Outmigration and unequal distribution of Filipino physicians and nurses: An urgent call for investment in health human resource and systemic reform

Filipino healthcare workers (HCWs) are globally renowned for exceptional patient care, and the Philippines continues to supply many of the world's doctors and nurses, especially in the US and the UK.

There has been a steady increase in new Filipino HCWs since the 1990s, but many regions in the country, especially in rural and conflict areas, remain underserved. Less than 25% of cities and municipalities¹ have met the WHO human resource for health density recommendation, yet outmigration and internal migration to urban cities of highly skilled personnel persist. This has led to many consequences² on health systems and populations, including shortage of workers, reduction in services provided, increases in errors and poorer quality of care delivered, and longer waiting times for essential services.

Almost a fifth² of Filipino HCWs are working overseas. In 2019 alone, at least 17,000 Filipino nurses signed overseas contracts.³ The impact of out-migration was more evident during the COVID-19 pandemic, with mass nurse resignations and consequent migration due to unjust compensation, unreceived benefits and hazard pay, and delays in insurance reimbursements. Working conditions were straining and debilitating as well, as HCWs were forced to work longer hours, with suboptimal and inadequate protective equipment. Increasing infection among hospital staff members further exacerbated HCW shortages, pushing the Philippine health system at the brink of collapse. This prompted the government to impose a temporary overseas travel ban, which was heavily protested by several HCW unions.

Better social, economic and professional opportunities, more robust infrastructure and technologies, and the possibility of family reunification² are some motivations to seek overseas employment. The salary differential is particularly glaring. The annual income of a first year medical resident in the Philippines is averaged at Php 720,000, while their counterparts in the US earn Php 3,000,000. Mid-level Filipino public hospital nurses earn 57% lower than their peers in Vietnam,⁴ the second lowest paying country in Southeast Asia. Entry-level and private hospital nurses receive even less, averaging Php 10,000 a month when household expenditure is averaged at Php 19,886.

Apart from out-migration, the Philippine health system also faces an unequal distribution of HCWs, who are increasingly concentrated in urban areas.⁵ 39,086 HCWs are in NCR, while only 3,445 practice in BARMM, a region in southern Philippines. With the exception of some nurses, more Filipino HCWs, including those from ethnolinguistic minorities, are found in regions with less ethnic concentration and poverty rates, in areas with greater activity and earning potential, in communities nearby their training institution, and in hospital-based services.¹ This challenges the notion that access to healthcare would improve with ethnic diversity, and casts doubt on the effectiveness of providing regional scholarships as a strategy to develop more HCWs for rural practice.

The Department of Health (DOH) took several measures to address these inequalities. The Doctors to the Barrios program⁶ was created to augment the health workforce in geographically isolated and disadvantaged communities lacking primary health care. Deployed physicians serve for three years, and receive pay and benefits, including a scholarship for a master's degree in public health. The Doktor Para sa Bayan Act⁷ provided medical scholarships at state schools to produce physicians, who will serve identified municipalities for at least 3 years in exchange, as part of the return service agreement. Shorter-term deployments were devised through the Medical Pool Placement and Utilization Program for medical specialists, and the Registered Nurses for Health Enhancement and Local Service for nurses. Similar strategies were likewise created for health professionals across different cadres of health (e.g. rural health midwives program, rural health team placement program).

Despite their contributions to health human resources, return service agreements have been criticized as band-aid solutions that do not guarantee long-term retention⁸ or substantially mitigate migration. Deployment programs have reportedly fostered overdependence⁹ among local government units (LGUs) on reinforcements from the DOH, leaving underlying barriers unresolved and key issues unaddressed. Among those cited by dissatisfied HCWs are isolation from and limited facilities for families, high out-of-pocket work expenses, poor infrastructure, and job instability.⁶ Physicians and nurses then proceed to leave their areas of assignment.

International and domestic movement is further exacerbated by an outflow of HCWs to better paying industries² due to inadequate support for HCW safety and well-being, and the limited number of attractive jobs in the health sector. Of the 867,974 registered Filipino HCWs in 2018, only 22% remain in service. Juxtaposed with the persistence of HCW shortages in the country, this also suggests challenges in production, recruitment, and retention of skilled workers.

The overproduction of nursing professionals is traced back to the early 2000s, when there was a surge in demand for international nurses.¹⁰ This led to the expansion of expensive but low-quality nursing schools in the Philippines. Many individuals overestimated their chances of being able to graduate and migrate to high-paying jobs abroad, which warranted a specific skill rather than a general qualification. Although many were successful, a significant number of graduates remained in the country, with limited opportunities for employment. This is particularly true in LGUs with limited resources to generate jobs.

Lower class municipalities struggle to employ their own scholars, create additional plantilla (permanent) positions, and augment their health workforce, largely due to budgetary constraints and competing local priorities. As a result, they resort to hiring HCWs on temporary or job order arrangements,⁹ having to inefficiently and unsustainably reemploy and retrain staff members once the short-term contracts expire. This faulty staffing practice discourages HCWs from pursuing careers in these areas, and consequently impacts delivery and quality of services provided at the primary level.

Retention is also affected by the capacity of LGUs to incentivize its HCWs. The Magna Carta of Public Health Workers of 1993¹¹ listed provisions on prescribed work conditions and corresponding compensation. However, its enactment coincided with the devolution of public health services, resulting in inconsistent implementation.¹² Many LGUs are unable to provide adequate benefits and professional support, either due to resource limitations or political biases, which contributes to the growing demotivation and dissatisfaction felt among HCWs.

Important legislation relevant to health human resources have been made through the years. The Mandanas-Garcia ruling of the Supreme Court of the Philippines¹³ fully transfers the delivery of basic services to LGUs, which promotes people empowerment, participation and inclusivity among locals and their chief executives when crafting area-specific solutions and ordinances. LGUs are also given shares on national taxes collected, which is projected to increase internal revenue allotment and hopefully increase local budget and spending on health. Meanwhile, the Universal Health Care (UHC) Act¹⁴ vows incentives and grants from the national government to improve competitiveness and functionality of provincial, municipal and city health systems, with special priority for underserved and unserved areas. It also commits permanent employment and competitive salaries for medical and allied health professionals, and pledges scholarship programs based on the needed cadres identified by respective communities. Although these are welcome developments, demotivation and subsequent mobility of Filipino HCWs will continue to persist until such measures take full effect and until systemic reform is truly achieved.

Among Filipinos, migration is overly romanticized and considered a selfless and patriotic act, instead of a desperate call to action. Filipino HCWs express concerns about cultural differences, discrimination, workplace abuse and loss of social support.¹⁶ However, despite these apprehensions and the inherent dedication to culture and community, many are pushed to leave for personal ambitions and familial obligations. While it is inevitable to lose Filipino nurses and doctors to opportunities overseas, the Philippine government must proactively seek ways to protect its HCWs abroad, and to create conducive working spaces to encourage local practice.

Health-related organizations must be strengthened to prevent work-related exploitation. Bilateral negotiations¹⁵ with destination countries must also be explored to craft mechanisms that could improve postgraduate training. Returnee integration programs should be established simultaneously to maximize skills and knowledge transfer, and to inspire eventual return and service to the country.

In line with this, it is important to grow from the common notion of health care as a purely altruistic vocation and recognize that compensation is crucial for sustained service,¹ especially if HCWs are to be deployed outside the metropolitan area. It is critical to revisit constraining provisions of legislation that aggravate inequities among resource-challenged LGUs, and ensure provision of additional support and sustainable measures. Alternate funding options, including potential partnerships with the private sector,¹ must be explored, and the national health insurance system (PhilHealth) must be concurrently and deliberately strengthened. With the proposed devolution of basic services, local chief executives must also be held accountable in exercising transparency and ensuring that HCWs receive their due.

Apart from salary and other monetary (e.g. travel allowance, hazard pay, clothing and subsistence allowance)⁹ and non-monetary (e.g. leave benefits, support for participation in training programs, recognition mechanisms) incentives, the national government must also confront the many sociopolitical and environmental factors that influence HCW decision to migrate. Major investments in health, infrastructure and social services¹⁶ are paramount to address socioeconomic inequalities and threats to physical safety, especially in the rural areas. Educational and employment opportunities must also be strengthened through expanded scholarships and sustainable career development programs, and health professional curricula must be revisited and revamped to promote primary care, public health and rural practice.¹⁶

It takes a whole-of-government approach to institute significant and palpable changes,⁹ but the Philippine government must act swiftly on measures to strategically recruit and retain HCWs. As more countries open their borders and extend opportunities for employment, resignations among skilled professionals are expected to increase. HCW migration will continue with inadequate support, and those remaining in the country are left with the burden of an overwhelmed health system, consequently affecting delivery of care and health outcomes.

HCW migration is a desperate call for international labor solidarity and regulation, but more so for national systemic health reform. With the added strain on the health system posed by the COVID-19 pandemic, a drain on health human resource, and the recent passage of the UHC Act, never has it been clearer that a substantial investment in Filipino HCWs is urgently needed to meet the health needs of the Filipino people.

Declaration of interests

All authors have no conflict of interest to disclose.