Lack of nurses burdens an ailing healthcare system

This month, some 20,000 nursing students will graduate from about 350 schools throughout the country. The best of these students will likely go abroad. A good number of them, however, will fail the nursing board exams. (The failure rate in the last few years has been close to 60 percent.)

The first part of this series examines the export of nurses and its impact on Philippine health care, where the shortage of skilled nurses has meant deteriorating hospital care and even the closure of many hospitals. In the last 10 years, the Philippines exported close to 90,000 nurses overseas. In addition, in the last four years alone, 3,500 doctors left the country to take on nursing posts abroad. We are now exporting more nurses than we are producing, resulting in substandard patient care and a real crisis in hospitals.

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,” 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 qualificatory 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 that is usually 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.

TABLE 1: Deployment of Filipino Nurses, 1994-July 2003

1994 6,699
1995 7,584
1996 4,734
1997 4,242
1998 4,591
1999 5,413
2000 7,683
2001 13,536
2002 11,911
July 2003 5,628
TOTAL 84,843

The impact of the nursing drain is compounded by the fact that doctors are also now taking nursing courses in the hope of going abroad, worsening the shortage of healthcare workers in many parts of the country. In the last four years, 3,500 Filipino doctors have left the country to take on nursing jobs overseas.

A study by the National Institutes 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 already 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 second 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 mainly 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.”

“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 workforce leaving in the last few years.

The preferred country of destination is the United States because of the possibility of acquiring U.S. 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, while 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.

TABLE 2: Nursing Board Performance

1994 41,459 25,477 61.45
1995 38,689 22,532 58.24
1996 25,163 13,643 54.22
1997 19,546 9,776 50.02
1998 17,101 9,541 55.79
1999 13,152 6,558 49.86
2000 9,270 4,601 49.63
2001 8,269 4,430 53.57
2002 9,449 4,228 44.75
2003 15,606 7,526 48.23
June 2004 13,194 7,371 55.87

SOURCE: Professional Regulation Commission

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 last 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, while 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, “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.”

This writer also witnessed a nurse at a government hospital using her cellphone’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.

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 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.

Among the reasons cited by health workers bound for abroad are 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 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.

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 U.S. 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.

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.