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By Chit Estella, Philippine Center of
Investigative Journalism
First of two parts
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 coworkers started
leaving. “That whole year, I kept seeing resignation papers,”
recalls Lani. 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.
This month, some 20,000 nursing students will
graduate from 350 schools in the country. As the global health
industry opens itself up to more migrant health workers, many of the
new graduates will be making a beeline for jobs overseas. But many
more of them will not pass the qualifying exams for nurses, thanks
to a boom in nursing schools that has led to a decline in the
quality of education and also of students being accepted into
nursing programs. In the last few years, less than half of those
taking the nursing board exams passed.
The best among the graduates, however, are often
bound for abroad, many of them skipping the one- or two-year
experience required by hospitals. In the last 10 years, the
Philippines sent close to 90,000 nurses overseas. Today it is
exporting more qualified nurses than it is producing, leading to a
nursing crisis that has already diminished the quality of hospital
care and even forced the closure of a number of hospitals.
A study by the National Institute of Health (NIH)
describes migrant health workers (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
United States where one can work for as long as one wants to.
Although the number of male nurses has been
observed to be on the rise, the migrant health workers are still
predominantly female, meaning more families are losing their
traditional caregivers—the wives, mothers and sisters. According
to a 2004 Asian Development Bank report, 65 percent of Filipino
workers overseas are women.
The NIH study also warns that because the
migrating nurses are usually the ones with training, experience and
skill, patients in hospitals and other health institutions in the
Philippines can expect a higher incidence of cross-infections,
adverse events after surgery, accidents, injuries and even increased
violence against the staff.
With the best among nursing students often
leaving as soon as they graduate, the less skilled are taking 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. It is, say many health
professionals, a cycle that leaves local hospitals in a state of
perpetual displacement—and patients in constant danger.
Next to India, the Philippines is already the
largest source of doctors in hospitals abroad. The country also
supplies 25 percent of all overseas nurses worldwide. Not
surprisingly, about 10 percent of the Philippines’ 2,500 hospitals
have closed down in the past three years because of the loss of
doctors and nurses to jobs overseas.
As more nurses leave and as fewer are qualifying
for the job, the situation in hospitals can only deteriorate. But to
Rita Tamse, deputy director for nursing of the Philippine General
Hospital (PGH), “that worse situation is happening right now.”
The exodus continues
“Our problem is unskilled, untrained
nurses,” says Dr. Irineo Bernardo, executive officer of the
Philippine Hospital Association and owner of a primary-care
community hospital in Tanay, Rizal. 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,” says Bernardo. “Last year, we
had five who left.”
Even the PGH, the country’s premier government
hospital, is also seeing an exodus, with up to a quarter of its
2,000-nurse work force leaving in the last few years.
The preferred country of destination is the
United States because of the possibility of acquiring US citizenship
and all its privileges. But 57 percent of Filipino nurses abroad are
in Saudi Arabia and only 14 percent are in the United States; 12
percent are in the United Kingdom.
But that may soon change. 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.
In 2001 the Philippine Overseas Employment
Administration (POEA) reported that 13,536 Filipino nurses went
overseas, almost double the previous year’s exodus of 7,683
nurses. The 2001 figure is the highest ever recorded. The same year,
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.
Falling standards
Tamse, who is also a member of the Technical
Committee on Nursing Education of the Commission on Higher Education
(CHED), notes that the latest Nursing Board Exam in December
registered its lowest passing rate ever at 43 percent. Of the about
12,000 students who took the board, only about 5,000 made the grade.
Thus, although the PGH used to accept only the
top graduates of the country’s nursing schools, it can no longer
afford to stick to such standards, says Dr. Jaime Galvez Tan, vice
chancellor of the University of the Philippines in Manila that is in
charge of the hospital. So long as a nurse makes the minimum passing
grade, an apparently desperate PGH will take the applicant.
Bernardo points out that the shortage of skilled
nurses compromises the quality of patient care. He says, “It takes
years for a new graduate, even for someone with good grades, to be
trained.” It is not enough that a nursing graduate knows the
theories, says the doctor, adding that “he or she must know the
culture inside a hospital as well.”
Skilled and trained nurses are a requisite of
proper health care. In some towns, small hospitals are run by
nurses, not doctors. Bernardo says that if the only nurse available
“is an idiot, then better not open the ward altogether. You’ll
be putting the patients at risk.”
One need not even go to distant barangays to
find unskilled nurses. In a top hospital in Metro Manila, Tan
recalls asking for a spittoon for a patient. “The nurse,” he
says, “came back with a urinal.”
I also witnessed a nurse at a government
hospital using her cell phone’s calculator to compute the intake
and outflow of fluid of a patient, only to come up with the wrong
numbers, which were recorded in the patient’s chart. Doctors base
their diagnosis and course of treatment on the patient’s chart and
wrong data could lead them to make wrong conclusions.
But even doctors are fast disappearing. On the
fifth floor of a busy hospital in Manila, for example, hundreds of
doctors congregate from Friday to Sunday in the early evening to
“learn nursing.”
Tan says that 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. Last year, the topnotcher in the
medical board exam announced his plans to work overseas as a nurse.
Dropping employment
Thus, even as more nursing schools pop up each
year, medical schools are getting less popular. Of the 39 medical
schools in the country, three have ceased operating because of
steeply declining enrollment. One report says that only six
medical schools out of 25 that it studied registered an increase in
enrollment. The highest increase in enrollment, registered by
Mindanao State University, was 29 percent.
This, however, is hardly encouraging compared
with 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 Santo
Tomas, nearly every medical school covered by the study reported a
shortfall in its enrollment quota.
Among the reasons cited by health workers bound
for abroad are political instability, corruption and the need for
political backing to get a job or a promotion. They also deplore the
long hours of work required of them. The most common reason they
give, however, is economic.
Tamse recalls that one nurse came back from the
United Kingdom with P500,000 after just six months there. For those
bound for the United States, there is even a signing bonus of
anywhere from $2,000 to $10,000.
Paltry salaries
These figures, she says, are “a far cry”
from what nurses are paid here. Those in the provinces, for
instance, get as low as P2,000 a month. 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 meantime, a
contractual nurse without experience gets P9,930 a month; with
experience, the pay goes a bit higher at P12,000.
Even recruiters are handsomely paid for every
nurse they bring to a foreign-health institution. Tan says a
recruiter once offered him $7,000 for every nurse that he could find
for a US hospital. When the disbelieving doctor finally got the
chance to talk to staff members of that hospital, he was even more
surprised.
“They denied it!” cries Tan. “They
weren’t giving $7,000 for every nurse. They were giving
$14,000!”
Tan worries that doing nothing to stop the flow
of Filipino doctors and health workers to other countries could only
lead to a “health human resources disaster.” Based on the
results of a project he has been conducting in the last several
years, he thinks the lack of good role models is partly to blame for
the exodus of health workers. Some teachers, he says, tell their
students there is no hope in this country.
Grades, not values
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 Tan says that medical students generally
start off with the right attitude and values. But somewhere on their
way to becoming doctors, something seems to happen to them, changing
their goals and plans, he says.
Over the years, Tan has been monitoring the
attitudes of medical students, asking them three questions: How do
you describe yourself? How do you see yourself 10 years from now?
What country do you want to serve?
During the first and second years, he says, a
medical student would usually describe himself as
“compassionate” and “humane.” The student would also see
himself working in public health, community medicine, or with a
nongovernmental health organization. Those years also see all
medical students replying that they would like to serve in the
Philippines.
Change, however, comes by the third year onward.
With students invariably describing themselves as “competent”
and “skilled,” many now want to become super-specialists. And by
the time they graduate, only 25 percent said they would stay.
But Tan says the outward flow of health workers,
however strong it is right now, can be “tamed” and lead to a
“win-win situation” for the Philippines and the importing
countries.
He suggests the initiation of bilateral
negotiations with countries that import Filipino health workers that
would lead to the allocation of development aid or compensation to
the Philippines in exchange for sending health workers abroad.
He also advises the government to create a
national commission to oversee the planning, production, deployment,
retention and development of health professionals. He deplores the
fact that there is no single body taking charge of these matters,
which explains why figures concerning health matters vary depending
on which government agency is consulted.
For now, however, Filipinos who fall ill will
find less skilled professionals attending to them.
(Concluded tomorrow)
Part 2 |
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