As one of the country’s most essential and demanding yet underpaid professions, nursing in the Philippines is fraught with many ironies. Despite being the top exporter of nurses in the world, the Philippines faces “chronic understaffing” in local hospitals and has the “lowest number of nurses per capita in Southeast Asia.” The shortage of practising nurses in the Philippines is a problem decades in the making, exacerbated and made most apparent by the COVID-19 pandemic—shedding light on the unjust compensation and dismal working conditions of Philippine healthcare workers, especially nurses, that have long pushed them to seek employment abroad or in other sectors.
The 2000s Philippine nursing boom and outmigration
There was not always a shortage of nurses in the Philippines. In fact, the late 2000s saw the opposite problem—an oversupply of registered nurses brought about by an export-oriented approach to the profession. Population growth and rapid ageing in developed nations sharply increased the demand for nurses in the late 1990s to early 2000s worldwide, and the recruitment of foreign nurses, typically from developing nations such as the Philippines, was deemed the most expedient way to fill this gap. Thus, in response to international demand, the deployment of Filipino nurses, primarily to the US, saw a steady and notable rise in the 2000s. The number of enrolees in Philippine nursing programs increased more than fivefold, from 90,000 in 2001 to nearly half a million or 497,000 in 2008.
However, the 2008 recession led to a slowdown in immigration and the prioritisation of the domestic labour force of many destination countries such as the US. This led to a significant downturn in the number of Filipino nurses deployed overseas. As a result, by the late 2000s, there was an oversupply of new nurses that both the international and domestic labour markets could not accommodate. With their migration aspirations dashed, Filipino nurses sought employment at home instead. Yet, while the Philippines had been producing 100,000 registered nurses annually, no new positions were being created in public and private hospitals nationwide—leading to massive domestic unemployment and underemployment among new nurses.
Impact on the domestic labour market
As destination countries recovered from the recession in the following decade, the recruitment of foreign nurses ramped up again, but this was not enough to address the problems created by the oversupply of nurses. In general, it had three lasting effects on the domestic labour market. First, the nursing surplus depressed wages, especially among entry-level nurses. While the 2022 salary standardisation law mandates a monthly salary of PHP 32,097 (SGD 772) for entry-level nurses in government hospitals, some working in the private sector currently earn as low as PHP 8,000 (SGD 192) per month, below the country’s minimum wage. Second, due to the export-oriented nature of the nursing profession in the Philippines, many nurses resigned from their jobs once they had gained enough professional experience to qualify for overseas employment. Thus, expecting high turnover rates, many hospitals only hired nurses on temporary contracts, often without benefits. Lastly, owing to poor compensation, lack of career progression from temporary contracts, and demanding workloads, many nursing graduates were discouraged and chose to leave the health sector altogether, taking on better-paying jobs for which they were overqualified.
Philippine nurses amid the COVID-19 pandemic
Mass resignations at the height of the pandemic worsened the nurse shortage. According to the Private Hospitals Association of the Philippines, a year and a half into the pandemic, 40 per cent of nurses working in private hospitals had resigned. Public hospitals also faced a similar challenge, albeit to a lesser extent. When coronavirus variants set off new waves of infections, even more resignations followed. At a time when the Philippine health system was already overwhelmed, this mass exodus by some of the most important healthcare workers severely limited the country’s pandemic response.
Applying the labour market framework to address nurse retention
The World Health Organisation’s (WHO) labour market framework views nurse retention as a complex and multifaceted policy issue. Nurse shortages cannot be resolved by simply training more nurses. Instead, the country’s health labour market dynamics must be restructured to accommodate newly trained nurses and provide decent job opportunities. Policy interventions should be part of a coordinated effort and based on a solid understanding of the nursing workforce profile.
The WHO identifies the following key areas of potential policy interventions: (1) production – training and adapting the nursing workforce; (2) better managing mobility and flows of nurses; (3) improving recruitment and retention of nurses; and (4) addressing inefficiencies and maldistribution of nurses.
Philippine nurse retention efforts in light of the WHO framework
Given these areas, we examine the Philippine government’s past and present nurse retention efforts.
1.
Production: Training and adapting the nursing workforce. In 2011, the Philippine Commission on Higher Education imposed a moratorium on nursing programs in several higher education institutions because of low performance in licensure examinations and the then-oversupply of nurses. However, due to the severe shortage of nurses amidst the COVID-19 pandemic, this was lifted in 2022. In addition, state universities are now encouraged to follow the University of the Philippines’ imposition of return service agreements (RSAs), which require students to work in the country for two years post-graduation.
2.
Better managing mobility and flows of nurses. During the pandemic, the Philippine government enacted a temporary deployment ban on nurses, later replaced by a quota, to ensure sufficient human resources. This quota was also used to negotiate for vaccines at the height of the pandemic.
3.
Improving recruitment and retention of nurses. Work-hour regulations for nurses were also implemented in private hospitals, while the public sector saw wage hikes. However, these measures were limited in scope and did not include career progression opportunities, a significant pull factor for nurses to seek employment abroad.
4.
Addressing inefficiencies and maldistribution of nurses. The 2009 Nurses Assigned in Rural Service (NARS) project, aimed at deploying nurses to underserved rural health centres, faced criticism due to misalignments between job expectations and actual tasks and inadequate compensation.
Over the years, numerous measures have been implemented to deal with the fallout of labour export promotion, but it is clear that effectively addressing this ongoing professional exodus requires more than patchwork solutions. Comprehensive and proactive policies are needed to alleviate the push factors that have long driven Filipino nurses out of the profession and out of the country.
Read the full case study Where Have the Nurses Gone written by Dianna Therese N. Limpin and Juan Paolo M. Artiaga, which was awarded the Distinguished Prize in the Case Writing Competition 2022/23 at the Lee Kuan Yew School of Public Policy.
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