How the Philippines became the biggest supplier of nurses worldwide

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The demand for Filipino nurses to work abroad has drained our own supply, incapacitating our already fragile public health system.

Manila (CNN Philippines Life) — In August 2009, Nenen Momay-Castillo passed the National Clinical Licensure Exam to be a Registered Nurse. She immediately worked at a provincial hospital in Sultan Kudarat, tending to an overwhelming number of patients, as is often the case in public hospitals in the Philippines.

Her days were fairly similar — going on duty, attending to her family — until one afternoon on November 23, 2009. That day, she received a call from her uncle, telling her that her father, Bebot Momay, a photojournalist for the publication Midland Review, was part of the convoy that was ambushed by armed men in the Ampatuan town of Maguindanao.

From this national tragedy, widely known as the Maguindanao Massacre, 57 bodies were found, but up to this day, Bebot’s was not. For years, Nenen did all she could to make her voice heard: spoke at international human rights conventions, fostered relationships with the media, told her father’s story to anyone who would listen. She became one of the loudest voices against the Ampatuans, who were convicted of the heinous murders after a decade, in December 2019.

“Noong kasagsagan ng panahon na ‘yun, medyo naging delikado narin ang buhay, ‘yung recruiter ko para maging nurse sa Amerika, talagang minadali niya ‘yung papeles,” Nenen shares. “Rason ‘yun kung bakit napadali, dahil dun sa case ng tatay ko.”

In 2012, Nenen, along with her husband and two children, left the Philippines to work as a nurse in Minnesota, U.S.A.

Colonial care

Nenen joins the over 150,000 Filipino nurses in the U.S., where most, if not all, of whom are currently in the frontline against the COVID-19 pandemic. Registered nurses make up the largest segment of the U.S.’ health workforce, making their work all the more crucial in the ongoing crisis.

This migration of Filipino nurses to the U.S. is not new, and it comes out of a longer history of U.S. colonialism in the Philippines. Catherine Choy, a professor on ethnic studies at the University of California Berkeley, details how the U.S. colonial regime started recruiting nurses from the Philippines in her book “Empire of Care.” She says that the demand for Filipino nurses in the U.S. simply started from the Philippines being a U.S. colony, where the colonial regime established an Americanized education system, including nursing education.

Additionally, the U.S. established an education abroad program in the Philippines called the pensionados program, which worked like a study abroad program. Many Filipino nurses became pensionados; some eventually stayed for employment, while others returned to the Philippines to help set up nursing schools in the country from 1903 to 1940.

After World War II, the demand for Filipino nurses grew. “As the United States started to experience nursing shortages after WWII, they started to look abroad to recruit nurses,” Choy says. “The Philippines became an obvious and important source for nurses in large part because they were American-trained.”

Choy explains that another wave of nursing shortages started to brew in the 1960s, mainly due to the growing women’s movement of that era. As a result, American women had more professional opportunities in all kinds of work. “Before, they were often relegated as professionals to things that were considered appropriate professions for women, like nursing, education, or social work,” she says.

“But as the movement grew, there were opportunities in a range of professions, so when that happened, it became difficult to recruit American women into nursing — also because nursing is really hard work.”

Marcos’ survival strategy

The constant demand for nurses made way to the continued migration of Filipino nurses to the U.S. This was all the more bolstered in the early 1970s when then-dictator Ferdinand Marcos started to promote labor migration from the Philippines. There was an increasing number of unemployed young men in the country due to the stagnant economy, and Marcos saw it as an opportunity to send them abroad for overseas work while establishing a system that easily regulates and supports labor outflows.

Marcos also observed that there was a high demand of nurses in the U.S. because there were American healthcare institutions specifically recruiting Filipino nurses. “He changed the government’s perspective,” Choy says. “He thought, ‘This could be good because if they want nurses from the Philippines, what we will do is we’ll produce more nurses.'”

His administration’s directive was only supposed to be a temporary policy measure to address the country’s immediate concerns, but because domestic socio-economic problems persisted, it turned into a survival strategy. Choy also highlights that Marcos’ approach, and the eventual migration of Filipinos, was a result of growing economic dissatisfaction.

“Nurses from that time period already started to witness or to observe some of the growing socioeconomic inequalities in the Philippines and some of the political turmoil,” she says. “They are also going abroad not just for social and economic mobility but also for stability and security.”

By 1982, the country had already established the Philippine Overseas Employment Administration (POEA), which manages the recruitment and deployment of overseas Filipino workers. Until now, the labor export system of the Philippines has been described to be ‘unparalleled’ in its sophistication. This, however, also lays bare what labor policy researcher Feina Cai articulated about the Philippines’ master plan: “The labour export policy only addresses the symptoms, but not the root causes. After years of implementing the policy, the factors shaping poor economic performance and the high unemployment rate have yet to be improved.”

Nonetheless, due to this organized labor export, countries other than the U.S. began looking to the Philippines to fulfill their countries’ nursing shortages as well. Today, the U.K. has approximately 18,500 Filipinos who work in its National Health Services; the United Arab Emirates has about 30,000 Filipino nurses; and with the rise of the global nursing shortages caused by the pandemic, European countries such as Spain and Germany had sought to recruit from the Philippines as well.

To stay or not to stay

The demand for Filipino nurses to work abroad, however, has drained our own supply, incapacitating our already fragile public health system. Records show that because of the increasing number of Filipino health workers going to other countries, the health professional to patient ratio in hospitals can be as worrying as one nurse to 60 patients.

This disproportionate ratio is made worse by COVID-19. As such, on April 2, Labor Secretary Silvestre Bello III, announced the temporary ban of medical frontliners from leaving the country. The POEA order stated that “it is of paramount national interest to ensure that the country shall continue to have, sustain the supply of, and prepare sufficient health personnel to meet any further contingencies...”

On April 13, the government lifted the ban, allowing health workers with existing contracts abroad to leave the country. But on May 4, President Duterte said that he wants the Department of Justice to look into the legality of banning Filipino health workers from going abroad to supposedly prevent them from contracting COVID-19.

Rosie De Leon, the president of the Philippine Nursing Association, had said that if nurses were to be forced to work in the country, they should be compensated properly. She also tells me that even without the pandemic, if we want for more Filipino nurses to stay, their salaries need to be improved. “Yung mga nurse dito they earn as low as ₱10,000 to ₱15,000 every month,” she says. “Sa ibang bansa, yung ₱15,000 siguro two to three days lang na trabaho kuna na nila yan.”

De Leon stresses that nurses should be given proper recognition, perhaps even akin to our reverence for doctors. “Nurses serve patients 24/7,” she says. “And they comprise the majority of health care workers in every hospital. Dapat mabigyan ng mabuting working conditions, ma-recognize ang trabaho, at sa sweldo, kung hindi mapantayan [sa ibang bansa], at least dapat competitive.”

Nenen says that working in America, despite its obvious advantages, has its low points as well. “My mom died na wala ako sa tabi niya,” she shares. “Ang hirap. Nagkasakit ang nanay ko, nagkacancer, nag-aalaga ako ng may sakit dito, nagbibigay ako ng gamot, pero ‘yung nanay ko hirap na hirap makakuha dahil walang mabilhan.”

In many ways, Nenen’s story is a typical tale of a Filipino nurse in a foreign land. But for her, and perhaps for many others, leaving the Philippines remains to be the better choice. “Dito, every after 1,000 hours meron kaming increase sa sweldo,” she says. “Sa Pilipinas, trabaho ka lang ng trabaho di ka naman aasenso.”