Background
Human resources for health (HRH) are crucial to the achievement of health outcomes and the overall sustainability of health systems [
1], and their migration from developing (low- and middle-income) to developed (high-income) countries has raised significant economic and ethical concerns. The Philippines, in common with many other “source” countries, suffers from a high burden of disease and an inequitable distribution of health workers, but has become a key source of health professionals who migrate to wealthier countries [
2,
3]. This paper presents the findings of a multi-year mixed method study of source country perspectives on the causes, consequences, and policy responses to the migration of HRH with specific reference to the Philippine context. It addresses one of four countries that participated in the larger study, which also included South Africa [
4], Jamaica [
5], and India [
6], all known for their high rates of HRH migration. The following questions guided the research:
1.
What are the recent historic trends and present situation of HRH migration from the Philippines?
2.
What, according to the experience of those who remain, are the causes and consequences of the emigration of Filipino HRH?
3.
What program and policy responses have been considered, proposed, and implemented by different stakeholders in the Philippines to address these consequences?
Brief overview of the Philippines context
This Philippine case study on HRH migration situated workforce mobility within the interactions of individual decision-making process and the wider structures of politics, economy, and history of the country. The Philippines is a lower middle-income country in Southeast Asia with a young population of more than 92 million. There are high levels of poverty in the country, with 26.5% of the population living below the poverty line. In the last quarter of the twentieth century, the Philippines, under direction of the International Monetary Fund and the World Bank, implemented a series of structural adjustment measures, modeled on neoliberal economics [
7], to ensure the country could repay its foreign debts, largely incurred under the Marcos regime [
8]. These conditionalities included
inter alia reducing spending in health and social sectors, devaluing the currency, and hastening the privatization of public resources, which contributed to increased poverty and economic instability [
9,
10]. These policies were continued under the Aquino government and included the automatic appropriation from the annual government budget of the full amount needed for debt servicing [
9].
With a median age of 23, the Philippines is a country of young people. Currently, the country is contending with a large number of unemployed and underemployed—an estimated 4.5 and 7.3 million respectively [
11]. Over one quarter of the labor force is unemployed or looking for more work [
12]. Large numbers of Filipinos, including some of the country’s most educated, are compelled to go abroad to find employment [
12]. The Philippines is the second largest exporter of human labor in the world, and health care professionals are one of the biggest groups of migrant labor for the country. The Philippine Overseas Employment Administration (POEA), which facilitates outmigration, reported that 1.8 million Filipinos left the country for work in 2013 [
13].
The national health system
The Philippines Health Care System, described as decentralized, is organized at three different levels—national, provincial, and local. While health care in the Philippines is provided by both public and private sectors, the total contribution allocated to the public sector has decreased for the past decade. Only 36.1% of the health expenditure is paid by the government; the private sector contributes 65.3% of the total health expenditure, and 83.8% of that private health care expenditure is paid out of pocket. Between 2009 and 2011, government spending on health care averaged 4.3% of GDP, lower than a cited, though never formally adopted, World Health Organization’s (WHO) suggested standard of 5%, illustrating that the country’s healthcare system is underfunded [
14]. Per capita health expenditure (at constant 2000 prices) in the country is PHP 2639 or around Php 7 per day, approximately 15 cents USD [
14].
Conceptual framework
Labor migration has widely been viewed as determined by a combination of demographic, socio-cultural, political, and economic factors interacting across macro-, meso-, and micro-levels. Micro-level issues include HRH migrants’ perceptions of their personal and household context in shaping their decision to work overseas. Meso-level phenomena include organizational settings such as workload, working conditions, and career opportunities relative to different health professions, in destination and source countries. These issues are influenced by macro-level phenomena—the myriad political, economic, and social factors at global and national levels including policies and recruitment strategies. Each of these levels intersect with the causes, consequences, and policy responses examined.
Methods
The study employed a decentered mixed method comparative approach [
15], comprising scoping reviews of the literature on health worker migration, surveys of health workers, and interviews with key stakeholders. Researchers in Canada (revealed after review) coordinating the four country studies collaborated with researchers in the Philippines (revealed after review) in undertaking the Philippines component in a way that enhanced comparability. Approval to conduct the study (both survey and interviews) was received from the (revealed after review) Research Ethics Board and from the ethics boards of the (revealed after review).
Scoping review
The scoping review of the literature followed the process developed by Arksey and O’Malley [
16], using the MeSH terms “migration”, “health professionals”, “health worker migration”, “brain drain”, “brain gain”, “return migration”, “health worker exodus”, and “Philippines” in a search of Medline, PubMed, and Embase databases [
16]. Sources were included if they addressed the Philippines and were published between 2000 and 2012. This was augmented with in country literature searching in seven university and three organizational libraries. We also searched the gray literature using key public and private stakeholder organizational websites resulting in 20 policy documents. The international research team developed a literature extraction tool to systematically record pertinent aspects of the literature. The literature was analyzed and summarized descriptively, and a preliminary report shared and revised with the Philippines-based research team members.
Stakeholder interviews
Interviews were conducted with key stakeholders including, but not limited to, professional educators, health profession regulators, national government agency officials who dealt with immigration and HRH, and representatives of local government authorities, private and public sector health facilities, recruitment agencies, migrant advocacy organizations, and professional associations and councils (Table
1). Participants were selected using three criteria: (i) their organization’s active role in social determinants of health and migration-related issues; (ii) their position within the organization (sufficiently senior to speak to the issues); and (iii) their experience related to the research questions we were exploring. The interview guide included a common set of questions asked of all stakeholders, but specific probes were developed to enable targeted data collection.
Table 1
Distribution of participants by a stakeholder group
Teaching/training institutions | 3 |
Professional regulatory boards | 4 |
Professional/worker association | 10 |
Development partners | 5 |
Recruitment agencies | 3 |
National government agencies | 10 |
Health | (1) |
Labor and migration | (8) |
Foreign affairs | (1) |
Return migrants | 2 |
Total | 37 |
A total of 36 interviews, averaging 45–60 min, were conducted between February 2012 and September 2013. All interviews were digitally recorded, after seeking consent, and transcribed. These data were analyzed simultaneously via systematic, documented procedures of thematic and constant comparative analysis using N-Vivo® 9 software following an initial comparative coding structure that was developed by members of the Canadian team and embellished with emergent codes derived from the Philippines team. This involved an iterative process producing a multifaceted description of the context, policy environment, and experiences of the migration of health care professionals.
Survey
Building on a common template designed by the international team, two questionnaires were developed involving two modes of data collection—an online version (
n = 202) and a face-to-face household survey (
n = 420) administered in Metro Manila and Metro Cebu, the major centers of health services in the Philippines where the chances of reaching respondents who graduated with a health degree would be higher (Table
2). Questions were pre-tested to ensure they could be clearly understood. Both surveys targeted respondents who studied to be physicians, nurses, midwives, and physical/occupational therapists. This paper focuses solely on results of the face-to-face survey. While patterns are generally similar for the face-to-face and online surveys, some are different which necessitates further examination beyond the scope of this overview paper.
Table 2
Percent distribution of survey respondents by health profession
Doctor | 1.7 | 7 |
Nurse | 78.3 | 329 |
Physical therapist/occupational therapist | 4.3 | 18 |
Midwife | 15.7 | 66 |
Total | 100.0 | 420 |
Sampling for the face-to-face household survey used the “30 × 7” cluster sampling technique. Within each of the two metro areas, 30 barangays (villages) were selected with probability proportional to the size of population and seven (7) households were chosen for each selected barangay using the WHO simplified cluster sampling for the Expanded Programme on Immunization (EPI) [
17]. All household members who completed formal education or training to become a doctor, a nurse, a midwife, or a physical therapist and who were not necessarily working as health professionals were interviewed. To ensure standardization, interviewers read and recorded responses on the survey instrument. Surveys averaged 60–90 min and were conducted in a time and place deemed appropriate by the respondents. Response rate for the face-to-face household survey was 91%. Data were encoded using CSPro. Data cleaning (for odd codes and consistency) and descriptive analysis using frequency and cross-tabulations were done using SPSS21.
Reflecting the general distribution of health professionals in the country, 78% of the survey respondents are nurses, 16% are midwives, 4% are physical/occupational therapists, and 2% are physicians. Notably, the face-to-face survey is a reflective of perspectives found in Metro Manila and Cebu and may not be representative of the Philippines as a whole.
Discussion
Individual decision-making about migration must be situated within a broader socioeconomic, historical context that attends to both discursive and material aspects of power operating across individual, institutional, national, and global spheres. At the micro-level, individual reflections on the country’s political and economic situation and the desire for career advancement influence the decision to migrate. These findings echo the results of previous research [
32‐
40]. Individuals may feel pushed to migrate due to the poor wages offered to HRH and pulled to migrate by the prospect of better social, economic, and professional opportunities abroad and by the presence of overseas kin. Countering these elements are ones that encourage health professionals to remain in the Philippines including dedication to family, culture, and community, and concern about encountering cultural differences, discrimination and workplace abuse, loss of social support, and the negative impact of family separation. The presence of family and the enhanced respect respondents anticipated they would receive as health professionals in another country could increase the likelihood that they would remain overseas.
At the meso-level, better economic benefits and organizational settings were seen as factors that affect migration decisions. The literature points to risks of work-related hazards [
36], and inadequate health care system and shortages in human resources [
22,
41,
42] as the primary meso-level factors that influence the individual’s decision to migrate. Specifically, poor health care infrastructure, low wages, job insecurity, inconsistencies in practice, outdated or inappropriate curricula, institutional politics, and inadequate opportunities for speciality training were all cited as influencing migration decisions while return community service and improved curricula were would encourage health workers to remain. Concomitantly, the potential to engage in advanced training and the perception of greater equality among, and respect for, health professionals overseas were regarded migration incentives. Interestingly, nearly three quarters of respondents chose a health career because of the potential for overseas opportunities. Importantly, the increasing number of trained nurses due to the rapid expansion of nursing programs, who had hoped to train graduates destined for the overseas market were confronted by a stagnant global market resulting in increased under- and unemployment. Many trained professionals were therefore compelled to take up lower skilled positions abroad, thereby thrusting them onto a path of deskilling [
43,
44]. Complicating the scenario is the declining quality of nursing education, which previous research suggests is the consequence of the commercial expansion of nursing programs whose goal is to produce graduates for export [
22,
42,
45‐
47], and an oversupply of health workers who cannot secure positions in the underfunded Philippine system.
Certain issues such as privatization of health care services and the prominent discourse of migration as key to success were situated at the interface of meso- and macro-level analyses. The impact of neoliberal globalization (structural adjustment and, more recently, post-financial crisis austerity programs, [c.f.
7]) has engendered the withdrawal of state support for health, social services, and education and promoted privatization contributing to job insecurity and unemployment. Labor export policies and programs provide an avenue for unemployed and under-employed, and encourage remittances from overseas Filipino workers. Ongoing state-supported human rights abuses, particularly in rural regions, also propel the exodus of health professionals and reinforce the maldistribution of health resources. Informed by discourses that have normalized migration and emphasized the right of citizens to migrate, HRH are attracted to overseas work by specific destination country policies, government-to-government agreements, and recruitment agency activities. These observations are corroborated by previous studies that enumerated the “culture of migration” [
48], labor export policy [
22,
48,
49], and unemployment [
41,
42,
50] as major push factors at the macro-level. Stakeholders further identified the development of specific retention programs, the implementation of the Magna Carta for Health Workers, and improved infrastructure as policies that could encourage HRH to remain in the Philippines, while the ability to settle abroad with one’s family and to return temporarily to contribute to knowledge and technology transfer were regarded as factors that would inspire HRH to remain overseas.
HRH migration impacts individuals, families, institutions, services, society, and nation states. While some key stakeholders argued that return migration or “brain circulation” offered benefits through short- or long-term knowledge transfer and exchange, there is insufficient evidence in the literature to support these assertions. Country case study findings on brain drain are consistent with the literature describing it as a process manifested in the deficit of specialized health professionals with grave consequences to both the health care system and the individual health workers [
41,
51]. The migration of health professionals results in a paucity of skilled personnel in health institutions across the country, especially in rural areas. HRH mobility also burdens the remaining health workers in the country in terms of workload. Previous studies suggest that if this migration trend continued, the Philippine health care system would be severely disadvantaged or worse, it would collapse [
38,
41,
52‐
54].
The plight of an individual HRH cannot be separated from the existing condition of the local health system and the country itself. The opportunities for professional and personal growth, economic wellbeing, and the conditions of local practice interact with the existing policies and programs of the country. While these affect the retention or dissatisfaction of HRH, the country’s health sector financing and health workforce management schemes are also inseparable from international political and economic conditions. Reductions in government expenditures in health, privatization as health financing strategy, and rationalization in public health institutions as a workforce management scheme are not de facto conditions present in the national health system. These are historical products of programs and policies instituted by the government and which include economic liberalization, structural adjustment programs, and the Labor Export Policy.
Conclusions
Grounded in a colonial legacy that has normalized labor migration as a means of social and economic mobility and propelled by the exigencies of neoliberal globalization, the Philippines has developed a sophisticated state apparatus that facilitates migration and encourages OFW remittances. HRH comprise an important sector of labor migrant flows and as such the Philippines continues to produce doctors, nurses, midwives, and other health professionals who are highly specialized and sought after in countries across the globe. The country’s dominance as a HRH exporter, however, means that it is losing its skilled resources while struggling to manage its own health care services, particularly in under-served, rural areas. With HRH migration, the Philippines is at the disadvantage not only due to the creation of a workforce predisposed for overseas employment instead of serving locally but also through the loss of a skilled workforce that is in essence given away to the benefit of destination countries. While host countries benefit from the care provided by the migrant Filipino health professionals, many of these health professionals are also subject to discrimination, exploitation, wage differentials, and deskilling. As the HRH work their way to provide for their families in the Philippines, the societal cost also can often outweigh the personal benefits of migration. Despite the drawbacks, the massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who are not being absorbed locally despite high needs especially in rural and remote areas. Although the majority of trained health professionals remain in the country, the numerous interacting micro-, meso-, and macro-level factors that propel Filipino HRH to seek work overseas far outweigh the factors that foster retention at home. International agreements, ethical recruitment guidelines, and programs to protect overseas HRH may mitigate some of the more egregious forms of exploitation they face; however, the complex and sometimes paradoxical nature of these intersecting, multi-level phenomena and their consequences will require greater consideration and systemic change. Importantly, major financial investments in health, education, and social services, and greater control over public resources are required to redress social and economic inequalities and the deteriorating human rights situation that contributes to the loss of HRH to ensure that migration is truly a choice for health professionals—one that Filipinos across the archipelago can afford.
Acknowledgements
We wish to thank the women and men who participated in this study and our colleagues who provided their expertise and research assistance: Jaime Galvez Tan, MD, MPH; Kenneth Ronquillo, MD, MPH; Nimfa B. Ogena, PhD; Andrew Bucu, MD, MPH; Christian Joy P. Cruz; Kenneth Cajigal, RN; Jerwin Evangelista, RN; Gary Pagtiilan, RN; Maria Fonseca Camille T. Baroña, RN; Danica September L. Mariano, Janet Rigby, and Jelena Atanackovic. We appreciate the assistance of the Office of Population Studies Foundation, University of San Carlos, Cebu City, lead by Dr. Nanette Lee-Mayol in the field work in Cebu City.