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For the past 60 years, The Philippines has had a world-leading reputation for preparing highly skilled nurses and healthcare workers for the purpose of exporting to countries in high demand of said services (Brush and Sochalski 2007:37). Simultaneously, the health care shortages in these high-income countries have resulted in “accelerated nurse recruitment, mobility, and migration” (Perrin, Hagopian, Sales and Huang 2007:219); leaving The Philippines itself with a “dangerous shortage” of nurses and healthcare workers (Overland 2005). This phenomenon is often referred to as a “brain drain”: qualified skill leaving its own country. This is a large issue relevant to development as it boasts implications for all parties involved; the country of emigration, the country of immigration, and the correlated healthcare systems as well as economies are all impacted. In connection to development one could also ask, does such mass movement further contribute to the First World’s success and further detriment the struggles of Third World nations? As an undergraduate student, concerns for me could lie in the area of job availability upon completion of school. Will I be competitive in the health care field or will preference be given to the reputably skilled, foreign-trained nurses? Thus, I will argue that although the mass nurse migration occurring in the Philippines is good in many ways, it has significant negative implications for the country; largely pertaining to the labour and employment, trade, and health sectors (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1414).
Push and Pull Factors
For nurses in The Philippines there are many reasons to leave the country in search of work in higher income countries like Canada and the United States. There are reasons not only to leave the islands (“push” factors) but also reasons to come to North America (“pull” factors). In both instances, factors can be economically related, work related, as well as socio-politically related (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1412).
In starting with reasons to leave The Philippines as a qualified nurse, the obvious might pertain to low wages; in a country where the healthcare budgets are minimal, low salary and weak benefits packages are elements that send employees looking elsewhere (Perrin, Hagopian, Sales and Huang 2007:219). On top of this, due to lack of investment in the health care sector, “poorly resourced and unsafe working environments have been identified as key motivators of migration,” (Brush and Sochalski 2007:43). From a logical standpoint, any skilled individual would opt to work in a clean and technologically advanced environment if the opportunity presented itself. Add on the fact that the cleaner and more equipped environment promises more financial benefit? Seems to be a pretty obvious choice, does it not? Tack onto all of this that The Philippines also encompasses a “tight domestic labour market”, and it pushes one into migrant work even further (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1406). In a country where the budget for health care is intolerably low, the wiggle-room for job availability will be correspondingly low too. Despite professional training and high level education, jobs will not be available due to a lack of resources. And this proves true regarding nursing in The Philippines. If one wishes to work domestically and is able to find a job, however, the next push is the current nurse-to-patient ratio. Forty to sixty patients per nurse is a ratio that is dangerous for not only the Filipino society (regarding the lack of care) but is also increasingly dangerous for the nurses themselves (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1414). To be run off of one’s feet, working inhumane hours, and being paid unbearable wages has very minimal appeal to it. Especially when there is a place that entices the workers using quite the opposite strategies…just an ocean away.
To pull is defined as to exert a drawing force; to move or go (Dictionary.com).
Factors that attract nurses and other Filipino healthcare workers to North America have this exact defined affect. The pull factors: “higher income, better living and working conditions, opportunities to travel and opportunities for skill development and career advancement,” (Perrin, Hagopian, Sales and Huang 2007:220). As with the factors that push nurses away from The Philippines, money seems to be the ultimate regarding the pull that North America has on the migration. It is claimed that nurses can “make in 1 year what it would take over 20 years to earn at home,” if they work overseas (Brush and Sochalski 2007:40). Numerically, it is an average of US$2,040 a year in The Philippines versus the potential of US$48,000 offered in countries abroad (Brush and Sochalski 2007:40). This makes for a financial difference so remarkable that an educated Filipino mother struggling to provide for her children might be seen as foolish to ignore the “fast” money — fast in the grand scale of things. Recruiters are a method used to demonstrate the many better opportunities that can pull nurses to North America (Brush and Sochalski 2007:37); opportunities especially pertaining to job availability and career advancement. In North America, with the aging of the Baby Boomers acting as a key ingredient, a growing need for healthcare has developed. As Brush and Sochalski further explain, our countries have been unable to produce and hold onto sufficient numbers of healthcare worker to fulfill the needs. Because while North America might be pulling nurses from The Philippines and various other nations in, inadvertently, the phenomenon is bilateral (Brush and Sochalski 2007:38). Not only are North American’s not enrolling in nursing programs at the necessary rate, but those who enroll are taking the opportunities to fulfill the needs of other nations with healthcare shortages. The pull of Filipino nurses to North America is so strong, and the benefits seen as so rewarding, even if an individual does not wish to become a nurse, patterns show they are doing so anyway — at large, for economic reasons (Overland 2005). It has been observed that the educated likes of law students or medical students are even switching into nursing (Overland 2005). Martha Overland is even so bold as to say that the numbers prove that “young, talented Filipinos would rather be nurses abroad than doctors at home” (2005).
The Philippines has been a world leader in the equipment of nurses for export since the 1950s (Brush and Sochalski 2007:39). What began as work-exchange programs in the 1940s (Perrin, Hagopian, Sales and Huang 2007:220), resulted in the “overturning of Asian immigration restrictions under the 1952 Immigration and Nationality Act”; encouraging skilled laborers to migrate to specific areas of the United States holding shortages in the labor sector (Brush and Sochalski 2007:39). The work exchange programs became a path that young Filipino women were using to get to North America and therefore “elevate” their lives economically as well as personally (Brush and Sochalski 2007:39). During this era, working overseas was typically seen as a method of advancing training and skills in order to bring the knowledge back to The Philippines and improve the standards of health services domestically (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1408). But the times were changing. As many of the students stayed in the United States as migrant workers, and were thus granted permanent residency (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1408) via the changing immigration laws, The Philippines emphasized the onset of an export-oriented economy (Brush and Sochalski 2007:39). The main commodity? Nurses. The Philippines hailed the nurse migrants as “heroes” for the reason that their remittances were seen as a huge contributor to nation building (Brush and Sochalski 2007:39). In fact, throughout the 1990s “remittances from skilled and professional Filipinos made up 5.2% of the country’s gross national product” (Perrin, Hagopian, Sales and Huang 2007:220); that signifies a large proportion of the nation’s people working out of the country. And, on top of that, a large percentage of GNP being obtained through working abroad as opposed to domestically. Within the past two decades nursing shortages have climbed in North America and the migration of Filipino nurses began as a temporary solution to fill the gaps (Brush and Sochalski 2007:42). The shortages have been observed to be cyclical though and the temporary solution by way of migrating nurses from The Philippines has become a permanent fix (Overland 2005). And this is where the division between positive and negative effects begins to cleave.
Good for The Philippines
Perhaps the positive implications for The Philippines as a whole are not quite as obvious as the positive implications for each individual nurse who migrates to North America in quest of higher income. As previously discussed within the Push and Pull Factors, migrating to a more developed nation in search of work as a nurse is widely seen as a move that enhances the quality of life for the nurse and his/her family (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1406). Seeing as “one out of every five employed [Filipino] workers is underemployed, underpaid, or employed below his/her full potential,” the opportunity to become employed abroad eases tough conditions and provides work to those seeking jobs (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1407). Dually, whilst of significant economic benefit to the individual involved, the migration of Filipino nurses is of great benefit financially for The Philippines; “These nurses stand to provide substantial remittances to their home countries,” (Brush and Sochalski 2007:44). As touched upon, remittances are an integral part of the Filipino economy. As an example, Marilyn Lorenzo and her team show the recent spike within the last decade to have reached US$ 10.7 billion in the year 2005; of this remittance total, nurses contributed by far the largest portion when all migrant professional workers were taken into account (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1407-1408). The avenue exhibited by The Philippines to gain money via the exportation of nurses as a commodity has become a model by other nations in search of the same thing (Brush and Sochalski 2007:44). The remittances are seen as so very significant to the respective home country that the next significant step could be seen to be the redistribution of said remittances into the domestic health care sector (Brush and Sochalski 2007:42).
Negative implications for The Philippines
Despite the significant contributions made remittently by Filipino nurses working abroad, The Philippines faces a serious risk to the nation’s health as a result of the mass migration of nurses occurring (Brush and Sochalski 2007:40). The lack of care being received by Filipino’s at home is just one of many negative implications that the “brain drain” has on The Philippines though. The world wide nursing shortage experienced by many developed countries has resulted in what has been dubbed by Brush and Sochalski as provider maldistribution (Brush and Sochalski 2007:37); developing nations, specifically The Philippines, are unprepared to deal with the extreme loss of their nurses to developed countries. As a result, the quality of nursing services received in The Philippines has diminished; the skilled workforce is being lost far faster than replaced (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1409). Via depletion of the pool of senior nurses (those with the most experience and skill), they add, the quality of care received is lesser. In addition, Lorenzo and crew also highlight that this loss requires continual investment in the training of new skilled nurses (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1413). When the nursing migration phenomenon ensued it brought with it an explosion of unregulated nursing schools in an attempt to satisfy the demand (Overland 2005). Because the regulation of these schools was given to the provinces, and there was “no single entity enforcing minimum standards”, the quality of the education received became unacceptably low (Overland 2005). This had a negative implication economically as the institutions cost a lot of money but was also hampering to the reputation of the quality of nurses that The Philippines was producing (Overland 2005). What is also happening with the schools is that the professors and teachers of nursing are also getting caught in the upswing that is migrating to North America; as the faculty members leave too, the demand seems impossible to meet, claims Martha Overland. But, to satisfy the numbers of students who want to become nurses, the requirement that an educator must hold atleast a master’s degree is being overlooked– yet another sacrifice of quality for quantity (Overland 2005).
Intranationally, the recruitment of nurses from rural areas of The Philippines into the urban centres (to fill the voids left by those who migrated Westerly) has left the health care service for the people in the countryside in a depleted state (Brush and Sochalski 2007:42). Unstable as it were, the people in the rural Philippines were now even more vulnerable in having to “bear the brunt” of the migration cycle (Brush and Sochalski 2007:40). For small towns that had always been serviced by maybe one nurse and not a single doctor, and had little access to transportation into the city, the people are now cut of their health care resource almost completely. Another grueling thing is that, even if there were enough nurses who remained in The Philippines, the cap placed on budgets is far exceeded by the demand for nurses and their services (Brush and Sochalski 2007:41). Between the closure of hospitals, the low quality of care, and the dropping standards of education, the nurse migration to North America has many negative implications for The Philippines.
Statistics have it that 84.75 percent of employed Filipino nurses work abroad; outside of the borders of The Philippines (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1409). For such a significant percentage of workers, employed in a sector so significant to society, to be working out of the country, one can expect for there to be implications — both positive and negative — involved. In saying this, Morris and Tevaarwerk claim that “truly democratic countries recognize the right of their citizens to seek their fortune wherever they wish” (Morris and Tevaarwerk 2008); in The Philippines case, this rests on the consideration of the fortune that they will in turn benefit from. There are, however, ways that The Philippines could make better effects of the brain drain. One proposed solution is that “healthcare professionals who move to another country would be required to reimburse their country of origin the amount by which their education was subsidized by the state,” (Morris and Tevaarwerk 2008). This would allow for the education and training of more professionals; it could also be potentially beneficial to Canada in that Canadian-trained nurses would have to reimburse Canada if they were to move elsewhere (Morris and Tevaarwerk 2008). This would fall under the category of bilateral negotiations explored by Lorenzo and team; negotiations that benefit both the sending and receiving countries (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1416). Or perhaps another idea: the forging of hospital-to-hospital partnerships between the North and South (Lorenzo, Galvez-Tan, Icamina and Javier 2007:1417).
All in all, said by a Filipino himself, “We will always have a brain drain when someone working abroad can earn what it takes five years to make here,” (Overland 2005). Nurses who migrate to North America in search of better opportunities are not concerned with the negative implications it will have for their homeland. All that concerns these individuals is the “bottom line”: there are families to be taken care of. It does not seem so out of the ordinary that qualified and skilled nurses go to the lengths they do to make more money when it is put into this context. If in need, North Americans would be apt to do the same thing. Thus, although there are many good implications of the mass nurse migration from The Philippines to North America, there are also many underlying negative implications for the country.
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