in the EU and the European Free Trade Association’, in A. Triandafyllidou and I. Isaakyan (eds.) High-Skill Migration and Recession. Migration, Diasporas and Citizenship (London: Palgrave Macmillan), pp. 103–123, DOI: 10.1057/9781137467119_5

Duterte, R.R. (2020) ‘Fifth State of the Nation Address’, Official Gazette of the Republic of the Philippines , 27 July, https://www.officialgazette.gov.ph/2020/07/27/rodrigo-roa-duterte-fifth-state-of-the-nation-address-july-27-2020/ (accessed on 29 March 2021).

Efendi, F., T. Mackey, H. Mei-Chih and C. Chen (2017) ‘IJEPA: Gray Area for Health Policy and International Nurse Migration’, Nursing Ethics , 24, pp. 313–328, DOI: 10.1177/0969733015602052

Focus Economics (2021) ‘Philippines: Remittances Drop for the First Time in Four Months in December’, Focus Economics, 14 February, https://www.focus-economics.com/countries/philippines/news/remittances/remittances-drop-for-the-first-time-in-four-months-in (accessed on 5 January 2021).

Gee, G.C., J. Chen, M.S. Spencer, S. See, O.A. Kuester, D. Tran and D. Takeuchi (2006) ‘Social Support as a Buffer for Perceived Unfair Treatment Among Filipino Americans: Differences Between San Francisco and Honolulu’,  American Journal for Public Health , 96(4), pp. 677–684, DOI: 10.2105/AJPH.2004.060442

Hallare, K. (2020) ‘Medical Frontliners to Gov’t: “Time-out,” Revert Mega Manila back to ECQ’, Newsinfo , 1 August, https://newsinfo.inquirer.net/1315204/medical-frontliners-to-govt-time-out-revert-metro-manila-back-to-ecq (accessed on 30 March 2021).

Hart, D.M. (2006) ‘From Brain Drain to Mutual Gain: Sharing the Benefits of High-Skill Migration’, Issues in Science and Technology , 23(1), pp. 1–8, https://davidhart.gmu.edu/pdfs/publications/articles_essays_reports/HartIssuesFall2006.pdf (accessed on 20 March 2021).

Hohn, M., J. Lowry, J. Fernández-Pena and J. Witte (2016) Immigrants in Health Care: Keeping Americans Healthy Through Care and Innovation (Fairfax, VA: Institute for Immigration Research, George Mason University), https://s3.amazonaws.com/chssweb/documents/22231/original/health_care_report_FINAL_20160629.pdf?1467209316 (accessed 10 August 2020).

House of Representatives (Philippines) (2020a) House Bill 7281: An Act Amending Certain Sections of Republic Act 9173 Otherwise Known as the Philippine Nursing Act of 2002, Providing for an Advanced Nursing Education Program , 5 August, https://www.congress.gov.ph/legisdocs/basic_18/HB07281.pdf (accessed on 15 September 2020).

House of Representatives (Philippines) (2020b) House Bill 6817: COVID-19 Related Anti-Discrimination Act , 6 June, https://www.congress.gov.ph/legisdocs/third_18/HBT6817.pdf (accessed on 15 September 2020).

House of the Senate (Philippines) (2019) Senate Bill 395: An Act Amending Certain Sections of Republic Act 9173 Otherwise Known as the Philippine Nursing Act of 2002, Providing for an Advanced Nursing Education Program , 11 July, http://legacy.senate.gov.ph/lis/bill_res.aspx?congress=18&q=SBN-395 (accessed on 15 September 2020).

ILO (International Labour Organization) (2020) Managing Work-related Psychosocial Risks During the COVID-19 Pandemic (Geneva: ILO), https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---safework/documents/instructionalmaterial/wcms_748638.pdf (accessed on 30 March 2021).

ILO (2016) Decent Work (Geneva: ILO), http://www.ilo.org/global/topics/decent-work/lang--en/index.htm (accessed on 1 December 2016).

ILO (2009) Protecting the Rights of Migrant Workers: A Shared Responsibility (Geneva: ILO), https://www.ilo.org/global/topics/labour-migration/publications/WCMS_180060/lang--en/index.htm (accessed on 7 June 2021).

Joint Learning Initiative (2004) Human Resources for Health: Overcoming the Crisis (Boston: Harvard Global Equity Initiative), https://www.who.int/hrh/documents/JLi_hrh_report.pdf (accessed on 29 March 2021).

Kisely S., N. Warren, L. McMahon, C. Dalais, I. Henry and D. Siskind (2020) ‘Occurrence, Prevention, and Management of the Psychological Effects of Emerging Virus Outbreaks on Healthcare Workers: Rapid Review and Meta-analysis’, British Medical Journal , 369, DOI:  10.1136/bmj.m1642  

Li, H., J. Li and W. Nie (2014) ‘The Benefits and Caveats of International Nurse Migration’, International Journal of Nursing Sciences , 1(3), pp. 314–317, DOI: 10.1016/j.ijnss.2014.07.006

Lopez, D. and C. Jiao (2020) ‘Supplier of World’s Nurses Struggles to Fight Virus at Home’, Bloomberg , 24 April, https://www.bloomberg.com/news/articles/2020-04-23/philippines-sends-nurses-around-the-world-but-lacks-them-at-home (accessed on 30 March 2021).

Lorenzo F.M., J. Galvez-Tan, K. Icamina and L. Javier (2007) ‘Nurse Migration from a Source Country Perspective: Philippine Country Case Study’, Health Services Research , 42(3 Pt 2), pp. 1406–1418, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955369/ (accessed on 25 August 2020).

Mackey, T.K. and B.A. Liang (2012) ‘Rebalancing Brain Drain: Exploring Resource Reallocation to Address Health Worker Migration and Promote Global Health’, Health Policy , 107(1), pp. 66–73, DOI: 10.1016/j.healthpol.2012.04.006

Malig, K. (2020) ‘Only 40% of Registered Nurses Work in the Philippines; Org Calls for Mass Hiring’, GMA News Online , 12 May, https://www.gmanetwork.com/news/news/nation/737958/only-40-of-registered-nurses-work-in-the-philippines-org-calls-for-mass-hiring/story/ (accessed on 10 October 2020).

Martin, N. and B. Yeung (2020) ‘“Similar to Times of War”: The Staggering Toll of COVID-19 on Filipino Health Care Workers’, ProPublica , 3 May, https://www.propublica.org/article/similar-to-times-of-war-the-staggering-toll-of-covid-19-on-filipino-health-care-workers (accessed on 10 July 2020).

Maru, D. (2020) ‘As Coronavirus Rages, Metro Manila Private Hospitals Face Shortage of Staff, Medical Supplies’, ABS CBN News , 3 April, https://news.abs-cbn.com/news/04/03/20/as-coronavirus-rages-metro-manila-private-hospitals-face-shortage-of-staff-medical-supplies (accessed on 29 March 2021).

McFarling, U.L. (2020) ‘Nursing Ranks Are Filled with Filipino Americans. The Pandemic Is Taking an Outsized Toll on Them’, Statnews , 28 April, https://www.statnews.com/2020/04/28/coronavirus-taking-outsized-toll-on-filipino-american-nurses/ (accessed on 15 July 2020).

McGannon, C. (2020) ‘Coping with COVID-19: How Filipino Nurses and Their Communities Support Frontline Healthcare Workers’, Asianmedia , 16 July, https://asiamedia.lmu.edu/2020/07/16/coping-with-covid-19-how-filipino-nurses-and-their-communities-support-frontline-healthcare-workers/ (accessed on 17 July 2020).

McLaughlin, T. (2020) ‘The Fragility of the Global Nurse Supply Chain,’ The Atlantic , 30 April, https://www.theatlantic.com/international/archive/2020/04/immigrant-nurse-health-care-coronavirus-pandemic/610873/ (accessed on 20 August 2020).

Morales, N. (2020), 'Losing battle: Philippine doctors, nurses urge new COVID-19 lockdowns as infections surge,’ Reuters , 1 August, https://www.reuters.com/article/us-health-coronarvirus-philippines-idUSKCN24X3IA (accessed 15 July 2020).

Ortiga, Y.Y. (2017) ‘The Flexible University: Neoliberal Education and the Global Production of Migrant Labor’, British Journal of Sociology of Education , 38(4), pp. 485–499, DOI: 10.1080/01425692.2015.1113857

Pang, T., M.A. Lansang and A. Haines (2002) ‘Brain Drain and Health Professionals’, British Medical Journal , 324(499), DOI: 10.1136/bmj.324.7336.499

Parrocha, A. (2020) ‘PRRD Heeds Front-Liners’ Call’, Philippine News Agency , 3 August, https://www.pna.gov.ph/articles/1110889 (accessed on 15 September 2020).

POEA (Philippine Overseas Employment Administration) (2020) Governing Board Resolution No. 9 Series of 2020 (Mandaluyong City: POEA), https://www.poea.gov.ph/gbr/2020/GBR-09-2020.pdf (accessed on 2 July 2020).

POEA (2014) Annual Report (Mandaluyong City: POEA), https://www.poea.gov.ph/annualreports/annualreports.html (accessed on 29 March 2021).

PSA (Philippine Statistics Authority) (2016) Census of Population 2015 , Public-Use File (Quezon City: Philippines).

PSA and UPPI (University of the Philippines Population Institute) (2019) 2018 National Migration Survey , https://psa.gov.ph/content/national-migration-survey (accessed on 30 March 2021).

Republic of the Philippines (2010) Republic Act No. 10022: An Act Amending Republic Act No. 8042, Otherwise Known as the Migrant Workers and Overseas Filipinos Act of 1995 , Section 5, 10 March, https://www.officialgazette.gov.ph/2010/03/10/republic-act-no-10022-s-2010/#:~:text=%E2%80%93%20Notwithstanding%20the%20provisions%20of%20Section,the%20deployment%20of%20migrant%20workers.%E2%80%9D (accessed on 10 May 2020).

Santos, A.P. (2020) ‘Attacked & Underpaid: Medics in Philippines Battle Stigma, Virus’, Al Jazeera , 2 April, https://www.aljazeera.com/news/2020/4/2/attacked-underpaid-medics-in-philippines-battle-stigma-virus (accessed on 10 August 2020).

Smiley, S. (2020) ‘Developed Countries are the Largest Importers of Healthcare Professionals’, Global Trade Mag , 4 May, https://www.globaltrademag.com/developed-countries-are-the-largest-importers-of-healthcare-professionals/ (accessed on 11 August 2020).

Thoun Northrup, D., C.L. Tschanz, V.G. Olynyk, K.L. Schick Makaroff, J. Szabo and H.A. Biasio (2004) ‘Nursing: Whose Discipline is it Anyway?’, Nursing Science Quarterly ,17, pp. 55–62, DOI: 10.1177/0894318403260471

Tomacruz, S. (2020) ‘PH Health Workers Infected with Coronavirus Reach 5,008’, Rappler , 3 August, https://www.rappler.com/nation/health-workers-coronavirus-cases-philippines-august-3-2020 (accessed on 10 December 2020).

UNCESCR (United Nations Committee on Economic, Social and Cultural Rights) (2006)  General Comment No. 18: The Right to Work (Art. 6 of the Covenant) , 6 February, E/C.12/GC/18.

UN DESA (United Nations Department of Economic and Social Affairs), Population Division (2020) SDG indicator 10.7. 2: Data Booklet (ST/ESA/ SER. A/441) https://www.un.org/en/development/desa/population/publications/pdf/sdg/SDG_10.7.2_2019_Data%20Booklet.pdf (accessed on 20 August 2020).

UNGA (United Nations General Assembly) (1966) International Covenant on Economic, Social and Cultural Rights, International Covenant on Civil and Political Rights and Optional Protocol to the International Covenant on Civil and Political Rights , 16 December, A/RES/2200.

UNOSD (United Nations Office for Sustainable Development) (2015) Sustainable Development Goals (SDGs) , https://unosd.un.org/content/sustainable-development-goals-sdgs (accessed on 20 August 2020).

UP COVID-19 Pandemic Response Team (2020) Estimating Local Healthcare Capacity to Deal with COVID-19 Case Surge: Analysis and Recommendations , University of the Philippines Research and Breakthroughs, 20 April, https://up.edu.ph/estimating-local-healthcare-capacity-to-deal-with-covid-19-case-surge-analysis-and-recommendations/ (accessed on 7 June 2021).

UPPI and DRDF (Demographic Research and Development Foundation, Inc.) (2020) Human Resource for Health in the Time of the COVID-19 Pandemic: Does the Philippines Have Enough? , UPPI/DRDF Research Brief No. 8, https://www.uppi.upd.edu.ph/sites/default/files/pdf/COVID-19-Research-Brief-08.pdf (accessed on 7 June 2021).

WHO (World Health Organization) (2020a) Global Strategic Directions for Strengthening Nursing and Midwifery, 2016–2020 (Geneva: WHO), pp. 1–56, https://www.who.int/hrh/nursing_midwifery/global-strategic-midwifery2016-2020.pdf (accessed on 15 October 2020).

WHO (2020b) State of the World’s Nursing – 2020 (Geneva: WHO), https://www.who.int/publications-detail-redirect/9789240003279 (accessed on 30 July 2020).

WHO (2020c) A Guide to Preventing and Addressing Social Stigma (Geneva: WHO), https://www.who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf (accessed on 30 July 2020).

WHO (2019a) National Health Workforce Accounts: Better Data and Evidence on Health Workforce (Geneva: WHO), https://www.who.int/publications/i/item/national-health-workforce-accounts (accessed on 15 October 2020).

WHO (2019b) Delivered by Women, Led by Men: A Gender and Equity Analysis of the Global Health and Social Workforce , Human Resources for Health Observer Series No. 24 (Geneva: WHO), https://apps.who.int/iris/bitstream/handle/10665/311322/9789241515467-eng.pdf?ua=1 (accessed on 15 October 2020).

WHO (2011) Strengthening Nursing and Midwifery , Sixty Fourth World Assembly, Agenda Item 13.4, 24 May, WHA 64.7.

WHO (2010) WHO Global Code of Practice on the International Recruitment of Health Personnel (Geneva: WHO), http://www.who.int/hrh/migration/code/practice/en/ (accessed on 19 July 2020).

WHO (‎2006)‎ The World Health Report: 2006: Working Together for Health (Geneva: WHO),  https://apps.who.int/iris/handle/10665/43432 (accessed on 19 July 2020).

Xu, Y. and J. Zhang (2005) ‘One Size Doesn’t Fit All: Ethics of International Nurse Recruitment from the Conceptual Framework of Stakeholder Interests’, Nursing Ethics , 12(6), pp. 571–581, DOI: 10.1191/0969733005ne827oa

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Jenny Lind Elmaco , “ Philippine Nurse Migration: Assessing Vulnerabilities and Accessing Opportunities during the COVID-19 Pandemic ” ,  International Development Policy | Revue internationale de politique de développement [Online], 14 | 2022, Online since 25 April 2022 , connection on 25 October 2024 . URL : http://journals.openedition.org/poldev/4853; DOI : https://doi.org/10.4000/poldev.4853

About the author

Jenny lind elmaco.

Jenny Lind Elmaco is the Regional Coordinator in Asia for EURAXESS, a European Commission research platform. She is Vice Chair for Asia Pacific of the Global Women Inventors and Innovators Network and a University Fellow at Wesleyan University. She has been academically connected with Royal Roads University in Canada, Complutense University of Madrid, the University of Muenster, Vienna School of Business and Economics and the University of Ljubljana. Her research interests include science diplomacy, peace and security, gender and diversity, international affairs, governance, and sustainable development.

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From US Reign to Brain Drain: The Mass Emigration of Filipino Nurses to the United States

After four centuries of colonization , the Philippines, influenced by Spanish, US, and Japanese rule, continues to feel the lasting impact of US colonial practices. This legacy is particularly evident in the emigration and export of Filipino nurses. Despite the Philippines gaining full independence in 1946, the United States continues to drain the country of its resources.  The incentivization and employment of Filipino healthcare professionals to fill staffing gaps in the US healthcare system, especially during crises, facilitates their mass emigration.

Colonial History Behind Filipino Nurse Migration

In 1898, the United States acquired the Philippines from Spain through the Treaty of Paris concluding the Spanish-American War. US President William McKinley wanted to garner support from the Filipino population and facilitate a smooth transfer of authority. To accomplish this goal, he characterized the colonization of the Philippines as a “ benevolent assimilation ,” pledging the protection of individual rights and freedoms throughout the transition of power.

McKinley declared in an executive order on December 21, 1898: “It will be the duty of the commander of the forces of occupation to announce and proclaim in the most public manner that we come, not as invaders or conquerors, but as friends, to protect the natives in their homes, in their employments, and in their personal and religious rights.” To initiate the process of “benevolent assimilation,” the US government dispatched US educators known as the Thomasites to the Philippines to integrate Filipinos into US culture and cultivate a new generation of followers who embraced US ideals and values.

Under this system , Filipinos were taught to speak English fluently, adopt US culture, and ultimately aspire to the American Dream. As University of California, Berkeley professor Catherine Ceniza Choy describes it, “[There were] American colonial officials going to the Philippines and exposing the Filipinos to American culture, to the English language, to Americanized education. And this kind of training influenced so many different groups of Filipinos to dream about the US and to desire to migrate there.”

In 1903, US President William Howard Taft enacted the Pensionado Act , creating a scholarship program enabling qualified Filipinos, known as pensionados , to pursue education and training in the United States. Focused on government and administration degrees, the act aimed to develop future Filipino leaders with knowledge of the US government system. The intention was for them to implement similar practices upon their return, shaping the Philippines’ government and institutions in alignment with US ideals.

Among the pensionados were some of the earliest Filipino nursing students. Upon returning to their home country, pensionado nurses played a crucial role in founding 17 nursing schools in the Philippines between 1903 and 1940. Meanwhile, those who stayed in the United States formed the Philippine Nurses Association in 1922 whose mission statement was: “Championing the global competence, welfare, and positive and professional image of the Filipino nurse.” The Pensionado Act, the largest US scholarship program until the Fulbright Program in 1948, concluded in 1943, just three years before the Philippines gained independence.

Enduring Impacts of Colonial Mentality

On July 4, 1946, the United States acknowledged the Philippines as an independent and sovereign nation, relinquishing its role as the colonizer and withdrawing its authority over the archipelago. Despite this transition, the United States continues to rely on the Philippines to address its medical staffing shortages.

In 1948—about four decades after the Pensionado Act and two years after the Philippines attained its freedom—the United States introduced the Exchange Visitor Program (EVP). This program invited individuals from foreign countries to temporarily study and gain work experience in the United States. Participants were granted admission as nonimmigrant visitors for business under the Immigration Act of 1924. The EVP was implemented to fight Soviet propaganda during the Cold War and spread US democratic ideals.

At the same time, the United States was experiencing a medical shortage after World War II. Numerous nurses left their jobs due to lower wages and harmful working conditions. Rather than addressing the root causes of the problem—such as increasing pay and improving working conditions to encourage people to return to work—the United States sought to fill the void by looking beyond its borders, turning to the Philippines to bridge the gap. This approach reflected the historical framework of “benevolent assimilation” from the early years of US occupation in the Philippines. The system trained Filipino nurses in an Americanized curriculum, creating a direct pathway for their education and migration to the United States.

The EVP was followed by amendments to the Immigration and Nationality Act (INA) in 1965. This landmark legislation eliminated the National Origins Quota System, which had served as the cornerstone of US immigration policy since the 1920s. More specifically, the INA of 1965 terminated a discriminatory immigration policy towards Asia and other regions, instituting a preference system that prioritized the entry of individuals with high educational qualifications and essential skills. These amendments appealed to Filipino nurses as they provided an opportunity to adjust nurses’ immigration status and seek permanent residency in the United States. Simultaneously, the United States experienced a heightened demand for healthcare workers due to the implementation of Medicare and Medicaid under the Social Security Amendments of 1965; for example, after coverage began in 1966, 19 million Americans enrolled in Medicare alone.

US immigration policies and sociopolitical conditions motivated an increased number of Filipinos to pursue careers in nursing. In just five years, the number of Filipino nurses in the Philippines grew by an astounding 700 percent, from 7,000 in 1948 to 57,000 in 1953. The surge continued, with the number of nursing schools in the Philippines increasing from 17 in 1940 to 429 in 2005 and reaching 1,282 as of September 24, 2023. Since 1960, over 150,000 Filipino nurses have immigrated to the United States. A 2021 study revealed that registered nurses (RNs) trained in the Philippines constitute one out of 20 RNs in the United States, maintaining their status as the largest group of foreign-trained nurses to date. As of 2022, Filipino nurses constituted 33 percent of all foreign-born RNs—and, as of 2021, four percent of all RNs—in the United States. The Philippines is the largest exporter of nurses worldwide.

Domestic Struggles in the Philippines in the Wake of Nurses’ Emigration

Due to the mass exodus of Filipino nurses both to other countries and from the profession within the Philippines, the country currently faces a shortage of nurses, undermining the quality of healthcare within the country. According to a 2023 study , 200,000 to 250,000 Filipino nurses have left the profession in the Philippines due to burnout, low pay, overextension, and job precarity. A 2021 estimate revealed that 51 percent of licensed Filipino nurses (about 316,000 nurses) had left the Philippines to work in foreign countries. The Philippines now faces a shortage of 127,000 nurses, which is expected to increase to 250,000 by 2030. In response, the Philippines has even lowered professional standards, allowing over 300 nursing graduates without licenses to be hired as nurses.

The United States is not the only country responsible for the mass emigration of Filipino nurses. The Philippines is also complicit in the United States’ continued pull on the nation’s labor export. Filipino nurses are caught in the crossfire between the United States and the Philippines due to various push and pull factors. On one hand, the United States pulls Filipino nurses to address its medical shortage. On the other hand, the Philippines actively pushes workers away due to poor working conditions and lower quality of life. Furthermore, the Philippine government actively promotes the export of Filipino workers globally for economic gains.

In the 1960s, when the United States carried out immigration policies and underwent important cultural developments, the Philippines experienced hardships under the dictatorial rule of former president Ferdinand Marcos . In September of 1972, Marcos proclaimed martial law to combat the growing chaos stemming from violent student demonstrations, perceived threats of communist insurgency by the new Communist Party of the Philippines, and the Muslim separatist movement of the Moro National Liberation Front. Under the Marcos regime , human rights violations and corruption were rampant. More notably, under Marcos’ rule, unemployment was exacerbated and poverty endured , which prompted many Filipinos to seek jobs overseas. In response, Marcos devised the Labor Export Policy in 1974 to tackle the economic struggles the Philippines faced. The initiative sought to address unemployment within the educated sector by providing opportunities for overseas employment, which in turn generated foreign currency revenues through remittances sent back by Filipinos working abroad.

Since the 1950s, money sent back home by nurses employed overseas has played a substantial role in the Philippine economy. According to the advocacy group Filipino Nurses United, about one-third of the over 900,000 registered nurses in the Philippines were working abroad as of 2021. The remittances from nurses contribute roughly US$8 billion annually to the economy, making up approximately 25 percent of all remittances. Collectively, these remittances account for around nine percent of the country’s gross domestic product.

Filipino nurses were significantly affected by US imperialism and misgovernment under Marcos’ dictatorship. During the period of US occupation, Filipino nurses were trained to work in the United States. After the Philippines gained independence, the United States continued to depend on the Philippines to address medical staffing shortages. Domestically, the Philippines’ promotion of overseas labor, coupled with challenging living conditions, has fueled an increase in Filipino nurses emigrating to the United States. The continued mass exodus of Filipino nurses underscores the need for a comprehensive examination of the factors contributing to this brain drain and a collaborative effort to address the associated challenges.

Laurinne Jamie Eugenio

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Home — Essay Samples — Life — Working Abroad — Unravelling Filipino Nurses Aspiration for Working Abroad

Unravelling Filipino Nurses Aspiration for Working Abroad

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Financial, Professional and Personal Reasons for Working Abroad

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The Heart of Working Abroad as a Filipino Nurse and Carer: Belonging in a Community

For many Filipino nurses and carers, the decision to work abroad is driven by a combination of professional ambition, economic necessity, and the desire to provide better opportunities for their families. However, beyond these motivations lies a deeper, more intrinsic need: the yearning for community and a sense of belonging.

A Tradition of Care and Compassion

Nursing is deeply embedded in Filipino culture, where care and compassion are integral values. This cultural trait makes Filipino carers and nurses highly sought after worldwide. They are known not only for their clinical skills but also for their ability to connect with patients on a personal level. This unique blend of professional competence and emotional intelligence helps them integrate into diverse healthcare settings across the globe.

The Challenge of Isolation

Despite their professional success, many Filipino nurses face significant challenges when they first move abroad. The initial period of adjustment can be daunting. Isolation from family and familiar cultural surroundings can lead to feelings of loneliness and homesickness. This emotional toll is often compounded by the pressures of adapting to new work environments, navigating different healthcare systems, and overcoming language barriers.

Building a New Community

For Filipino nurses and carers, the sense of belonging often begins with finding and building a new community. Filipino associations and organizations play a crucial role in this regard. These groups provide a support network that helps newcomers navigate their new environment, offering everything from practical advice on daily living to emotional support and cultural activities.

Cultural Celebrations and Gatherings

Regular cultural celebrations and gatherings are a staple within Filipino communities abroad. Events such as the celebration of Philippine Independence Day, Summer Festivals, Christmas parties, and local festivities offer Filipino nurses a chance to reconnect with their heritage and share it with their peers. These occasions foster a sense of unity and pride, making the distance from home feel a little shorter.

Professional Networks

Professional networks also contribute significantly to the sense of community. Filipino nurses often form bonds with colleagues who share similar experiences and challenges. These networks provide opportunities for mentorship, career advancement, and collaborative learning. By connecting with other Filipino nurses, they create a support system that extends beyond the workplace, enriching their personal and professional lives.

The Filipino UK Nurses Community

Recognizing the profound need for a supportive community, Manong George and his friends founded the Filipino UK Nurses Community. Their goal was to create a platform where Filipino nurses in the UK could find the support and companionship they needed. They wanted to build a network that would offer practical assistance, emotional support, and a sense of belonging to every Filipino nurse who joined. This community has become a cornerstone for many, helping to ease the transition to life in the UK and fostering a spirit of camaraderie and mutual aid.

Contributions to Host Communities

The sense of belonging is a two-way street. Filipino nurses not only seek community but also actively contribute to their host communities. Their dedication, hard work, and compassion often leave a lasting impact on the patients and colleagues they work with. Many Filipino nurses participate in volunteer work, community health outreach programs, and local initiatives, further embedding themselves in the social fabric of their adopted countries.

Embracing Diversity

Working abroad allows us to embrace and celebrate diversity. Exposure to different cultures, healthcare practices, and patient populations broadens their perspectives and enriches their professional experience. This cultural exchange fosters mutual respect and understanding, creating a more inclusive and harmonious work environment.

The Heart of Belonging

At its core, the experience of working abroad as a Filipino nurse is about finding and fostering a sense of belonging. It is about building connections that transcend geographical boundaries and cultural differences. Through their resilience, compassion, and dedication, Filipino nurses not only find their place in new communities but also create spaces where others can feel at home. It is not just about the professional journey but also about the personal and communal one. It is a testament to the strength of the human spirit and the enduring power of community.

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• Published: 31 March 2017

An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving—a mixed method study

• Erlinda Castro-Palaganas 1 ,
• Denise L. Spitzer 2 ,
• Maria Midea M. Kabamalan 3 ,
• Marian C. Sanchez 4 ,
• Ruel Caricativo 5 ,
• Vivien Runnels 6 ,
• Ronald Labonté 7 ,
• Gail Tomblin Murphy 8 &
• Ivy Lynn Bourgeault 9  

Human Resources for Health volume  15 , Article number:  25 ( 2017 ) Cite this article

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Dramatic increases in the migration of human resources for health (HRH) from developing countries like the Philippines can have consequences on the sustainability of health systems. In this paper, we trace the outflows of HRH from the Philippines, map out its key causes and consequences, and identify relevant policy responses.

This mixed method study employed a decentered, comparative approach that involved three phases: (a) a scoping review on health workers’ migration of relevant policy documents and academic literature on health workers’ migration from the Philippines; and primary data collection with (b) 37 key stakeholders and (c) household surveys with seven doctors, 329 nurses, 66 midwives, and 18 physical therapists.

Filipino health worker migration is best understood within the context of macro-, meso-, and micro-level factors that are situated within the political, economic, and historical/colonial legacy of the country. Underfunding of the health system and un- or underemployment were push factors for migration, as were concerns for security in the Philippines, the ability to practice to full scope or to have opportunities for career advancement. The migration of health workers has both negative and positive consequences for the Philippine health system and its health workers. Stakeholders focused on issues such as on brain drain, gain, and circulation, and on opportunities for knowledge and technology transfer. Concomitantly, migration has resulted in the loss of investment in human capital. The gap in the supply of health workers has affected the quality of care delivered, especially in rural areas. The opening of overseas opportunities has commercialized health education, compromised its quality, and stripped the country of skilled learning facilitators. The social cost of migration has affected émigrés and their families. At the household level, migration has engendered increased consumerism and materialism and fostered dependency on overseas remittances. Addressing these gaps requires time and resources. At the same time, migration is, however, seen by some as an opportunity for professional growth and enhancement, and as a window for drafting more effective national and inter-country policy responses to HRH mobility.

Conclusions

Unless socioeconomic conditions are improved and health professionals are provided with better incentives, staying in the Philippines will not be a viable option. The massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who cannot be absorbed by a system that is underfunded. This results in a paradox of underservice, especially in rural and remote areas, at the same time as underemployment and outmigration. Policy responses to this paradox have not yet been appropriately aligned to capture the multilayered and complex nature of these intersecting phenomena.

Peer Review reports

Human resources for health (HRH) are crucial to the achievement of health outcomes and the overall sustainability of health systems [ 1 ], and their migration from developing (low- and middle-income) to developed (high-income) countries has raised significant economic and ethical concerns. The Philippines, in common with many other “source” countries, suffers from a high burden of disease and an inequitable distribution of health workers, but has become a key source of health professionals who migrate to wealthier countries [ 2 , 3 ]. This paper presents the findings of a multi-year mixed method study of source country perspectives on the causes, consequences, and policy responses to the migration of HRH with specific reference to the Philippine context. It addresses one of four countries that participated in the larger study, which also included South Africa [ 4 ], Jamaica [ 5 ], and India [ 6 ], all known for their high rates of HRH migration. The following questions guided the research:

What are the recent historic trends and present situation of HRH migration from the Philippines?

What, according to the experience of those who remain, are the causes and consequences of the emigration of Filipino HRH?

What program and policy responses have been considered, proposed, and implemented by different stakeholders in the Philippines to address these consequences?

Brief overview of the Philippines context

This Philippine case study on HRH migration situated workforce mobility within the interactions of individual decision-making process and the wider structures of politics, economy, and history of the country. The Philippines is a lower middle-income country in Southeast Asia with a young population of more than 92 million. There are high levels of poverty in the country, with 26.5% of the population living below the poverty line. In the last quarter of the twentieth century, the Philippines, under direction of the International Monetary Fund and the World Bank, implemented a series of structural adjustment measures, modeled on neoliberal economics [ 7 ], to ensure the country could repay its foreign debts, largely incurred under the Marcos regime [ 8 ]. These conditionalities included inter alia reducing spending in health and social sectors, devaluing the currency, and hastening the privatization of public resources, which contributed to increased poverty and economic instability [ 9 , 10 ]. These policies were continued under the Aquino government and included the automatic appropriation from the annual government budget of the full amount needed for debt servicing [ 9 ].

With a median age of 23, the Philippines is a country of young people. Currently, the country is contending with a large number of unemployed and underemployed—an estimated 4.5 and 7.3 million respectively [ 11 ]. Over one quarter of the labor force is unemployed or looking for more work [ 12 ]. Large numbers of Filipinos, including some of the country’s most educated, are compelled to go abroad to find employment [ 12 ]. The Philippines is the second largest exporter of human labor in the world, and health care professionals are one of the biggest groups of migrant labor for the country. The Philippine Overseas Employment Administration (POEA), which facilitates outmigration, reported that 1.8 million Filipinos left the country for work in 2013 [ 13 ].

The national health system

The Philippines Health Care System, described as decentralized, is organized at three different levels—national, provincial, and local. While health care in the Philippines is provided by both public and private sectors, the total contribution allocated to the public sector has decreased for the past decade. Only 36.1% of the health expenditure is paid by the government; the private sector contributes 65.3% of the total health expenditure, and 83.8% of that private health care expenditure is paid out of pocket. Between 2009 and 2011, government spending on health care averaged 4.3% of GDP, lower than a cited, though never formally adopted, World Health Organization’s (WHO) suggested standard of 5%, illustrating that the country’s healthcare system is underfunded [ 14 ]. Per capita health expenditure (at constant 2000 prices) in the country is PHP 2639 or around Php 7 per day, approximately 15 cents USD [ 14 ].

Conceptual framework

Labor migration has widely been viewed as determined by a combination of demographic, socio-cultural, political, and economic factors interacting across macro-, meso-, and micro-levels. Micro-level issues include HRH migrants’ perceptions of their personal and household context in shaping their decision to work overseas. Meso-level phenomena include organizational settings such as workload, working conditions, and career opportunities relative to different health professions, in destination and source countries. These issues are influenced by macro-level phenomena—the myriad political, economic, and social factors at global and national levels including policies and recruitment strategies. Each of these levels intersect with the causes, consequences, and policy responses examined.

The study employed a decentered mixed method comparative approach [ 15 ], comprising scoping reviews of the literature on health worker migration, surveys of health workers, and interviews with key stakeholders. Researchers in Canada (revealed after review) coordinating the four country studies collaborated with researchers in the Philippines (revealed after review) in undertaking the Philippines component in a way that enhanced comparability. Approval to conduct the study (both survey and interviews) was received from the (revealed after review) Research Ethics Board and from the ethics boards of the (revealed after review).

Scoping review

The scoping review of the literature followed the process developed by Arksey and O’Malley [ 16 ], using the MeSH terms “migration”, “health professionals”, “health worker migration”, “brain drain”, “brain gain”, “return migration”, “health worker exodus”, and “Philippines” in a search of Medline, PubMed, and Embase databases [ 16 ]. Sources were included if they addressed the Philippines and were published between 2000 and 2012. This was augmented with in country literature searching in seven university and three organizational libraries. We also searched the gray literature using key public and private stakeholder organizational websites resulting in 20 policy documents. The international research team developed a literature extraction tool to systematically record pertinent aspects of the literature. The literature was analyzed and summarized descriptively, and a preliminary report shared and revised with the Philippines-based research team members.

Stakeholder interviews

Interviews were conducted with key stakeholders including, but not limited to, professional educators, health profession regulators, national government agency officials who dealt with immigration and HRH, and representatives of local government authorities, private and public sector health facilities, recruitment agencies, migrant advocacy organizations, and professional associations and councils (Table  1 ). Participants were selected using three criteria: (i) their organization’s active role in social determinants of health and migration-related issues; (ii) their position within the organization (sufficiently senior to speak to the issues); and (iii) their experience related to the research questions we were exploring. The interview guide included a common set of questions asked of all stakeholders, but specific probes were developed to enable targeted data collection.

A total of 36 interviews, averaging 45–60 min, were conducted between February 2012 and September 2013. All interviews were digitally recorded, after seeking consent, and transcribed. These data were analyzed simultaneously via systematic, documented procedures of thematic and constant comparative analysis using N-Vivo® 9 software following an initial comparative coding structure that was developed by members of the Canadian team and embellished with emergent codes derived from the Philippines team. This involved an iterative process producing a multifaceted description of the context, policy environment, and experiences of the migration of health care professionals.

Building on a common template designed by the international team, two questionnaires were developed involving two modes of data collection—an online version ( n =  202) and a face-to-face household survey ( n =  420) administered in Metro Manila and Metro Cebu, the major centers of health services in the Philippines where the chances of reaching respondents who graduated with a health degree would be higher (Table  2 ). Questions were pre-tested to ensure they could be clearly understood. Both surveys targeted respondents who studied to be physicians, nurses, midwives, and physical/occupational therapists. This paper focuses solely on results of the face-to-face survey. While patterns are generally similar for the face-to-face and online surveys, some are different which necessitates further examination beyond the scope of this overview paper.

Sampling for the face-to-face household survey used the “30 × 7” cluster sampling technique. Within each of the two metro areas, 30 barangays (villages) were selected with probability proportional to the size of population and seven (7) households were chosen for each selected barangay using the WHO simplified cluster sampling for the Expanded Programme on Immunization (EPI) [ 17 ]. All household members who completed formal education or training to become a doctor, a nurse, a midwife, or a physical therapist and who were not necessarily working as health professionals were interviewed. To ensure standardization, interviewers read and recorded responses on the survey instrument. Surveys averaged 60–90 min and were conducted in a time and place deemed appropriate by the respondents. Response rate for the face-to-face household survey was 91%. Data were encoded using CSPro. Data cleaning (for odd codes and consistency) and descriptive analysis using frequency and cross-tabulations were done using SPSS21.

Reflecting the general distribution of health professionals in the country, 78% of the survey respondents are nurses, 16% are midwives, 4% are physical/occupational therapists, and 2% are physicians. Notably, the face-to-face survey is a reflective of perspectives found in Metro Manila and Cebu and may not be representative of the Philippines as a whole.

Historic trends and the present picture of HRH migration

The Philippines has been engaged in labor export since the early twentieth century when its colonial rulers, the USA, facilitated the outmigration of agricultural workers to Hawaii and the US mainland [ 18 ] and afforded Filipino workers access to the American labor market. Before nursing education was well established in the Philippines in the 1920s–1930s, many Filipino nurses trained in the USA, returning to take up well-respected hospital positions and cementing the notion that going overseas was a pathway to prosperity [ 18 ]. In 1974, President Marcos issued Presidential Decree 442 to promote labor export, which led to the development of government agencies dedicated to facilitating outmigration and overseas remittances [ 18 , 19 ]. The promulgation of labor export policies and programs expanded under the auspices of subsequent Filipino leaders [ 18 ]. By the twenty-first century, remittances had become a major source of foreign exchange and constituted a significant part of the Philippine economy—amounting to more than 17% of GDP [ 19 , 20 ]. Between one third and one half of the Philippine population is dependent on remittances to sustain themselves [ 21 ].

Thirty years ago, physicians comprised the major group of health professionals leaving the country. In recent years, however, female health care providers, particularly nurses, have become the dominant migrant group [ 22 ]. Annually, 17,000 to 22,000 health professionals leave the Philippines to work abroad [ 23 ], most of them nurses who represented 29% of the total number of migrant HRH from 1993 to 2010. In 1998, almost 85% of all nurses were employed overseas compared to only 15% employed in the country [ 24 ]. Between 2008 and 2012, 90,382 nurses went to Saudi Arabia, while 15,701 migrated to the UK and 14,895 to the USA [ 25 ]. Currently, Singapore and the United Arab Emirates have become major recipients of Filipino nursing personnel. International labor markets have continued to grow, marked by an increase in the number of hired nurses from 11,805 to 17,236 between 2010 and 2011.

Factors that influence migration

Micro-level factors.

Stakeholders said that perceptions and evaluations of the country’s situation relative to their personal and family context significantly influenced migration decisions. Survey responses indicated that the desire to migrate was widespread among all health professionals (24% of midwives, 29% of doctors, 51% of nurses, and 61% of PTs in the next 2 years) (Fig.  1 ). The top four preferred destination countries by survey respondents were the USA, Canada, Australia, and the UK. Among those who said that they contemplated working abroad, 90% indicated that they planned to work as health professionals in the country to which they intend to move.

Percentage of health professionals reporting “very likely” to migrate

In identifying why they wanted to become a health professional, three of the top six reasons cited by survey respondents, perhaps with the exception of physicians, related to the opportunities it provided them to work or migrate overseas (Fig.  2 ). As a government stakeholder elaborated, however, sometimes the eventual migration of health workers was unrelated to their profession, and instead linked to family members already working overseas:

Frequency of seeking migration information by source

A lot of those who leave, even though they are graduates of health-related courses, or might be health professionals in the Philippines, do not necessarily apply for visas abroad as workers. It’s just a consequence of them being part of an immigrant family. (Government stakeholder 11272012)

Stakeholders said that perceptions and evaluations of the country’s situation relative to their personal and family context significantly influenced migration decisions. There are also factors that keep some Filipino HRH from migrating overseas, including limited employment overseas, absence of family support, and potential abuse of migrant workers in their destination country. Retaining proximity to their families was also a strong influence on migration decision-making. “There are many stories now about the social cost of the separation of the family due to migration. Some choose not to migrate because they cannot imagine life separate from their family” (Government informant 03182013). Finally, love and passion for, and commitment to, one’s profession were among the reasons many stakeholders gave for staying in the country:

[It’s] because they love the community or [for those] working in the rural communities, providing health services to the community, [it’s] really out of love. (Government informant 11272012)

Meso-level factors

Some stakeholders pointed to local organizational settings, specifically dismal working conditions and limited employment or career opportunities, as major factors in migration decision-making.

Are there facilities for health? Are there plantilla Footnote 1 positions for health, for all these professionals, for them to engage not only in gainful employment but to practice their profession? (Government informant 07152013)

For a majority of survey respondents, job satisfaction was a crucial factor in migration decisions (Fig.  3 ). The level of satisfaction among different health worker groups is reasonably high for respect but is low for income and ambivalent with work benefits, workload, and infrastructure.

Level of job satisfaction in migration decision-making among survey respondents

Stakeholders noted how poor funding of the healthcare system, resulting in unemployment or underemployment, compelled many health workers to seek work overseas. Across health professions, career opportunities in the Philippines are also limited: “There are not enough training opportunities for doctors to specialize” (Government informant 07152013) and “nurses are not able to practice their profession because of the lack of positions in hospitals” (Recruitment agency informant 06112013). Some informants noted that an ongoing privatization of public health institutions has led to HRH job loss, compelling workers to seek opportunities overseas: “the government’s existing policy is to privatize [the health system]. And with privatization comes more push for migration” (Migrant advocacy group informant 01222013). Some stakeholders also noted that the country’s health education curriculum pushes health workers to migrate:

What is the content of your curriculum? Do you expose them to the hard realities of life, or do you limit them to tertiary hospitals? What kind of exposure do they get? Do they have exposure to public health? (Training institute informant 04052013)

Participants across stakeholder groups agreed that better salaries and working conditions entice Filipino HRH overseas.

The problem is, they have a low salary [here] and…you’ll be working for a lot of bosses since you work for the local government. You’ll be subjected to a lot of politics. (Migrant advocacy group informant 01222013).

Furthermore, one nurse leader noted that Filipino health workers are pulled towards overseas employment because of the quality of practice and the respect given to health professionals. Other important factors included opportunities for advanced professional learning and training overseas.

Finally, some health professionals also find that they cannot utilize their skills in the Philippines due to what are perceived as outdated practice guidelines. Midwifery regulations, for example, limit “the practice of midwifery only to low-risk deliveries [while] internationally, midwives can do other high-risk functions” (Training institute informant 08062013). As with other health professions, such practice scope limits may propel midwives to seek foreign employment where more of their training and knowledge can be deployed.

Macro-level factors

Our interviews demonstrated that migration and its causes are disputed phenomena. Participants from government agencies explain that labor movement is part of every citizen’s right to mobility. One stated that: “migration is the stepchild of globalization… we cannot prevent the professionals from going out” (Government informant 07152013).

Some stakeholders were optimistic that migration is a key to solving the country’s unemployment problem and oversupply of nurses. Some nursing leaders argued that migration is an opportunity for social mobility and for Filipino HRH to prove their capacity to “nurse the world.” There are respondents who view migration as a temporary outflow, a positive situation, which, when facilitated well, could lead to better things: “I think we should not stop (migration). We should give more consideration for people going abroad and we should not make it hard for them” (Professional association informant 03182013).

Advocacy group representatives, in sharp contrast, argue that labor migration is forced mobility rooted in limited opportunities in the country. Some stakeholders shared the view that migration and the orientation of Filipino graduates to work overseas was the result of colonization, media hype, and the proliferation of a discourse of “migration as a sign of success” (Government informant 03132013).

In addition, the national economic and political situation impacts HRH migration.

They [HRH] see the Philippines as not being the most conducive place for their family, and being parents, you want to provide the best opportunity for your children. So naturally, people would want to migrate instead. (Recruitment agency 06112013)

Militarization and branding of health workers as anti-state activists further incentivizes HRH migration [ 26 ]. The militarization and safety concerns in some rural areas have led to extreme measures:

The doctors bring a gun instead of a stethoscope… and they are trained to shoot guys. In the south Footnote 2 for example, if you’re living in the city and there are three hospitals that you cover and you have to travel at night. You have to be ready for (security) emergencies. (Professional association informant 02282013)

Finally, it was argued that the forces of neoliberal globalization opened the arena for recruitment of migrant health workers as a cost-efficient economic strategy for both the Philippines and destination countries.

The Philippines has the best system for migration… (the government) has these machinery or system created to facilitate migration POEA [Philippines Overseas Employment Administration], DOLE [Department of Labor and Employment], OWWA [Overseas Workers’ Welfare Administration]… We are the role model. Remittances are used to pay debt. … Migration is our best industry. (Migrant advocacy group informant 01162013)

On the other hand, countries with less stringent policies on immigration and employment greatly influence migration decisions. Canadian and American policies and practices facilitated the recruitment of HRH to North America. The Middle East, prior to the revisions of employment rules and Saudization which is meant to reduce reliance on foreign labor and enhance employment opportunities for Saudi citizens, was also a top destination as countries in the region did not require additional licensure and training. Government-to-government recruitment or bilateral agreements (i.e., Germany, UK, and some regions of Canada) also played significant roles in the institutionalization of Filipino HRH’s overseas migration.

These countries have also become top destinations for Filipino migrant HRH because of opportunities for HRH’s families to immigrate: “If you go to Canada, you go to the US, your family is automatically included into the petition, so (it is among) some of the factors” (Recruitment agency informant 05092013). As noted in the survey findings, English speaking countries remain among the top destinations of Filipino health professionals. For countries that demand proficiency in other languages for employment, the availability of training institutes and the guarantee of remuneration equivalent to local HRH (e.g., Germany) serve as pull factors for Filipino HRH.

Consequences of migration

The migration of health professionals has had important consequences for the health system in the Philippines, affecting both health professionals and the population in need of their services. Stakeholders argued that it aggravated the existing deficit for specialized health professionals and the inequitable production and distribution of health workers across the country. One asked: “How do you respond to the health needs of the country when those who can respond are outside of the country?” (Migrant advocacy group informant 01162013).

The survey results suggested that shortages of workers and reduction in services provided were the most evident effects of health worker migration according to survey respondents (Table  3 ). Respondents also highlighted increased errors and poorer quality of health care service provision as results of the continuing HRH migration.

Stakeholders argued that HRH migration negatively affected the functioning of the health care system as generally health professionals with substantial amounts of training, experience, and skills are the ones who leave.

We have nurses who are very good. Where are they now? One left for US, two left for Australia, and there are the very good faculty that we are hoping to be our replacement someday. Now they’re gone (Professional association informant 07152013).

Nevertheless, there are some respondents who expressed wariness on the perception of a “brain drain” caused by HRH migration.

Are you saying that those who out are there have brains, but those who are left behind have none?… let’s just put things in the proper perspective (Government informant 07152013).

Stakeholders from government institutions, professional associations, and training institutes argued that return migration has the capacity to bring about knowledge transfer and improvements in health care practice in the country. We found, however, among our survey respondents that typically, Filipino labor migrants would want to return to the Philippines when they can no longer work (Table  6 ). Specifically, the majority of survey respondents would want to retire in the Philippines and be buried in the Philippines (Table  4 ).

In addition, the projection of available opportunities for health professionals also influenced the country’s health education system. All key informant groups acknowledge that the most obvious impact of migration had been the uncontrolled expansion of certain health professions, in particular, nursing education.

I think the problem started late 90s to early 2000s because of the increased enrollment in nursing. As of now there are 491 colleges, and before it was only half. And so I think because of the demand, they all got attracted to go into nursing, and the main reason during that time, when it was still early, was to go abroad. (Training institute informant 08052013)

Respondents argued that this expansion also led to the commercialization and deterioration of nursing education standards. Moreover, the burgeoning numbers of nursing graduates cannot be absorbed by the health care system. Resultantly, nurse unemployment and underemployment contributes to increased outmigration. Health institutions face greater costs to constantly recruit, train, and retrain personnel to fill positions left vacant by emigrating HRH. The delivery of health care services in rural underprivileged areas of the country has been greatly affected by the perennial departure of health professionals.

There’s inadequacy of health workers because most of the health workers in the public sectors would go into the urban areas. Some of rural health workers would end up working overseas.... Barangay [village level] officials would appoint Barangay health workers who are trained but not necessarily about the nursing profession, but more on first aid…so that’s the reason why health services in the rural areas are in dire (condition) (Government informant 11272012).

Consequences for Filipino migrant health workers

Most respondents recognized that overseas migration may have a positive impact on individual Filipino health workers; however, there were some adverse effects as well. Key stakeholders from all sectors noted that migrant Filipino HRH experience exploitation, discrimination, unfavorable work load, and human rights violations.

One form of exploitation is on hours of work. The Filipino workers are not given what is due them. What is agreed upon before departure for the destination country, the salary agreed upon is not given to them. And then the inhuman conditions, the treatment. That is the most common (Government informant 03262013).

In addition, migrant Filipino health workers also experienced and suffered from illegal recruitment, contractualization (a government system which allows a company or an employer to hire a worker for a temporary period without security of tenure or benefits) and contract substitution.

There is a case of doctors who have migrated abroad in the United States but work there as medical representatives of drug companies or as nurses…There are nurses who migrated but are employed as a private nurse and are treated like a domestic helper (Government informant 03182013).

The consequences on migrant households in the context of the national economy

The contribution of migrant remittances to the economic development of source countries has been a key reason why governments support labor export [ 10 , 27 ]. Remittances may have kept the Philippine economy afloat since the formalization of its labor export policies under Marcos, and it has been a concrete survival mechanism for many families. Survey respondents who are considering migration within the next 6 months to 2 years affirmed that they would send remittances to the Philippines (Table  5 ).

Remittances may have a direct impact on migrants’ families and indirectly to the economy: “When the family procures things that they don’t normally buy without the remittances, and then a certain amount of money goes to the government by way of the Value Added Tax” (Professional association informant 07152013). Another respondent remarked that remittances affect the economy in the form of human capital development when migrants’ families invest in education.

… An OFW [overseas Filipino worker] who can afford to send the children to good schools would certainly have good qualified children that will pursue employment in the future both locally and overseas. A global workforce is easily achievable. (Government informant 03182013)

Some stakeholders noted the exponential growth of remittances in the country over recent years but acknowledged that the contribution of labor migration to the country’s economy cannot be accurately measured. Importantly, the accrual of education does not always translate into remunerative employment as evidenced by the under- and unemployment of professionals including HRH and the numbers of educated Filipinos who work abroad as household service workers [ 28 ].

Additionally, participants considered the impact of migration on families. One concern was familial overdependence on, and misspending of remittances. “There are also stories where if the OFW is able to send home lots of money, his or her family in the Philippines stops working and relies solely on the OFW” (Professional association informant 03182013). Migration may also lead to the deterioration of familial relationships or family disintegration.

Policy responses

Policy and program responses managing HRH migration span international, national, and regional levels. These responses include (1) the enactment of retention and reintegration programs; (2) the signing of multilateral and bilateral agreements and recruitment codes; (3) the establishment of international organizations attempting to document migration flows and advise on policies to mitigate negative externalities; and (4) the promotion of initiatives towards the protection of migrant workers’ welfare and incentives for returning émigrés. The impact of these policies depends on the form and scope of the policy proposed and implemented, the extent of their enforcement and reach, and their transferability across different levels of management and regulation.

Retention and reintegration programs

Some stakeholders offered recommendations concerning the retention of health care workers in the country, which address the perceived causes of Filipino HRH migration. These include short- and long-term policy solutions such as improvements in working conditions, providing financial and technical support for the health sector, improving health education curricula, and establishing good governance practices.

How much do health workers get for their salary? … Before we can even have a promise of a retention policy, these things need to be take care of (Government informant 07152013) A policy of good governance that will cover nationalism and patriotism. Good governance is a good intervention that I think will prevent migration of our nursing—and other health—professionals (TI Informant 04052013).

Some respondents also noted that the Magna Carta for Public Health Workers of 1992 (MCPHW) should be properly implemented. Through the provision of improved salaries and compensation, the MCPHW was meant to increase the number of health workers serving in marginalized areas, although “it is not being observed, the Magna Carta is not being implemented” (Government informant 08122013). In addition, the devolution of public health services in 1995 found that some local governments were ill-equipped to implement the law.

To address the problem of uneven distribution of healthcare professionals among urban and rural areas, the Philippine government implemented a program to train medical and nursing graduates to serve in rural or underdeveloped areas, which included a return-of-service requirement. More than three fourths of survey respondents thought it was justified for all health professionals trained in the country to do return of service or community work for a specified time, and 87% agreed that this was especially true for those who received government scholarships (Table  6 ).

Multilateral and bilateral agreements

To directly address practices and policies on recruitment of HRH from under-resourced countries such as the Philippines, international and multilateral ethical codes of conduct have been developed [ 29 , 30 ]. Bilateral agreements serve as a method of regulating HRH migration in number, type, and quality of health personnel recruited from source to destination countries with the aim that both countries derive benefits from the exchange, while protecting the welfare and rights of the migrating health workers [ 27 ]. To this end, the Philippine government has undertaken arrangements with partnering countries in the formulation and implementation of bilateral agreements on the flow of HRH (see Table  7 ). Nevertheless, to harness the benefits of knowledge and technology transfer, some stakeholders recommended that provisions in bilateral agreements should allow willing Filipino health professionals to return for 1 or 2 months to share their skills and talents gained from experience with the destination country without risk of job loss.

For most of the stakeholders, however, these actions and policies have neither restricted nor effectively regulated the migration of Filipino health workers; rather, they have systematized further their recruitment and mobility. Stakeholders’ perspectives revealed that because the adoption of international recruitment codes is only voluntary, they remain considerably ineffective in the management of international migration of HRH [ 31 ]. Despite the presence of these agreements, some participants highlighted how the Philippines has faced significant setbacks, owing to disagreements regarding the equivalence of education, training, and quality of the country’s HRH.

Individual decision-making about migration must be situated within a broader socioeconomic, historical context that attends to both discursive and material aspects of power operating across individual, institutional, national, and global spheres. At the micro-level, individual reflections on the country’s political and economic situation and the desire for career advancement influence the decision to migrate. These findings echo the results of previous research [ 32 – 40 ]. Individuals may feel pushed to migrate due to the poor wages offered to HRH and pulled to migrate by the prospect of better social, economic, and professional opportunities abroad and by the presence of overseas kin. Countering these elements are ones that encourage health professionals to remain in the Philippines including dedication to family, culture, and community, and concern about encountering cultural differences, discrimination and workplace abuse, loss of social support, and the negative impact of family separation. The presence of family and the enhanced respect respondents anticipated they would receive as health professionals in another country could increase the likelihood that they would remain overseas.

At the meso-level, better economic benefits and organizational settings were seen as factors that affect migration decisions. The literature points to risks of work-related hazards [ 36 ], and inadequate health care system and shortages in human resources [ 22 , 41 , 42 ] as the primary meso-level factors that influence the individual’s decision to migrate. Specifically, poor health care infrastructure, low wages, job insecurity, inconsistencies in practice, outdated or inappropriate curricula, institutional politics, and inadequate opportunities for speciality training were all cited as influencing migration decisions while return community service and improved curricula were would encourage health workers to remain. Concomitantly, the potential to engage in advanced training and the perception of greater equality among, and respect for, health professionals overseas were regarded migration incentives. Interestingly, nearly three quarters of respondents chose a health career because of the potential for overseas opportunities. Importantly, the increasing number of trained nurses due to the rapid expansion of nursing programs, who had hoped to train graduates destined for the overseas market were confronted by a stagnant global market resulting in increased under- and unemployment. Many trained professionals were therefore compelled to take up lower skilled positions abroad, thereby thrusting them onto a path of deskilling [ 43 , 44 ]. Complicating the scenario is the declining quality of nursing education, which previous research suggests is the consequence of the commercial expansion of nursing programs whose goal is to produce graduates for export [ 22 , 42 , 45 – 47 ], and an oversupply of health workers who cannot secure positions in the underfunded Philippine system.

Certain issues such as privatization of health care services and the prominent discourse of migration as key to success were situated at the interface of meso- and macro-level analyses. The impact of neoliberal globalization (structural adjustment and, more recently, post-financial crisis austerity programs, [c.f. 7 ]) has engendered the withdrawal of state support for health, social services, and education and promoted privatization contributing to job insecurity and unemployment. Labor export policies and programs provide an avenue for unemployed and under-employed, and encourage remittances from overseas Filipino workers. Ongoing state-supported human rights abuses, particularly in rural regions, also propel the exodus of health professionals and reinforce the maldistribution of health resources. Informed by discourses that have normalized migration and emphasized the right of citizens to migrate, HRH are attracted to overseas work by specific destination country policies, government-to-government agreements, and recruitment agency activities. These observations are corroborated by previous studies that enumerated the “culture of migration” [ 48 ], labor export policy [ 22 , 48 , 49 ], and unemployment [ 41 , 42 , 50 ] as major push factors at the macro-level. Stakeholders further identified the development of specific retention programs, the implementation of the Magna Carta for Health Workers, and improved infrastructure as policies that could encourage HRH to remain in the Philippines, while the ability to settle abroad with one’s family and to return temporarily to contribute to knowledge and technology transfer were regarded as factors that would inspire HRH to remain overseas.

HRH migration impacts individuals, families, institutions, services, society, and nation states. While some key stakeholders argued that return migration or “brain circulation” offered benefits through short- or long-term knowledge transfer and exchange, there is insufficient evidence in the literature to support these assertions. Country case study findings on brain drain are consistent with the literature describing it as a process manifested in the deficit of specialized health professionals with grave consequences to both the health care system and the individual health workers [ 41 , 51 ]. The migration of health professionals results in a paucity of skilled personnel in health institutions across the country, especially in rural areas. HRH mobility also burdens the remaining health workers in the country in terms of workload. Previous studies suggest that if this migration trend continued, the Philippine health care system would be severely disadvantaged or worse, it would collapse [ 38 , 41 , 52 – 54 ].

The plight of an individual HRH cannot be separated from the existing condition of the local health system and the country itself. The opportunities for professional and personal growth, economic wellbeing, and the conditions of local practice interact with the existing policies and programs of the country. While these affect the retention or dissatisfaction of HRH, the country’s health sector financing and health workforce management schemes are also inseparable from international political and economic conditions. Reductions in government expenditures in health, privatization as health financing strategy, and rationalization in public health institutions as a workforce management scheme are not de facto conditions present in the national health system. These are historical products of programs and policies instituted by the government and which include economic liberalization, structural adjustment programs, and the Labor Export Policy.

Grounded in a colonial legacy that has normalized labor migration as a means of social and economic mobility and propelled by the exigencies of neoliberal globalization, the Philippines has developed a sophisticated state apparatus that facilitates migration and encourages OFW remittances. HRH comprise an important sector of labor migrant flows and as such the Philippines continues to produce doctors, nurses, midwives, and other health professionals who are highly specialized and sought after in countries across the globe. The country’s dominance as a HRH exporter, however, means that it is losing its skilled resources while struggling to manage its own health care services, particularly in under-served, rural areas. With HRH migration, the Philippines is at the disadvantage not only due to the creation of a workforce predisposed for overseas employment instead of serving locally but also through the loss of a skilled workforce that is in essence given away to the benefit of destination countries. While host countries benefit from the care provided by the migrant Filipino health professionals, many of these health professionals are also subject to discrimination, exploitation, wage differentials, and deskilling. As the HRH work their way to provide for their families in the Philippines, the societal cost also can often outweigh the personal benefits of migration. Despite the drawbacks, the massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who are not being absorbed locally despite high needs especially in rural and remote areas. Although the majority of trained health professionals remain in the country, the numerous interacting micro-, meso-, and macro-level factors that propel Filipino HRH to seek work overseas far outweigh the factors that foster retention at home. International agreements, ethical recruitment guidelines, and programs to protect overseas HRH may mitigate some of the more egregious forms of exploitation they face; however, the complex and sometimes paradoxical nature of these intersecting, multi-level phenomena and their consequences will require greater consideration and systemic change. Importantly, major financial investments in health, education, and social services, and greater control over public resources are required to redress social and economic inequalities and the deteriorating human rights situation that contributes to the loss of HRH to ensure that migration is truly a choice for health professionals—one that Filipinos across the archipelago can afford.

In the Philippines, a plantilla refers to an approved listing of personnel for a particular government agency; someone in a plantilla position is regarded as a regular employee.

Referring to southern Philippines, which include the island groups of Visayas and Mindanao.

Abbreviations

Association of Southeast Asian Nations

Chief executive officer

Census and Survey Processing System (software)

Department of Health

Department of Labor and Employment

Gross Domestic Product

• Human resources for health

Labor Export Policy

Medical subject headings

Municipal Health Officer

(National Statistics Coordination Board) Philippine Statistics Authority

Overseas Filipino workers

Overseas Workers Welfare Administration

Philippine peso

Philippine Overseas Employment Administration

Physical therapists (physiotherapists) and occupational therapists

Special Administrative Region (Hong Kong)

Statistical Package for the Social Sciences (software)

The United States of America

United States

US dollar ($)

World Health Organization

WHO (World Health Organization). Working together for health–2006. Geneva: World Health Report; 2006.

Google Scholar  

Mackey TK, Liang AA. Rebalancing brain drain: exploring resource reallocation to address health worker migration and promote global health. Health Policy. 2012;107(1):66–73.

Article   PubMed   Google Scholar  

O’Brien P, Gostin LO. Health worker shortages and global justice. Milbank Memorial Fund. 2011. [Internet]. Available from: http://www.milbank.org/publications/milbank-reports/158-reports-health-worker-shortages-and-global-justice-2 .

Labonté R, Sanders D, Mathole T, Crush J, Chikanda A, Dambisya Y, Runnels V, Packer C, McKenzie A, Tomblin Murphy G, Bourgeault IL. Health worker migration from South Africa: causes, consequences and policy responses. Hum Resour Health. 2015;13:92. http://human-resources-health.biomedcentral.com/articles/ 10.1186/s12960-015-0093-4 .

Article   PubMed   PubMed Central   Google Scholar  

Tomblin Murphy G, MacKenzie A. Waysome B, Guy-Walker J, Palmer R, Elliott RA, Rigby J, Labonté R, Bourgeault IL. A mixed-methods study of health worker migration from Jamaica. Hum Resour Health. 2016; 14 (Sup 1). https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-016-0125-8

Walton Roberts, M, Runnels V, Rajan I, Sood A, Thomas P, Nair S, Packer C, MacKenzie A, Labonté R, Tomblin Murphy G, Bourgeault IL. Source country perspectives on the migration of highly trained health personnel: Causes, consequences and responses in India. Hum Resour Health. (in press).

Labonté R, Stuckler D. The rise of neoliberalism: how bad economics imperils health and what to do about it. J Epi Com Health. 2016;70(3):312–8.

Article   Google Scholar  

Diokno-Pascual MT. The turbulent and dismal record of World Bank structural adjustment lending in the Philippines, Paper prepared for the Trade and Economy Forum, ASEM 2000 People’s Forum. 2000.

Bello W. The food wars. Manila: Anvil Publishing, Inc; 2010.

Spitzer DL, Piper N. Retrenched and returned: Filipino migrant workers during times of crisis. Sociology. 2014;48:1007–23.

IBON Foundation. Confronting underdevelopment through people’s struggles. La Trinidad: Benguet State University; 2014.

IBON Foundation Inc. Economy under the Aquino administration: a case of worsening exclusivity. Quezon: IBON Foundation Inc; 2014. Available from: http://defence.pk/threads/philippines-military-thread-economy-news-and-updates.234998/page-46 .

POEA. Overseas Philippine Worker Statistics. 2014. Available from: https://psa.gov.ph/content/statistical-tables-overseas-contract-workers-ocw-2014 .

Asia Pacific Observatory on Health Systems and Policies. Philippines Living Hit Update. Health Systems in Transition , September 2013. 2013; Available from: http://www.wpro.who.int/asia_pacific_observatory/hits/series/phl_living_hits_3_2_health_expenditure.pdf .

Wrede S, Benoit C, Bourgeault IL, Sandall J, DeVries R, Van Tiejlinden E. Decentred comparative research: context sensitive analysis of health care. Soc Sci Med. 2006;63:2986–97.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32.

Henderson RH, Sundaresan T. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. Bull of WHO. 1982;60(2):253–60.

CAS   Google Scholar  

Rodriguez RM. Migrants for export: how the Philippine state brokers labor to the world. Minneapolis: University of Minnesota Press; 2010.

Book   Google Scholar  

Barber PG. Locating gendered subjects in vocabularies of citizenship. In: Tastsoglou E, Dobrowlsky A, editors. Women Migr. Citizsh. Mak. Local Natl. Transnatl. Connect. Aldershot: Ashgate; 2006. p. 61–83.

Soriano L. Remittances and the Philippine mal-development. In: Ofreneo R, Samonte I, Soriano L, Prieto P, editors. Migr. Dev. Policy Reforms. Manila: Asian Institute of Management Policy Center; 2009. p. 7–19.

Parreñas RS. Children of global migration: transnational families and gendered woes. Stanford: Stanford University Press; 2005.

Brush BL, Sochalski J. International nurse migration: lessons from the Philippines. Policy Polit Nurs Pract. 2007;8:37–46.

WHO 2013 World Health Organization (2013) World Health Statistics 2013 Geneva: World Health Organization. Retrieved from http://www.who.int/gho/publications/world_health_statistics/EN_WHS2013_Full.pdf .

Lorenzo FM, de la Rosa J, Cella V, Celino S. National profile of migration of health professionals—Philippines [Internet]. Manila: University of the Philippines; 2011. Available from: http://philipus.de/mohprof.eu/LIVE/DATA/National_profiles/national_profile_Philippines.pdf .

POEA. 2008–2012 Overseas Philippine Worker Statistics. 2012. Available from: https://psa.gov.ph/content/statistical-tables-overseas-contract-workers-ocw-2014 .

Boehringer GH. (2012) Blighted: Philippine Jurisprudence and State Repression – the “Morong” 43. http://bulatlat.com/main/2010/04/12/blighted-philippine-jurisprudence-and-state-repression-the-morong-43/ (cached: http://www.arkibongbayan.org/2010/2010-04April18-MorongDocs/docendre/05-Morong%2043%20BLIGHTED%20Boehringer%20article.doc .

International Labour Organization (ILO). Protecting the rights of migrant workers: a shared responsibility. Geneva: ILO; 2009.

Cruz GT, Laguna EP. Overseas labour migration and well-being of older Filipinos. In: Arifin EN, Ananta A, editors. Older persons in SE Asia: an emerging asset. Singapore: Institute of Southeast Asian Studies; 2009. p. 314–34.

Connell J, Buchan J. The impossible dream? Codes of practice and the international migration of skilled health workers. World Med Health Policy. 2011;3:1–17.

Runnels V, Labonté R, Packer C. Reflections on the ethics of recruiting foreign-trained human resources for health. Hum Resour Health Electron Resour. 2011;9. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-9-2 ; doi 10.1186/1478-4491-9-2 .

Bourgeault IL. Labonté R, Packer C, Runnels, V, Tomblin Murphy G. Knowledge and potential impact of the WHO Global Code of Practice on the International Recruitment of Health Personnel: Does it matter for source and destination country stakeholders? Hum. Resour. Health – special supplement on the WHO Code. 2016; 14 (Sup 1). https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-016-0128-5

Henderson L, Tulloch J. Incentives for retaining and motivating health workers in Pacific and Asian countries. Hum Resour Health. 2008;6:18.

Allan H, Larsen JA. “We need respect”: experiences of internationally recruited nurses in the UK [Internet]. London: Royal College of Nursing; 2003. Available from: https://www2.rcn.org.uk/__data/assets/pdf_file/0008/78587/002061.pdf .

Daniel P, Chamberlain A, Gordon F. Expectations and experiences of newly recruited Filipino nurses. Br J Nurs. 2001;10(4):254–6, 258–65.

Lorenzo M. Nurse supply and demand in the Philippines. Manila: Institute of Health Policy and Development Studies, University of the Philippines; 2002.

Brown RPC, Connell J. The migration of doctors and nurses from South Pacific island nations. Soc Sci Med. 2004;58:2193–210.

Lorenzo F, Dela Rosa J, Yabes J. Philippines HRH Master Plan 2005–2030. Manila: University of the Philippines Manila & World Health Organization; 2005.

Clark PF, Stewart JB, Clark DA. The globalization of the labour market for health-care professionals. Int Labour Rev. 2006;145:37.

Alonso-Garbayo A, Maben J. Internationally recruited nurses from India and the Philippines in the United Kingdom: the decision to emigrate. Hum Resour Health. 2009;7:37.

Hayne AN, Gerhardt C, Davis J. Filipino nurses in the United States: recruitment, retention, occupational stress, and job satisfaction. J Transcult Nurs. 2009;20:313–22.

Lorenzo FM, Galvez-Tan J, Icamina K, Javier L. Nurse migration from a source country perspective: Philippine country case study. Health Serv Res. 2007;42:1406–18.

Masselink LE, Lee S-YD. Nurses, Inc.: expansion and commercialization of nursing education in the Philippines. Soc Sci Med. 2010;71:166–72.

Pratt G. From registered nurse to registered nanny: Discursive geographies of Filipina domestic workers in Vancouver, B.C. “In Reading Economic Geography, T.J. Barnes (ed). Malden, MA: Blackwell Publishing. Pp. 375–388. In: Barnes TJ, Peck J, Sheppard E, Tickell A, editors. Read. Econ. Geogr. Malden, MA: Blackwell Publishing; 2003. p. 375–88.

Salami B, Nelson S. The downward occupational mobility of internationally educated nurses to domestic workers. Nurs Inq. 2014;21:153–61.

Goode AS. Global economic changes and the commodification of human capital: implications of Filipino nurse migration. East Asia. 2009;26:113–31.

Cheng MH. The Philippines’ health worker exodus. Lancet. 2009;373:111–2.

Villegas MCL. Achievement tests and their relevance to examination performance of nursing graduates. IAMURE Int J Health Educ. 2012;1:45–57.

Dimaya RM, McEwen MK, Curry LA, Bradley EH. Managing health worker migration: A qualitative study of the Philippine response to nurse brain drain. Hum Resour Health. 2012;10. alternative: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3541120/ .

Hawthorne L. The globalisation of the nursing workforce: barriers confronting overseas qualified nurses in Australia. Nurs Inq. 2001;8:213–29.

Article   CAS   PubMed   Google Scholar  

Ronquillo K, Elegado-Lorenzo FM, Nodora R. Human resources for health migration in the Philippines: a case study and policy directions. Bangkok: Paper for ASEAN Learning Network for Human Resources for Health. 2005. Available from: http://s3.amazonaws.com/zanran_storage/www.healthworkforce.info/ContentPages/46790460.pdf .

Lorenzo FM, Dela Rosa Jannifer F, Villegas S, Yabes J, Trinidad F, Fernando G, et al. Migration of health workers: country case study Philippines [Internet]. International Labour Office. Geneva: International Labour Organization (ILO); 2006. p. 1–92. Report No.: 92-2-118204-5. Available from: http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/publication/wcms_161163.pdf .

Troy PH, Wyness LA, McAuliffe E. Nurses’ experiences of recruitment and migration from developing countries: a phenomenological approach. Hum Resour Health. 2007;5. Available from: https://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-5-15 .

Anderson BA, Isaacs AA. Simply not there: the impact of international migration of nurses and midwives—perspectives from Guyana. J Midwifery Womens Health. 2007;52:392–7.

Labarda MP. Career shift phenomenon among doctors in Tacloban City, Philippines: lessons for retention of health workers in developing countries. Asia Pac Fam Med. 2011;10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204289/ .

Blank NR. Making migration policy: reflections on the Philippines’ bilateral labor agreements. Asian Polit Policy. 2011;3(2):185–204.

Sabater MR. Win-win bilateral agreements to ensure ethical recruitment of Pinoy health professionals abroad urged. 2009. Retrieved May 25, 2011 from http://haunurses.blogspot.com/2009/03/accord-sought-with-countries-recruiting.html .

Orbeta A, Abrigo M. 2011. Managing International Labour Migration: The Philippine Experience. Philippine Institute of Development Studies Discussion Paper Series 2011-33. Available from:  http://dirp3.pids.gov.ph/ris/dps/pidsdps1133.pdf .

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Acknowledgements

We wish to thank the women and men who participated in this study and our colleagues who provided their expertise and research assistance: Jaime Galvez Tan, MD, MPH; Kenneth Ronquillo, MD, MPH; Nimfa B. Ogena, PhD; Andrew Bucu, MD, MPH; Christian Joy P. Cruz; Kenneth Cajigal, RN; Jerwin Evangelista, RN; Gary Pagtiilan, RN; Maria Fonseca Camille T. Baroña, RN; Danica September L. Mariano, Janet Rigby, and Jelena Atanackovic. We appreciate the assistance of the Office of Population Studies Foundation, University of San Carlos, Cebu City, lead by Dr. Nanette Lee-Mayol in the field work in Cebu City.

The funding source for the study was the Canadian Institutes of Health Research (Health Services and Policy Research Institute) for the “‘Source country’ perspectives on the migration of highly trained health personnel: Causes, consequences and responses.” Funding Reference No: MOP 106493. CIHR did not participate in any way in the study design, collection, analysis and interpretation of data, and writing of the manuscript.

Availability of data and materials

The participating countries’ dataset(s) supporting the conclusions of this article are not publicly available to ensure respondents’ anonymity in reporting and confidentiality in participating in the study as per the study’s ethical requirements.

Authors’ contributions

ECP oversaw data collection, engaged in data analysis, conceptualized, drafted and reviewed the article; DLS participated in qualitative data collection and analysis, and contributed to the direction, writing and revision of the article; MMK oversaw quantitative data collection and analysis and contributed the quantitative data and interpretation to the manuscript; MCS made substantial contributions to data collection and analysis and helped draft and revise this manuscript; RC aided in data analysis and in the writing and revision of this article; VR drafted elements of and reviewed the article. RL, GTM, and IB conceived of the study and RL and IB reviewed and revised several drafts. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Approval to conduct the study was received from the University of Ottawa Research Ethics Board and those of the University of the Philippines Manila.

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Institute of Management, College of Social Sciences University of the Philippines Baguio, Governor Pack Road, 2600, Baguio, Philippines

Erlinda Castro-Palaganas

Institute of Feminist and Gender Studies, University of Ottawa, 120 Université FSS 11042, Ottawa, Ontario, K1N 6N5, Canada

Denise L. Spitzer

Population Institute, College of Social Sciences and Philosophy University of the Philippines, 1101, Diliman, Quezon City, Philippines

Maria Midea M. Kabamalan

Luke Foundation, Inc., 90 Leonard Wood Road, Engineers’ Hill, 2600, Baguio, Philippines

Marian C. Sanchez

College of Social Sciences University of the Philippines Baguio, Governor Pack Road, 2600, Baguio, Philippines

Ruel Caricativo

Centre for Research on Educational and Community Research, University of Ottawa, 1136 Jean-Jacques Lussier, Ottawa, Ontario, K1N 6N5, Canada

Vivien Runnels

Faculty of Medicine, University of Ottawa, 850 Peter Morand Crescent, Ottawa, Ontario, K1G 3Z7, Canada

Ronald Labonté

Department of Community Health and Epidemiology, Faculty of Medicine, WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, School of Nursing, Faculty of Health Professions, Dalhousie University, 5869 University Avenue, Halifax, Nova Scotia, B3H 4R2, Canada

Gail Tomblin Murphy

Telfer School of Management, University of Ottawa, 1 Stewart St., Ottawa, Ontario, K1N 6N5, Canada

Ivy Lynn Bourgeault

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Correspondence to Denise L. Spitzer .

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Castro-Palaganas, E., Spitzer, D.L., Kabamalan, M.M.M. et al. An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving—a mixed method study. Hum Resour Health 15 , 25 (2017). https://doi.org/10.1186/s12960-017-0198-z

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Received : 27 May 2016

Accepted : 18 March 2017

Published : 31 March 2017

DOI : https://doi.org/10.1186/s12960-017-0198-z

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