LETTING THEM GO
Not only has the number of nurses leaving for abroad gone up, but also the number of doctors entering nursing school--so they could go abroad. Has medicine now become a prenursing course?
Labor is the Philippines' primary export. In fact, as much as US$8.5 billion worth in remittances entered the country in 2004 alone--nearly half of the national budget, or about three percent of the gross domestic product.
The national government does not only tolerate but encourages its citizens to look for jobs abroad. Labor secretary Patricia Santo Tomas told Agence France-Presse in May that this should not be seen as the government's failure to provide a better life for many of its citizens, but as a natural consequence of globalization. Human resource, she said, is now global resource, and should move around the world the way that capital from more developed countries move.
And it is, indeed, a great resource: outside of the seafarers, domestics, teachers, engineers, and entertainers the country has spread around the world, the Philippines also provides the world with many health professionals. The Philippines has the most number of nurses working outside it; it is second only to India in the number of doctors who work in a foreign territory.
Thousands of nurses leave every year. The Professional Regulations Commission reported that from 1994 to 2000, between 4,200 and 7,500 Filipino nurses were deployed abroad. By 2001, the numbers reached five figures; in 2003, the number was only 1,500 shy of reaching the 20,000 mark.
Doctors to nurses
With the promise of nearly 20,000 nursing positions every year in 32 countries--with the United States even offering citizenship to nonnative health workers and their families--there is a fast turnover of people comprising hospital nursing staff, and an increased demand for nursing education. In 1998 there were fewer than 200 nursing schools in the country; as of April 2004 there were 370.
And then there are the medical practitioners and specialists who abandon the profession to become nurses.
At present there are no definitive data on the number of doctors who have entered nursing school. Late last year there were reports that it reached 2,000; lately it's only reported to be "thousands." In June, a reported 1,200 former doctors took the nursing board exams.
Dr. Jaime Galvez Tan, executive director of the National Institutes of Health and vice chancellor for research at the University of the Philippines Manila, conducted a series of studies to understand this "phenomenon." With a grant from the United States Educational Commission of Foreign Medical Graduates, he sent out questionnaires, conducted interviews and focused group discussions to gain a deeper understanding of the issue, and chart possible solutions.
Based on the interviews, Galvez Tan found that at least 45 nursing schools offer "abbreviated one-and-a-half- to three-year courses for doctors to become nurses," which some respondents called the "Alternative Health Science Education Program." Each class has between 50 and 500 students meeting every weekend.
In a survey of 100 doctors who have entered nursing schools--Galvez Tan labels them as "nursing medics"--from various sites, more than three-fourths of the respondents turned out to have been doctors for at least 10 years before taking up nursing. Many of them were specialists.
One-word question: Why?
The respondents blamed five key issues for their career shift: political instability, poor working conditions, the "threat" of a malpractice law, low salary and compensation, and peace-and-order problem. Galvez Tan added: "I've always felt that doctors are organized…. Individually they are respected by the community. But given a larger issue… even doctors find themselves in a situation where they themselves feel disempowered. Just like a sick person being disempowered by the illness."
One of the key informants, a surgeon, in Galvez Tan's study had this to say: "I belong to a batch of 534 medical doctors taking up nursing way back in 2001…. The first batch already went abroad, and we hear good news from them. Their life now is much, much better. Those remaining here are still in medical practice, but are all prepared and ready to leave anytime, if the country's situation gets [worse]."
Another respondent, an obstetrician-gynecologist, seemed more obviously upset: "It seems that there is no hope for the country--[the] graft-and-corruption situation is really at its worst! And life is really difficult. There's a part of me wanting to stay and practice here but I can see that there is no hope for me and my family."
Aside from their perception that the national situation is desperate, they also perceive the rewards of working as nurses abroad far outweigh the risks. The immediate attractions were the perceived sociopolitical and economic security abroad, the attractive salaries and compensation packages, and more job opportunities and better chances at career growth.
The domino effect
Now that nurses leave the country and doctors become nurses so they could leave the country, the nursing and medical professions are starting to feel their loss.
Because of the demand for nursing education, many schools are now offering nursing courses; established nursing schools are forced to open up more sections to accommodate the enrollees. Galvez Tan said that one Metro Manila nursing school began offering 40 sections--from just four--of 40 students each.
There is also a dearth in nursing instructors--even nursing-school administrators. Many have to juggle teaching positions in various schools. Few of the instructors have master's degrees, which are a requirement for academic positions. Galvez Tan also mentioned that there have been reports of "flying deans"--those who serve as dean in more than one school--in several nursing schools just to fill the vacancies.
These are believed to lead to a decline in the quality of nursing education. Between 1994 and 2004, there was a 22-percent drop in the number of students who pass the nursing board examinations; the total number of passers hardly even cleared the 50-percent mark. And while the Commission on Higher Education (CHED) attempted to close nursing schools with poor performances, Galvez Tan reported that there are still those that go on operating.
On the side of medical education, fewer people now seem to be interested in becoming doctors. The number of students taking the National Medical Admissions Test (NMAT) has gone down 33 percent in 2004; enrollment in medical schools experienced a proportionate decrease. "They really only felt the jolt in 2003-2004," said Galvez Tan.
Last year, three medical schools closed down, and if enrollment doesn't pick up in the coming years, more are expected to close.
The search for solutions
What, then, should be done? "It is an out-of-the-box situation demanding an out-of-the-box solution," said Galvez Tan.
In May's Philippine College of Physicians annual convention, Galvez Tan was awarded the 2005 Antonio G. Sison Memorial Lecture, where aside from unveiling some of the results of his study, he came up with 10 strategic solutions to the large-scale migration of Filipino professionals. Four of these solutions are for global action, while the remaining six have to be done locally. He acknowledged, however, that the solutions he is proposing are not the only solutions that could be employed.
1. Initiation of high-level bilateral negotiations with host countries importing Filipino health professionals
A team composed of leaders from key government agencies (the Department of Foreign Affairs and the Philippine Overseas Employment Agency, among others) will conduct bilateral discussions with countries in need of health workers. These discussions will center on a partnership and development-aid approach.
This aims to make equitable the current "lopsided" approach to the importation of labor, which mostly benefits the importing countries. Galvez Tan emphasized that Filipino health workers are "gems" and should be treated as such. To strike some form of balance, the importing countries may choose to provide the Philippines "development aid packages," that will help train globally competitive nurses and doctors; upgrade nursing and medical education, health services, and remuneration; offer scholarships.
2. North-South hospitals to sign health-facility partnership agreements
This also aims to achieve a better balance by asking a hospital from "Northern" countries to provide a financial grant for every Filipino health professional joining its staff. The financial grant will go to a medical- and nursing-development trust fund of a Philippine hospital or medical or nursing school.
3. Inclusion of multilateral agreements in the trading of medical and nursing services among North and South countries in the General Agreement on Trade and Services (GATS), and the formation of a World Health Organization (WHO) Commission on Health Human Resource Management.
4. Forging a joint or multicountry research agenda and action program on health-human-resources (HHR) development.
This strategy aims to encourage a regular sharing of HHR policies and database among the countries involved.
5. Creation of a National Commission on Health Human Resources Development
This may be started through a presidential executive order, and then through legislation. The commission will be composed of leaders from the executive and legislative branches of the government, the private sector, academia, and civil-society groups.
The commission will develop a unified HHR policy and a national HHR policy-research agenda. It will also assess the current situation of nursing and medical human resources, as well as look into their history and prospects. It will also embark on coming up with a definitive database on Filipino HHR.
6. The institution of a National Health Services Act (NHSA)
The Philippines, said Galvez Tan, is one of the few Southeast Asian countries without an NHSA. The NHSA will help the country scientifically program the exit of its health professionals to ensure that the country will not run out of health professionals. The NHSA may choose to require medical and nursing graduates, specially those from state colleges and universities, to serve a few years in the country.
7. Establishment of the Philippine Health Professional Registries
Medical and nursing registries will be corporate-run human-resource-development centers that provide hospitals, clinics, and other facilities with their medical and nursing personnel needs. Registries will effectively locate and monitor medical and nursing human-resource availability.
8. Creation of the Philippine National Council for Health Professional Concerns
This council will be composed of all the major national organizations involved in nursing and medicine. Its functions will be mainly to develop a 10-year strategic plan for nurses and physicians in the country, and to act as a body for the implementation of all medical and nursing policies.
9. Development of new learning and career opportunities for health professionals
This requires the development of new residency training programs, fellowships, and postgraduate courses that cover such areas as health informatics, health economics, health entrepreneurship, health advocacy, health communication, and public-health management.
10. Institution of reforms in health financing and management of medical education
Reforms include increasing health scholarships in underserved areas and putting up medical schools in the ARMM and CARAGA, where there are still no medical schools, and adopting the seven-year integrated medical curriculum initiated by UP and La Salle to lower the cost of medical education. With a report from Arnel Mendoza
Masters for breast-feeding
In celebration of World Breast-Feeding Week, the University of the Philippines-Philippine General Hospital department of pediatrics gathered the country's visual-arts masters for a "Breast-Feeding Madonna with Child" painting session on August 1. Participants included (from top left) Napoleon Abueva and Anita Magsaysay Ho, National Artists; and Phyllis Zaballero, Celia Diaz-Laurel, and Araceli Limcaco Dans.
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