Brain drain is an international pheno-menon and has been a major concern of the World Health Organization. The Philippines is one of its victims.
I shall begin with the situation before 1985 and shall adopt the findings on the subject of the 1986 conference of the Council of International Organizations of Medical Sciences (CIOMS) on Health Manpower Out of Balance.
I shall read the findings of the conference on Brain Drain which covered the first two waves of migration, word for word. What is happening today is the third wave.
The First Wave
“First, the emigration of professional manpower amounted to an extensive form of unplanned donation from poor countries to rich countries. The poor countries paid for or heavily subsidized the education of health manpower, and the rich countries received the gift of qualified manpower without having to pay anything for the original cost of their education. A net loss of 50,000 doctors from the developing countries to the developed, even at the Canadian cost of educating a doctor, was a gift of 10 billion Canadian dollars from the poor to the rich. The Philippines alone had lost by 1982 a total of 14,000 doctors, mainly to the USA, and 89,000 nurses—imports worth billion dollars to the recipients. The argument that emigrants transfer funds back to relatives in their developing country of origin and thus serve as invisible exports was hardly a convincing reply to this basic point—particularly if the funds came back through black markets at unfavorable rates of exchange for the recipient country and thus outside the grasp of the governments, which had paid the original cost of the education.
“Secondly, the developed countries generally used foreign medical graduates under the guise of training as “interns” and “residents” —in practice, pairs of hands working long hours—in the less prestigious hospitals in which nationals refused to accept appointments.
“Thirdly, a substantial proportion of emigrants stayed on and was given full rights of citizenship. When the United States was short of doctors it recruited them from the United Kingdom (often via Canada), Latin America and the Far East. When Britain became short of doctors owing to losses, mainly to North America, it made good the loss mainly from India, Pakistan and Sri Lanka. Britain also made good its shortage of nurses by recruitment of trained or trainee nurses from Ireland, the West Indies, Mauritius and other countries.”
The Second Wave
“The next wave of migration was to the newly oil-rich countries of the Middle East and Africa. It included doctors and dentists but also nurses and allied health workers, probably on a scale greater than earlier patterns of migration. Syria lost doctors to both Europe and the Middle East. Malta lost more to the former, Egypt more to the latter. This, however, is far from completing the story of the movement of medical manpower and its complex patterns based on culture, language and acceptability of qualifications.”
Health Manpower Imbalance
Brain drain is an element of manpower imbalance.
Health manpower imbalance is a diverse and complex phenomenon. It has three dimensions: numerical, over- or under-supply of one or several categories of health workers in relation to what a country or community needs; qualitative, a mismatch between training and job requirements; and distribu-tional, which may be geographical, occupational, institutional and by specialty.
Balance implies that the supply of health manpower and its distribution and utilization in a country are in line with the values of social accountability: equity, relevance, cost-effectiveness and high quality. The health professionals and workers must respond to the health needs and demands of the people. Imbalance is a serious obstacle to the organization and provision of health care and the attainment of health for all.
From 1946 to 1985, there was unprecedented growth in the supply of health manpower, particularly of doctors and nurses. There was overproduction of these professionals. But the economics of the developing countries could not support them. There was much under- and inappropriate employment. Migration to developed countries escalated. The unmet needs for health care expanded. Thus the growth in the production and supply of health workers did not narrow the gap between developed and developing countries as regards adequacy of health care. On the contrary, the growth in production in certain countries has accentuated some types of imbalance in distribution by discipline and geographically.
At the peak of the medical diaspora, a medical degree from an internationally recognized school was equivalent to an international passport. But after 1980 the developed countries began closing their doors to physicians. They erected barriers to keep them out as readily as they once created loopholes to let them in. In the Middle East, foreign doctors were replaced by graduates of their own schools.
Doctors who returned after training in the developed countries found themselves over-trained for the medical infrastructure in their homeland. Neither could they adjust to the relatively low salaries or income. The Philippines has been fortunate that we were able to build our infrastructure, but salaries and income of health workers remain very low as the country’s economy floundered.
In countries that do not control migration of health workers, nurses leave with impunity. Nurses stay in their own countries only for a very short time. Turnover of nurses in hospitals is generally less than a year on the average.
The result of the closure of the developed countries to physicians had a salutary effect to the Philippines. The annual addition to the stock of doctors went up from 300 to almost 3,000.
With the opening of medical schools, less and less municipalities had no doctors. If in 1992 there were 273 doctors-less municipalities, it was because many barriers were upgraded to municipalities and they were mostly economically depressed.
to Health Professions
In the 1980s Medicine and Nursing began losing their popularity as career choices in the developed countries: Medicine, because the basic and postgraduate education and training is long and difficult as well as expensive; the life of a physician is hard; as a profession, it is not as lucrative as others, and exposure to dreadful diseases such as HIV-AIDS is great. Nursing because it is no longer glamorous and the risk to AIDS is even greater.
In 1989, I represented the Philippines in a meeting sponsored by ECFMG in New York. The Americans proposed to reopen its door to physicians. We vehemently objected.
Also in 1989 we went to the Senate to ask that nurse migration be regulated. We were bluntly told “No way” because the country needs the dollars they are remitting.
Expanding Need for Nurses
Nurses from developing countries continued to migrate for economic reason. The market for nurses in developed countries showed a cyclical pattern before 2000 (there were dips in 1980 and 1998). This is reflected in the enrollment data of schools in the developing countries. It is estimated that the need for nurses in the developed countries in the next 10 years would reach several hundred thousands. And that this is not going to be cyclical.
The Third Wave
The present problem of brain drain in the Philippines is different from what it was from 1960 to 2000. It is now more complex and more difficult to solve, because it is rooted in the nursing phenomenon. It is the consequence of the failure of the country to formulate and implement rational nationalistic policies and coordinate plans on health human resource development, despite the constitutional mandate. Our work on HHRD under Dr. J. G. Tan gathered dust in some shelves at the DOH.
Shift of Doctors to Nursing
This phenomenon is unique to the Philippines. It has been observed in the early 1980s. It was labeled “reverse education.”
It began escalating at the turn of the millennium. We estimate from the data we gathered that nine to ten thousand doctors have been lost to the profession. Four to five thousand doctors have left as nurses from 2000 to 2005. There are over 4,000 still in nursing school. All doctors are affected regardless of the geographic location, the specialties, all ages and both sexes, government and private practitioners.
The following reasons doctors gave for wanting to leave the country are:
1.they are fed up with the political situation
2.the uncertainty of the future
3.the deteriorating peace-and-order situation
4.the bad economy
The effect on our health system is disastrous. According to a study of the UP College of Economics, the health system in many areas of the country has already collapsed.
A few more facts we gathered:
• 84,150 nurses were deployed to at least 10 countries between 1994 and 2003. The top three countries were Saudi Arabia, the United Kingdom and the United States.
• The cost of training of health professionals is much cheaper in the Philippines. The USA saved $2.1B by importing rather than training the 8,000 nurses they got from the Philippines. The total cost/loss to the Philippines for the 80 thousand plus nurses deployed is more than $20B.
• The production of doctors has drastically declined. Enrollment in medical schools has markedly dropped. NMAT takers have been cut by more than 50%. Medical schools are on the brink of closure. Seventeen of the 36 schools have less than 50 freshmen this year. Three have less than 10.
• Less and less graduates are going to specialization. We have begun accepting foreign graduates (from Indonesia, Iran, etc.) to fill in the hospital workforce.
• One thousand primary hospitals in the provinces have closed for lack of doctors since 2000. Many district hospitals of government have an inadequate number of doctors. Those who are left to man them are overworked.
• Rural health units are likewise losing their physicians.
Many government officials are still in a state of denial.
More than 25 years ago we have been calling attention to the problem, and that the lack of rational nationalistic policies on HHRD and the lack of coordinated planning would cause disaster.
Previous secretaries of health ignored our warning. Only Dr. J. G. Tan listened. Dr. Manuel Dayrit, who is the head of Health Manpower of the WHO in Geneva, did not. The same with CHED officials who refused to look at the quantitative aspect of health sciences education.
Now the DOH is moving but they are very slow. We worked on a Medical Summit to discuss the problem more than a year ahead of the DOH.
A case of too little too late.