By Chit Estella
Lani, a radiology technologist in a government hospital in Quezon City, remembers the time when she moved among the best in her department. “We used to have good senior nurses here,” she says.
Then, almost suddenly, her co-workers started leaving.
“That whole year, I kept seeing resignation papers,” she says. Even the aides were disappearing, going off to London or the United States or elsewhere for good. Today, out of the 40 staff members that she had originally worked with in the department, only four have stayed behind. But even they—including Lani—have either applied or are planning to apply for work abroad.
The year Lani remembers for the rash of resignations must have been 2001 when the highest number of nurses ever recorded left for abroad. At that time, the Philippine Overseas Employment Agency (POEA) reported a total of 13,536 Filipino nurses who left the country, almost double the previous year’s exodus of 7,683 nurses. That year, too, only 4,430 students passed the Nursing Board Examination.
The pattern would be repeated in 2002 when 11,911 nurses chose to work abroad as against a much smaller number of nursing students—4,228—who passed the Board. Clearly, the country has been exporting more nurses than it was producing.
But it was not always like this. Just eight years before, the Philippines was producing more nurses than it was sending abroad. In fact, it was producing way more nurses, period. In what was to become a strange and discomfiting twist to the nursing profession, fewer nursing graduates were taking and passing the Board exam even as far greater numbers were leaving the country. (See tables 1 and 2)
Nursing Board Performance (Table 1)
|Year||No. of Examinees||No. of Passers||Passing Rate (%)|
|Source: Professional Regulation Commission|
Deployment of Filipino Nurses, 1999 – June 2004 (Table 2)
|Source: POEA, Institute of Health Policy and Development Studies, 2004|
Rita Tamse, member of the Technical Committee on Nursing Education of the Committee on Higher Education (CHED), noted that the latest Nursing Board Exam last December registered its lowest passing rate ever at 43 percent. Of the 12,000 students who took the Board, only about 5,000 made the grade.
As more nurses leave and as fewer are qualifying for the job, the situation in hospitals can only get worse. But to Tamse, who is also deputy director of the University of the Philippines College of Nursing, “That worse situation is happening right now.”
The Philippine General Hospital, the country’s premier government hospital, used to accept only the top graduates of the country’s nursing schools. Today, according to Dr. Jaime Galvez Tan, vice chancellor of the University of the Philippines in Manila which is in charge of the PGH, it settles for much less. As long as a nurse makes the minimum passing grade, he or she can be accepted. It seems there is no choice for the hospital which sees up to 500 of its 2,000 nurse workforce leave every year.
The best of the nursing students are leaving as soon as they graduate, skipping the one or two-year experience that is usually required by hospitals. Those left behind take the place of senior or relatively more experienced nurses who have also left for other shores. In a year or two, they too would be gone. The void would be filled once more by fresh graduates who would repeat the same cycle: get a few years experience in a local hospital, apply for work abroad and then leave.
The cycle leaves local hospitals in a state of perpetual displacement–and patients in constant danger.
“Our problem is unskilled, untrained nurses,” says Dr. Irineo Bernardo, head of the Philippine Hospital Association and owner of a primary care community hospital in Tanay. “It takes years for a new graduate, even for someone with good grades, to be trained,” he adds. It is not enough that a nursing graduate knows the theories. “He or she must know the culture inside a hospital as well,” Bernardo says.
He notes that the turnover of nurses has been particularly high in the last five years. “In a small hospital, we’d expect one or two to leave for abroad in a year. Last year, we had five who left,” he says.
The necessity of having skilled and trained nurses cannot be underestimated. In certain municipalities, small hospitals are run by nurses, not doctors. “Excuse my language pero kung pagago-gago ang nurse na ito, huwag ka nang magbukas ng ward. Baka kung ano pa ang mangyari sa pasyente. We’ve had problems with nurses graduating from schools and we find ourselves asking, bakit nakapasa ang mga ito?” Bernardo says.
One need not even go to distant barangays to find unskilled nurses. In a top hospital in Metro Manila, Dr. Tan recalls an incident: “We asked for a spittoon for the patient. The nurse came back with a urinal.”
A study by the National Institutes for Health led by Fely Marilyn Elegado-Lorenzo warned that because the migrating nurses are usually the ones with prior training, experience and skill, patients can expect that with lesser-skilled nurses, there would be higher incidence of cross-infections, adverse events after surgery, accidents and injuries and even increased violence against the staff.
The Professional Regulatory Commission puts the number of licensed nurses at about 354,000 as of last year, but only a tenth are said to be practicing their profession. The bigger number chose to become flight attendants, bank tellers, entrepreneurs, and other positions that would earn higher pay. The choice is not a difficult one to make considering that nurses get as low as P2,000 a month in the provinces. Ironically, government hospitals pay more than private hospitals. Nurses in public hospitals receive at least P9,000; in private hospitals, it could go down to P4,000 a month. Under the Nursing Law of 2002, an entry-level nurse should get about P13,300 a month.
“It’s such a small amount and yet the government is unable to give that,” Tamse says, citing “unavailability of funds” as the constant reason being given by the Department of Budget and Management. In the mean time, a contractual nurse without experience gets P9,930 a month; with experience, the pay goes a bit higher at P12,000.
“It is a far cry from what a nurse would receive abroad,” she adds, recalling a nurse who had come back from the United Kingdom with half a million pesos after just six months. For those bound for the United States, there is even a signing bonus of anywhere from $2,000 to $10,000.
Recruitment is brisk because recruiters are handsomely paid for every nurse that they bring to a foreign health institution. Dr. Tan remembers being offered by a recruiter $7,000 for every nurse that he could find for a US hospital. When the disbelieving doctor finally got the chance to talk to the members of that American hospital, he was even more surprised by their reaction.
“They denied it! They weren’t giving $7,000 for every nurse. They were giving $14,000!” he says.
Figures vary but the United States is said to need about a million nurses over the next few years; Canada, 10,000; the Netherlands and the United Kingdom, 7,000; other countries, 27,000. The huge demand for nurses abroad—and the equally huge pay that comes with it—cannot be denied. It is a development that has given rise to a situation unique to the Philippines: that of doctors wanting to become nurses.
On the fifth floor of a busy hospital in Manila, hundreds of doctors congregate from Friday to Sunday in the early evening. They are there not to listen to a seminar or a lecture on the latest medical developments. They are there to learn nursing.
According to Dr. Tan, 5,500 doctors are now enrolled in 45 nursing schools in courses that were tailor-made for them. Two thousand doctors have already taken up the Nursing Board Exams, topping the test in 2003 and 2004. Since two years ago, more than 3,500 doctors are estimated to have left the Philippines to work as nurses abroad.
As the number of nursing schools rose from 40 in the 1970s to about 350 last year, that of medical schools is going down. Of the 39 medical schools in the country, three have ceased operating because of steeply declining enrollment. According to a report cited by Dr. Tan’s study, only six medical schools out of 25 that were studied registered an increase in enrollment. The highest increase in enrollment, registered by Mindanao State University, was 29 percent. This, however, is hardly encouraging when compared to the decline in enrollment experienced by most schools. The Iloilo Doctors College of Medicine, for instance, reported a 74-percent decrease in enrollees. Except for the University of Sto. Tomas, nearly every medical school covered by the study reported a shortfall in its enrollment quota. (Table 3)
Enrollment Trend in Selected Medical Schools
|Schools||Quota||2001-2002||2004-2005||Increase||Shortfall of AY 2004-|
|(%)||2005 enrollment from|
|Angeles University Foundation||150||72||30||-58%||-80%|
|Bicol Christian College of Medicine||160||25||19||-24%||-88%|
|Cebu Doctors College of Medicine||200||120||99||-18%||-50%|
|Cebu Institute of Medicine||260||118||77||-59%||-70%|
|Cagayan State University||80||33||19||-42%||-76%|
|Davao Medical School Foundation||160||88||100||1%||-38%|
|De La Salle University – HSC||200||257||117||-54%||-42%|
|Far Eastern University||360||379||248||-35%||-31%|
|Iloilo Doctors College of Medicine||160||78||20||-74%||-88%|
|Manila Central University||210||148||54||-64%||-74%|
|Mindanao State University||80||42||54||29%||-32%|
|Pamantasan ng Lungsod ng Maynila||160||160||135||-16%||-16%|
|Remedios T. Romualdez Mem’l Found.||80||73||30||-59%||-62%|
|Saint Louis University||160||112||64||-43%||-60%|
|South Western University||210||138||78||-43%||-63%|
|St. Luke’s College of Medicine||120||128||76||-41%||-37%|
|University of Sto. Tomas||410||421||440||5%||7%|
|University of the Philippines||167||160|
|University of Visayas||160||80||40||-50%||-75%|
|Virgen Milagrosa University Foundation||160||68||24||-65%||-85%|
|West Visayas State University||160||99||100||1%||-38%|
|Zamboanga Medical School Foundation||80||30||33||1%||-59%|
|Source: Association of Philippine Medical Colleges, 2004|
A future with fewer doctors is an unsettling scenario. More alarming, however, is the possibility that that future is already upon us.
According to Dr. Bernardo, 250 hospitals, or about 10 percent of the country’s total number of such institutions, have closed down in the past three years. These are usually devolved government hospitals and private primary hospitals. Dr. Bernardo says that in a study he made of such hospitals, 25 percent closed down because of loss of doctors as a result of death, transfer to another career like politics or shift to another business; 22 percent due to the failure of the hospital to meet the nurse-patient ratio of one for every four; 18 to 20 percent, labor problems; and 15 percent, financial problems.
The closure of hospitals as result mainly of the absence of doctors and nurses is a development that worsens a health delivery situation that has been compromised for a very long time. Half of Filipinos die without seeing a doctor. Most doctors and nurses practice in urban areas; only medical technologists, midwives and barangay health workers venture to the rural areas.
“Most doctors can’t work in an area without a cell phone site! Nurses go to the urban areas because these serve as their launching pad for deployment abroad,” complains Dr. Bernardo.
Against the diminishing number of available health workers, the Philippines continues to make its mark as the biggest health service provider to the world. It supplies 25 percent of all overseas nurses worldwide. Next to India, it is the second largest source of doctors in hospitals abroad. Few ironies can match that.
When students are called upon to recite in this nursing school, they are admonished by the teacher to speak in English. “How can you work abroad if you can’t even answer in English?” the teacher tells them.
Soon, the school will introduce a new subject: Transcultural Nursing. It will teach students how to practice their profession in countries whose culture and environment differ vastly from the one they had always known.
Preparing for a job abroad is the clearest lesson that students in this Manila nursing school are learning. But it is not the only thing that is unique about the new crop of nursing schools. Students include not just the usual graduates fresh out of high school but middle-age professionals who are seeking a new career. They belong to a category not usually heard of in ordinary college classes: the second-coursers. A good number are mid-level executives from professions that bear little resemblance to the health sciences. In their first jobs, they were accountants, clerks, teachers, journalists, government employees, secretaries. Now they hope to become nurses, preferably in a foreign land.
With the surge of second-coursers, many nursing schools are adjusting their requirements to fit the needs of this type of students. There is an abbreviated course, for example, for doctors since they have already taken up much of the basic science subjects required in nursing. Other professionals wanting to become nurses could have their basic science subjects in their first course credited as well. The result is a shorter term for such students.
There are, however, nursing schools that do not admit second-coursers, including doctors, in their classes. The demand from regular students appears to be enough to make up for any financial gain that is given up.
“Nursing is not a poor man’s course,” says a social scientist major who decided to change professional gears. Tuition per semester is P40,000. Other costs include reading materials, about P5,000 (for books, both bought and photocopied); stethoscope, P850; white shoes, P1,500; white shoe polish, P500; food and lodging, P25,000.
For students who could not afford the full semestral payment, an installment plan is available. A down payment of P10,000 is required, with the balance paid in three “gives,” each to be given before the three major tests: prelims, midterm and finals. Inability to pay at any point would mean dropping out from class, repeating the semester and paying up once more. In the end, the poorer the student, the higher the costs incurred.
Yet, students continue to enroll in droves in nursing schools. According to the CHED Technical Committee on Nursing Education, 80,000 students were enrolled in more than 300 nursing schools in 2004. There are schools that do turn down enrollees for sheer inability to accommodate them. Far Eastern University, for example, reportedly rejected 5,000 applicants last year. In the same period, the UP College of Nursing admitted only 70 students out of 11,000 who applied. That number for admission will not increase even as 14,000 applicants have already asked to be taken in for the coming school year. Where will the rest of them go?
“As of last count, there were 350 nursing schools,” says Tamse of CHED’s Technical Committee on Nursing Education. The number includes 23 schools that failed to meet the requirements set by the government for them to operate. The schools are supposed to have until March this year to stop operating and start transferring their students but they have appealed to CHED to let them continue for one more year. They have also sought the help of congressmen to avoid closure.
To warn students, Tamse urges them to check with the commission about the status of the nursing schools they plan to enroll in. It has also issued a list of the performance of the various schools in the Nursing Board Exam. By looking at the performance record, students would know which schools were able to turn out students that were able to pass the Board Exam. (I have the list but it’s quite long. It would be useful to release it, though. Will send it as soon as I can.)
The schools were classified in five categories: outstanding performance, for schools where 90 percent or more of their examinees passed the Board in the last five years; high performing, those with 75 to 89 percent; average performing, 50 to 74 percent; low performing, 30 to 49 percent; and very low performing, 29 percent and below.
Only 12 nursing schools, or 6 percent of the total, made it to the outstanding category (UP Manila, 100 percent; St. Paul College of Iloilo, 99.57 percent; Silliman University, 98.39 percent; West Visayas State University, 97.06 percent; University of Sto. Tomas, 96.67 percent; St. Louis University, 95.05 percent; Mindanao State University in Marawi City, 95 percent; St. Paul College in Dumaguete, 93.38 percent; Pamantasan ng Lungsod ng Maynila, 92.53 percent; St. Mary’s University in Bayombong, 91.02 percent; St. Paul College in Manila, 90.81 percent; and University of the East Ramon Magsaysay Memorial Medical Center, 90.57 percent).
Low performing schools made up the biggest group at 36 percent, followed by average performers (26 percent), very low performers (21 percent) and high performers (8.5 percent).
Of the 94 schools that had less than five years of Board performance, 42 had zero passing rates, meaning none of their graduates passed the national exam.
Under the law, a nursing school must have a passing rate of 5 percent to be able to continue operating. CHED wants to push the rate up to 30 percent, a level that could close down many of the nursing schools.
For almost a year, CHED’s technical committee monitored the nursing schools throughout the country. Its members reviewed their compliance with five requirements: adherence to the nursing curriculum, availability of facilities, ratio of faculty to students, affiliation with or existence of an active tertiary hospital to serve as base for the students, and a qualified faculty.
Tamse notes that many schools “are really having trouble with the last three requirements.” Depending on the year level of the students, a school is supposed to observe a teacher-student ratio. In the subject on Related Learning Experience, for example, there should be one teacher for just eight students.
A school must also have a dean—a requirement which seems reasonable enough but which nursing schools find hard to meet. “It’s very easy for them to have facilities because they have lots of money. They can construct a school, put up air-conditioned classrooms, a nursing laboratory and all that,” says Tamse, but one apparently cannot buy something that’s simply not available, such as qualified teachers.
Base hospitals are also a problem. “We have too many nursing schools for the number of qualified training hospitals available all over the country,” she says. Not just any hospital can qualify as a base. It has to have the major departments—surgical, ob-gyn and pediatric wards. It should be a tertiary hospital accredited by the Department of Health. And it must have an occupancy rate of 80 percent, which means it is an active hospital where students can be exposed and properly trained.
Some schools also want to offer classes in trimesters or quartermasters, a suggestion that would fast-track the course but inevitably lead to half-baked students. “In many health sciences, exposure is important because that is where skills are honed. If you shorten that, you come up with graduates who are half-baked. And when they get to the hospitals to work, they’re dangerous. Talagang makakapatay,” says Tamse.
To certain schools, CHED might appear to be a villain. But the government and even recruiters know that in the end, having high-quality graduates is the best way the country could stay in the business of exporting nurses.
Dr. Rusty Francisco, a nurse with a doctorate in nursing education and an owner of a training center for nurses bound for abroad, says many students are deluded into thinking that enrollment in a nursing school is a guaranteed passport to a job abroad.
“Passing all examinations does not make them competitive,” he says. Not many Filipino nurses are familiar with the medical equipment being used in American hospitals. Nor do they know how to operate in an environment where patients are more assertive and aware of their rights. That is why in his training center, which is located right behind the Professional Regulatory Commission and right smack in the heart of Manila where nursing schools and training centers have sprouted, Francisco emphasizes what Filipino nurses should expect when they are in the US.
He adds that while Filipinos are still the preferred health workers, they may soon be facing stiff competition from the Chinese and the Indians who have come to realize the financial windfall from the export of nurses to developed countries.
Although Filipino nurses are known for being compassionate and caring, these qualities appear to be disappearing because the goals for taking up nursing have changed. From desiring to be of service to another human being, nursing students are now primarily motivated by the need to make money.
“A school curriculum does not automatically turn a person into a caring, compassionate nurse with the ability to be assertive and articulate oneself,” Francisco says.
Tamse agrees with the observation. “Some of them don’t even have the heart for it. They’re just there because they know it’s a good passport for going abroad…Nursing is about caring and being compassionate. It’s difficult to be compassionate if your only purpose is to earn,” she says.
But who can deny the validity of the economic reason behind most decisions to leave? At the PGH, “99 percent left because they have to finance the schooling of their brothers and sisters, the husband is unemployed or underemployed, the children need to be given quality education and so on,” Tamse says.
Many of the nurses cry and tell her, “I don’t want to leave naman ma’am, eh. It’s just that I have to do it.” In one exit interview, a nurse underscored the words, “Pera lang po.”
If all the corrupt people that you know in government are lined up against the wall and shot, would you reconsider your decision to leave?
When Dr. L. Santiago, 46, was asked this question, he said, “Yes.” But moments later, he took it back and said, “No, because those people have children and relatives who must also be corrupt. If we shoot all corrupt Filipinos, who will be left?”
And so the doctor will go on with his plan to find a job in Canada. He is giving himself five years to do that. First, he will take up the medical board exam in that country. But he knows that years ago, a foreigner who passes the board is not automatically given a job as a doctor in Canada. It is a restricted occupation, given only to Canadian citizens. He is hoping that times have changed there. If not, there is still hope. He will take the road taken by many others before him: he will enroll in a nursing course and then apply for a job as a nurse.
The most common reason given by health workers who leave is economic. But they are also troubled by political instability, corruption and the need for political backing in order to get a job or a promotion. They also deplore the long hours of work that go with the measly pay. Getting out then becomes the only way out.
A study by the National Institutes of Health describes health worker migrants (nurses, physical and occupational therapists, and midwives) as generally young, from 20 to 30 years old. Migrant doctors are between 31 and 40 years old. But these figures can deceive. Now and then, hospital staffers would speak of doctors who have retired or are about to retire and taking up nursing. Age is not a hindrance to working abroad, especially in the US where one can work for as long as one wants to.
The migrant health workers are still predominantly female, although the number of male nurses has been observed to be rising.
And because a health science education costs quite a lot of money, most workers who migrate belong to the middle class.
The preferred country of destination is the United States because of the possibility of acquiring American citizenship and all its privileges. In reality, however, 57 percent of Filipino nurses abroad are in Saudi Arabia; a comparatively lower number at 14 percent are in the US; and 12 percent are in the United Kingdom.
Dr. Jaime Galvez Tan has an ongoing project: he is monitoring the attitudes of medical students over the years. He asks them three things: How do you describe yourself? How do you see yourself ten years from now? What country do you want to serve?
This is what he found out so far:
On a medical student’s first and second years, he would usually describe himself as “compassionate” and “humane.” On the third year and onward, he would say he is “competent” and “skilled.
On his first and second years, the student would also see himself working in public health, community medicine, or with a non-government health organization. By his third year, however, his goal has changed to that of becoming a super-specialist.
On the first and second years, 100 percent of all medical students replied that they would like to serve in the Philippines. By the time they graduate, however, only 25 percent said they would stay.
Somewhere on their way to becoming doctors, something must have happened to these medical students. Dr. Tan thinks that the lack of good role models is partly to blame. Some teachers, he says, tell their students there is no hope in this country. The medical curriculum, he adds, gives premium to grades and competencies rather than values. Globalization of labor has also contributed to a materialistic attitude even among those whose profession is supposed to serve others.
Yet, there is no stopping the flow of Filipino doctors and health workers to other countries. Doing nothing or letting matters run their course could only lead to a “health human resources disaster,” Dr. Tan says.
He proposes to “tame” the exodus of health workers to the Northern countries, achieve a “rational, programmed” departure of health professions and “secure a win-win situation” for the Philippines and the importing countries.
Specifically, Tan suggests the initiation of bilateral negotiations with countries that import Filipino health workers that would lead to the allocation of development assistance or compensation to the Philippines in exchange for the sending of such workers abroad.
He also advises the government to get its act together by creating a national commission to oversee the planning, production, deployment, retention and development of health professionals in the country. He deplores the fact that there is no unified agency that takes charge of these matters, which explains why figures concerning health matters vary depending on which government agency is consulted.
In a rather controversial scheme, Dr. Tan also suggests the enactment of a National Health Service Act that would require health sciences education graduates of state colleges and universities to serve the equivalent number of years of study in the country. Since the state has subsidized the education of these health science graduates, he reasons, they should pay back the favor by serving in the country for a few years.
Several bills have been filed in Congress imposing mandatory service for nurses. Predictably, these have been opposed by nurses’ organizations that say the practice is discriminatory and oppressive.
But Tan believes otherwise. He points out that the current health crisis warrants compulsory service by health workers for a specified period. He also notes that countries like Indonesia and Malaysia require their medical and health science graduates to work in the country before going abroad. In fact, Tan says, the Philippines is the only country in Southeast Asia that does not have a National Health Service Act.
Dr. Irineo Bernardo of the Philippine Hospital Association has a story. In Saudi Arabia, it was once observed that there were too many burn cases, especially during the Haj or pilgrimage. Responding to the situation, hospitals asked for more doctors, nurses and medicines. One day, an engineer asked: Why are there so many burn cases in the first place? Someone then explained that these would happen because Arabs like to boil tea but in the process would accidentally burn themselves because of the way the water pitcher is designed. And the engineer suggested, why not change the design of the pitcher? And they followed his advice. The number of burn victims went down.
“We need to look at a problem from many angles,” Dr. Bernardo says. Instead of dreading the loss of more nurses, doctors and other health workers, he suggests working harder to improve the health condition of Filipinos so that they would not get sick so often and so quickly.
“The government keeps talking about having a strong republic. Why not have healthy Filipinos so we can really have a strong country?” he says.
Up to now, Bernardo says, the government has not established the health status of the country. “How healthy or how sick are we?” he asks, adding, “If the number of health providers go down, will that make more people sick? No!”
But if the government fails to look after the health of its people—such as by making it easy for cigarette companies to sell their products—then Filipinos will get sick, he says.
“Sickness comes from our lifestyle, from what we take in. We need food, not medicine,” the doctor says.
Educating the population on how to take care of themselves could do more to improve public health rather than having a big number of health providers, he says.
While the disappearance of doctors and nurses is indeed a problem, Dr. Bernardo suggests taking good care of those who stay behind. “Recognize the competence of nurse anesthetists, for example, and pay them as well as a doctor,” he says. After all, surgery would be impossible if no anesthesia is administered.
There is, in fact, a boon for those who will remain in the country: they would now have a bigger market for themselves. Fewer rivals, in other words.
“There will be a time when things will not be good. But they will become better. Many hospitals will close down but they will be replaced by new players. We will change,” he says. ###