Dr. Alfredo J. Ganapin Advocacy Forum Series III Policy Issues on Skilled Migration: The Case of Filipino Nurses Organized by: September 30, 2005 Max’s Restaurant Quezon Memorial Circle Supported by:

The Center for Migrant Advocacy honors the memory of Dr. Alfred J. Ganapin, an overseas Filipino worker and committed advocate, by naming the forum after him. Alfred passed away in Riyadh, Saudi Arabia in 2004. Alfred advocated for the integration of the concerns of Filipino migrant workers in the national agenda. He engaged and called on government officials and legislators to serve and protect the interests of migrant workers. He was a reliable kababayan (compatriot) who helped migrant workers in Saudi Arabia and other places. The Advocacy Forum focuses on labor migration and issues affecting overseas Filipino workers. Center for Migrant Advocacy Philippines(CMA) 72-C Matahimik Street, Teachers’ Village Quezon City, Philippines Website: www.pinoy-abroad.net E-mail: cma@tri-isys.com Telefax:+632 4330684 CMA is a member of Philippine Migrants Rights Watch(PMRW), the Network Opposed to Violence Against Women Migrants(NOVA) and the Migrant Forum in Asia(MFA).

Acknowledgments The Center for Migrant Advocacy Philippines thanks the Friedrich Ebert Stiftung(FES) for its generous support of the Dr. Alfred J. Ganapin Advocacy Forum Series, Kanlungan Center Foundation for logistical support during the forum, and all the volunteers who made the project possible.

TABLE OF CONTENTS Introduction ………………………………………………………………. 1 Opening Remarks ………………………………………………………… 1 Panel Presentations Skilled Migration from the Philippines…………………………… 2 Nursing Education: Challenges and Directions…………………… 3 The Brain Drain Phenomenon and its Implications on the Health Care System……………………………………………… 5 Response …………………………………………………………………… 8 Open Forum ………………………………………………………………… 9 Closing Remarks …………………………………………………………… 13 Appendices Program………………………………………………………….. 14 List of Participants………………………………………………… 15 References………………………………………………………… 17

INTRODUCTION From 1992 to 1998, the number of Filipino professional workers who went abroad exceeded by almost 46% the net addition to the professionals in the country's workforce in the 1990s. Overall, Filipino migrant workers have a higher share of the most productive age group in the Philippine labor force as well as a higher share in the number of years of education, especially those who have obtained a college or higher degree. From 1994 to 2003, the country deployed some 85,000 nurses abroad. To date, 57% of them are in Saudi Arabia, 14% are in the United States and 12% are in the United Kingdom. There are also some 5,500 medical doctors who are currently enrolled in nursing schools. Last March 2005, some 20,000 nurses graduated in 350 nursing schools.2 Given the economic and political crisis in the Philippines, labor migration remains a necessity for many Filipinos and an option for others. In the case of nurses and other health workers, there is a high demand for them abroad due to the demographic changes in many developed countries where the aging population is increasing rapidly. OPENING REMARKS Mike Bolos, Board Member, Center for Migrant Advocacy Mr. Bolos welcomed the participants and provided the Philippine context for the migration of skilled workers, particularly nurses. Doctors are enrolling in nursing to facilitate their migration and employment abroad. The forum aims to look into the brain drain phenomenon caused by the migration of skilled workers, gaps in policies, and ways to address these issues.

PANEL PRESENTATIONS (L-R) Caridad Tharan, Florian Alburo, Carmelita Divinagracia, Jaime Galvez Tan, Liberty Casco(CMA Photo Library) SKILLED MIGRATION FROM THE PHILIPPINES Florian Alburo, Co-Author of Skilled Labour Migration from Developing Countries: Study in the Philippines Migration Trends Comparing two decades of migration in four countries which had similar levels of outmigration in the 1980s, the Philippines came out as the top labor-sending country. Approximately half of overseas Filipinos were temporary workers and the other half had permanent employment. The number of overseas Filipino workers(OFWs) was more than the number of migrants from emerging, labor-sending countries like Indonesia. The Philippines continues to export hundreds of thousands of skilled workers, including nurses and doctors who took up nursing. Brain Drain The brain drain issue has existed since 1971 when a survey showed that half of the doctors registered in the Philippines were working in the United States. The following factors contributed to brain drain: high unemployment, declining absorption of college graduates into the labor force, imbalance in supply of skills, opening up of more opportunities abroad, and others. From 1990 to 1998, there were more college graduates who migrated than were absorbed in the labor force. For example, only 643,000 graduates were absorbed into the labor force while 129,000 graduates left for permanent 2 Policy Issues on Skilled Migration: The Case of Filipino Nurses

migration and 2.3 M graduates as temporary migrant workers. From 1992 to 1998, more licensed professionals left for a total of 445,000 individuals, broken down into 399,000 land-based OFWs and 46,000 permanent migrants. There was a 4% increase in the number of nurses, 28% of engineers,.12% of teachers and 12% of Information Communication Technology graduates . Around 40% of the employable population in the 25-34(most productive years) years old category are abroad. Many of the OFWS were employed in the Philippines and had professional work experience and responsibilities. Thus, there was a void in the country’s labor force which was not easily filled by the new graduates. Many of the OFWs were also in the most productive stage of their lives. Although most were temporary migrants, they worked abroad as soon as they had new contracts. Brain Gain? Changes in the global economy and advances for example in information and communications technology could address the employment gap and brain drain. For example, migrants from China returned to develop their country from 1990 to 2000. In other countries, the migrant workers’ financial resources and savings are channeled for productive use. However, in the case of the Philippines, OFWs have low savings and few bond investments. Regional cooperation could also help reverse brain drain. For example, Mindanao could serve as a health center for the region and provide services to Indonesia and Malaysia. In Thailand, retirement and caregiving villages were set up as employment options for caregivers. Directions and Recommendations In some countries, the share of professionals in their migrant workforce is declining. Some countries, which were previously sending labor are now net labor-importers as in the case of South Korea. To address brain drain, there is a need to institute policy reforms that accelerate employment generation, raise real incomes, and reduce poverty on a sustained basis. The policies should address high unemployment rates, inequitable income and wealth distribution. and poor infrastructure. There is also a need to create better social, cultural and political conditions to keep the workforce in the country. NURSING EDUCATION: CHALLENGES AND DIRECTIONS Carmelita Divinagracia, President, Association of Philippine Colleges of Nursing The high global demand for Filipino nurses only shows the cutting edge skills of Filipino nurses. However, the commercialization of nursing education and the resulting decline of the quality of nurses could result in losing such an edge. New nursing schools continue to sprout- from 175 Colleges of Nursing in the 1990s to 450. The number could reach up to 500 if politicians have their way. Most of the colleges lack experienced and qualified faculty. Out of 2,392 faculty members surveyed, only 48.37% had Bachelor of Science Nursing(BSN) degrees with MA units, 22.53% had a Masters degree in Nursing, and .59% had a Doctoral degree in Nursing. Many nursing schools are small and inefficient. 3 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Around 62% of the schools had faculty members of 15 or less and 64% of the faculty members had monthly salaries of P15,000 or below. Student nurses could affiliate in only 144 accredited training tertiary hospitals, resulting in very high nurse to patient ratio of 1:15. The number of Nursing graduates who pass the board is decreasing from 57% in 1994-98 to 46.5 in 2002 to 43% in 2004. There was an upturn recently, mainly because the doctors-turned-nurses were among those who took the examinations. Challenges and Directions The high quality of Philippine nursing education should be maintained if Filipino nurses are to compete for employment worldwide. There should be regulations and accreditation guidelines for nursing schools, improvement in the salaries and working conditions of the faculty, regulation of hospital affiliation of nursing students, and restoration of values formation among educators and nursing service personnel. 4 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Dr. Jaime Galvez Tan(CMA Photo Library) THE BRAIN DRAIN PHENOMENON AND ITS IMPLICATIONS ON THE HEALTH CARE SYSTEM Jaime Z. Galvez Tan. MD, MPH, Vice Chancellor for Research, University of the Philippines-Manila and Executive Director, National Institutes of Health Philippines Philippine Health at a Glance A major health system problem is the conflict between the availability of health professionals to address local health needs and the global demand. Due to the lack of nurses and doctors who could provide health care, there is a high maternal mortality rate. Ten mothers are dying per day due to pregnancy and childbirth-related causes. This situation affects the women’s families, especially their children. The children who are left behind, especially those below five years old, have lower chances of surviving. It also affects the economy. These factors, however, are not considered by government planners and economic managers. President Gloria Macapagal Arroyo, a woman president, allocated 1% of the national budget for health programs. No previous government has ever allocated such a small amount for the health budget. Under former Presidents Elpidio Quirino, Ramon Magsaysay and Carlos P. Garcia, 8% of the national budget was allocated to health. It was 2% under former Presidents Ferdinand Marcos and Fidel Ramos and 1.8% under Joseph Estrada. Government’s Human Resources Policy What the Philippines needs is brain gain not brain drain. What the country actually has is brain hemorrhage being the top exporter of nurses. We are proud of our nurses abroad. 5 Policy Issues on Skilled Migration: The Case of Filipino Nurses

The West demands more nurses because of their high standards for health care skills. If the Philippine government raises its standards and hires more health professionals, fewer mothers will die. The Philippines is also the number two exporter of doctors. For the past two years, 115 localities had no doctors because succeeding governments did not pursue ex-Health Secretary currently Senator Juan Flavier’s“Doctor to the Barrios” program. These vacancies should be filled up first before exporting anymore doctors. The government’s labor export policy is understandable given that the Philippines ranks third after Mexico and India in the amount of remittances sent by migrant workers. OFWs sent US$8.5 B in remittances in 2004, which is actually an underestimation. The total amount could be twice as much. Major Policy Gaps The three major policy issues are: • the lack of a unified health policy vis a vis the labor export policy- This has resulted in the conflict between the health sector’s call for health professionals to stay versus the government’s push for them to work abroad. • the lack of a single government agency which oversees such a policy- All agencies involved should sit together to address this problem with the Department of Health as the natural leader. The Philippine Nurses Association and the Association of Philippine Colleges of Nursing should likewise be included. • the lack of unified figures on which to base a master plan. Pull and Push Factors for Outmigration From 1994 to 2003, an estimated 100,000 nurses left to work abroad. The Philippine Overseas Employment Administration(POEA) has under-reported the number of nurses who migrated. For example, US-based hospitals have been directly recruiting nurses, bypassing the POEA process. Filipino nurses are also directly recruited from their employment in the Middle East. From 2000 to 2003, around 10,000 nurses left annually. Since only around half of the graduates passed the Nursing Board Examinations each year, it means many nurses who were already employed in the health system left the country. In addition, doctors also applied for nursing jobs abroad. Since 2002, doctors have been undergoing training in nursing. A reason commonly cited as a push factor is the threat of a malpractice law pending in Congress. More doctors want to leave as the country’s situation worsens and they see no hope for their families and themselves. There are also fewer student doctors and fewer medical positions in hospitals that are being filled. Some medical schools have closed and more are in danger of closing. Consequences to Health Care Five hospitals no longer have doctors and nurses- three in Mindanao and two in Isabela. Health services coverage is decreasing and there is heightening health disparities and 6 Policy Issues on Skilled Migration: The Case of Filipino Nurses

inequities nationwide. Hospitals across the country are losing senior nurses, thus increasing the nurse-patient ratio, which is 1:15-26 at the Philippine General Hospital, 1:30-40 at the Jose Reyes Memorial Medical Center, and 1:45-55 at some hospitals in Davao del Sur. There are also increasing vacancies for doctors(219) and nurses’(152) posts in eight regions. Ten Strategic Solutions The following ten strategic solutions were proposed: (1) initiation of high-level bilateral negotiations with northern countries importing Filipino health professionals similar to the South Africa-United Kingdom(UK) and Poland-Netherlands Agreement; (2) development of North-South hospital to health facility partnership agreements; (3) convening of the health human resources development agenda of the General Agreement on Trade and Services(GATS) of the World Trade Organization(WTO); (4) institution of the National Health Service Act; (5) development of new learning and career opportunities for health professionals, particularly doctors and nurses; (6)initiation of reforms in health financing and management of medical education in the country; (7)establishment of Philippine Health Professional Registries; (8)creation of the Philippine National Council for Health Professional Concerns; (9)development of new learning and career opportunities for health professionals (particularly doctors and nurses); (10) initiation of reforms in health financing and management of medical education in the country. Other countries, such as Turkey, Germany and South Africa, benefit from the outmigration of health professionals. The UK pays 1,200-1,500 pounds to the South African government for every South African nurse who is hired and it pays scholarships for more nurses. The POEA only markets our nurses to the UK. The Philippine government could negotiate for development aid to develop Filipino nurses. Hospital-to-hospital agreements could also be forged. While in principle, Dr. Tan is against compulsory service, other countries have implemented this policy. Thus, there are no communities in these countries that do not have nurses or doctors. So far, many in the state universities in the Philippines favor compulsory service. Schools with high numbers of health professionals who pass the Board exams may be rewarded. For example, 14,000 students applied at the UP College of Nursing but not all could be accepted because of budget cuts. Loans should be made available to new doctors to set up their clinics. Philhealth should provide twice the pay for health professionals choosing to work in the rural areas. Global and national solidarity matched by political will and action are needed. Let’s do it and sustain it. The time to act is now. 7 Policy Issues on Skilled Migration: The Case of Filipino Nurses

RESPONSE Liberty Casco, Director II, Marketing Branch, Philippine Overseas Employment Administration The Philippine Overseas Employment Administration(POEA) has monitored the very strong demand for Philippine nurses. The local health industry is worried over the quality of nursing graduates and that those who leave for employment abroad are the most experienced and occupy responsible positions. While the government cannot prevent skilled workers from leaving the country, it cooperates with other stakeholders to manage the labor outflow and to minimize the impact on communities and maximize the effects on the country as well as individuals. Private recruitment agencies should also be sensitized because they have a role to play. There are ethical recruitment agencies which protect migrant workers that could share best practices and help find solutions to existing problems. To address the lack of the nurses in the country, the government is studying a Health Human Resource Master Plan in response to Dr. Tan’s“Ten Solutions”. Bilateral or multilateral labor agreements(BLAs) are hard to negotiate. For example, governments in the Middle East explained that if they signed a bilateral labor agreement (BLA) with the Philippines, they would have to do the same with all labor-sending countries. The Philippine government with the Department of Health is exploring a BLA with the Netherlands. It is patterned after the Netherlands/Poland BLA which facilitates the nurses’ eventual return to Poland. The Philippine government is also exploring a BLA with the UK. Government agencies and various sectors could help push these agreements by asking for training and funding, thus turning brain drain into brain gain. The Department of Foreign Affairs is currently preparing for a policy consultation with all its posts to develop their Strategic Plan for the next three years. There is a need to provide recommendations on how they should pursue bilateral labor agreements. 8 Policy Issues on Skilled Migration: The Case of Filipino Nurses

OPEN FORUM Akbayan PartyList Representative Loretta Ann Rosales.(CMA Photo Library) (l-R) JC Atienza-Embassy of Singapore, May-an Villalba-Unlad Kabayan, Jun AguilarFMW Nurse/Doctor Migration Statistics Florian Alburo: It is difficult to collect data on the number of nurses and doctors who work abroad, duration of their stay, or the percent of the remittances they send home. But these data can be extracted from the POEA data. Liberty Casco: There is no such data because disaggregation is limited. Figures are only on new hires or new contracts. Renewals, rehires, returnees and direct hires are not 9 Policy Issues on Skilled Migration: The Case of Filipino Nurses

disaggregated. For example, nurses hired by the UK from their placements in the Middle East are not documented. The nurses prefer direct hiring because if they return home, they have to submit a verified contract to the Philippine government. There are also undocumented nurses and those with immigrant visas who are not processed by the POEA. We try to get the data from recruiters who should be registered. POEA has agreed that the Commission on Filipinos Overseas(CFO) will provide data on nurses with immigration visas and who have new contracts. But there are also delays in the CFO’s data gathering. The e-card for OFWs that serve as an exit clearance will link the databases for 14 agencies. Currently, DOLE is studying how to enhance the e-card to be able to monitor the entry and exit of workers. Value Formation in Nursing Education May-an Villalba: The economic problems of the country are accompanied by moral crisis. There is no coordination within the education sector itself. The national health service should be promoted not only in state universities but also in private schools, especially among those that are church-related and have their own hospitals. Contrary to the current trend where medical schools are closing down, Silliman University will set up its medical school. Carmelita Divinagracia: The shortage of nurses affects only the positions of the dean and faculty. There are many student nurses and as trainees they have to be supervised. They assist in health campaigns, for example immunization campaigns. But they have to be supervised by faculty or graduate nurses. Jaime Galvez-Tan: Unfortunately, this health service is not done across all nursing schools. Perhaps, there should be directives to partner schools with local health centers. The communities are waiting for community health nursing services. Potential nurse migrants can even develop their clinical experience at the community level. Local Absorption of Nurses Jaime Galvez-Tan: While medical transcription and caregiving are a waste of talent of the Filipino nurses, those who fail the Nursing Board Examination or some 50% of the nurses could go into these areas. Training local communities to provide health care Caridad Tharan: Nursing schools could undertake community outreach and train local peoples as auxiliaries to fill the gap in health care. Carmelita Divinagracia: The programs of the University of the East-Ramon Magsaysay Memorial Medical Center(UERMMMC) are partly based in hospitals with 50% devoted to community health nursing. From their first year of studies, nurses assist individual 10 Policy Issues on Skilled Migration: The Case of Filipino Nurses

families in the community. A nursing program is expected to adopt a community, to take care of its health and to work with barangat health workers using the team concept. Irynn Abano: The Palo UP Health Sciences Center is a model that should be replicated nationwide. It recruits potential health workers from poor communities who, upon graduation, serve these communities. Jaime Galvez-Tan: Nursing students who were trained in the 70s are still in the communities but they need more support, including scholarship for their children since their earnings are not enough. Ninety-five percent(95%) of Palo Center's graduates are placed in the Philippines unlike the University of the Philippines-Manila which could place locally only 30% so. We offered P5M to replicate the Palo Center but it was not pursued in the Philippines. But it was replicated in Fiji. Erlyn Sana(UP Manila):In relation to the devolved system where rural health units (RHUs) without skilled workers are turning to auxiliaries to perform emergency care, the more complicated cases are brought to the district health facility. For home situations, it is not as dark as we perceive it, given inter-local health zones where local health facilities can be transformed into wellness centers. “Compensation for Brain Drain” Caridad Tharan: We have a very strong negotiating chip when bargaining with laborreceiving countries. The government should show how much these western countries save instead of training their own doctors and nurses. JC Atienza(Singaporean Embassy): We have short training grants and scholarships to train nurses in Singapore in coordination with the National Economic Development Authority(NEDA) . Singapore recognizes human resources as a vital factor in the economy and society. It would be good if Singapore officials could participate in talks. We want to help out. Liberty Casco: The private sector pioneered in recruiting nurses in the UK. At the beginning, the nurses were interested because of the benefits. Nurses were protected by labor laws and employers were required to pay L 1,200-1,500 to recruiters. But then, it turned into cutthroat competition. The recruitment agencies started to divide the contracts among themselves and charged applicants even though the UK did not require placement fees. The UK government requested the Philippine government to step in. The POEA charges the employer$250 for each nurse hired because it is a non-profit entity. The Philippine and UK governments tried to discipline the overcharging recruitment agencies. There are very few government-to-government contracts for nurses. Some employers don’t want to deal with private agencies. Jaime Galvez-Tan: The British, Japanese and US embassies are all interested in the above recommendations. The question is will the government pursue negotiations? 11 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Alternatives for Returning Health Migrant Workers Erlyn Sana: Regarding retirement villages for returning health workers, the POEA and other agencies could coordinate with the Department of Health. Government Efforts Liberty Casco: The Department of Labor and Employment family is trying to work out how to harness the benefits of migration. Though we have high levels of remittances, the effect or impact is more at the consumption level. There are not much savings. Whatever savings are generated are put in small investments. More investments should target long term benefits, for example employment generation to restrict the push for migration. The POEA’s role is to ensure that if the workers decide to leave there is an orderly process and they are protected. Employers and contracts should be documented and their workplaces are identified. DOLE has beneficial programs before, during and after overseas employment. Filipino resource centers implement training programs on-site to prepare OFWs when they return home. For example, they learn how to save and identify options upon their return. Lev Alcantara: As the research arm of DOLE, Institute for Labor Studies(ILS) documents successful reintegration efforts nationwide and areas of improvement in government-initiated reintegration programs. Legislative Proposal Loretta Ann Rosales: As a member of the House of Representatives representing the Akbayan party list, I am willing to sponsor a related bill and budget for Dr. Tan's recommendations. We can also talk to the Chair of the Committee on Foreign Affairs to meet with the British Ambassador regarding a more favorable bilateral labor agreement covering our nurses. 12 Policy Issues on Skilled Migration: The Case of Filipino Nurses

CLOSING REMARKS Joanne Carmela Barriga, Program Officer, Friedrich Ebert Stiftung Ms. Barriga summarized the forum by highlighting the magnitude of brain drain, how it affects the Philippines and the educational system, and its impact on the Filipino people and their morale. The government has an important role in coordinating relevant agencies and stakeholders, negotiating with labor-receiving countries, and in managing both the losses and gains from migration. She expressed her hope that soon there will be a more systematic approach to addressing this situation. 13 Policy Issues on Skilled Migration: The Case of Filipino Nurses

PROGRAM Dr. Alfredo J. Ganapin Advocacy Forum Series III Policy Issues on Skilled Migration: The Case of Filipino Nurses September 30, 2005 Max’s Restaurant, Quezon Memorial Circle, Quezon City The forum was organized to determine the impact of migration of skilled nurses on the Philippine health care system, the effects of the commercialization of the nursing education on the quality of Filipino nurses, gaps in policies and practices and recommendations and proposed course of action that government, civil society and other stakeholders to make brain drain redound to the holistic developmental benefits not only for the migrant workers and their families themselves but for the country as a whole. Opening Remarks Mike Bolos , Board Member, Center for Migrant Advocacy Panel Presentations Skilled Migration from the Philippines Florian Alburo, PhD, co-Author of Skilled Labour Migration from Developing Countries: Study in the Philippines Nursing Education: Challenges and Directions Carmelita Divinagracia , PhD, President, Association of Deans of Philippine College of Nursing The Brain Drain Phenomenon and its Implications on the Health Care System Jaime Galvez-Tan , MD, MPH, Vice Chancellor for Research, University of the Philippines Manila and Executive Director, National Institutes of Health Philippines Response Liberty Casco , Director II, Marketing Branch, Philippine Overseas Employment Administration Open Forum Moderator: Caridad Tharan , Founding Member, Migrant Forum in Asia Closing Remarks Joanne Carmela Barriga , Program Officer, Friedrich Ebert Stiftung 14 Policy Issues on Skilled Migration: The Case of Filipino Nurses

LIST OF PARTICIPANTS NAME Levinson Alcantara Sister Eva Palencia Sister Delia Maui Lazaro JC Atienza Joanne Carmela Barriga Mary Josephine Famorca Maria Victoria Avila Elvira Lim Ruth Padilla Jonie Minguillan Rino Paez Erlyn Sana Cha Cha Joy Obera Julie Javellana Lily Ramos Mayan Villalba Meps Artagame Victor Narceda Isagani de Castro Carmencita Abaquin Virgilio San Diego Jillian Roque Loida Bernabe Aileen Leycano Jose Tabbada Christina Maya Bans-Cortina Ginger de Guzman William Gois Azela Arumpac ORGANIZATION Institute for Labor Studies – Department of Labour and Employment(ILS-DOLE) Daughters of Charity, Justice and Peace Office Daughters of Charity Partido ng Manggagawa Embassy of Singapore Friedrich Ebert Stiftung University of the East Ramon Magsaysay Memorial Medical Center(UERMMMC) UERMMMC UERMMMC Philippine Nurses Association Action for Health Initiatives Commission on Filipinos Overseas National Teachers Training Center for Health Professionals, University of the Philippines Manila (NTTCHP, UP Manila) Representative from ILS-DOLE Peoples’ Global Exchange Arab News Philippine News Agency Unlad Kabayan Migrant Services Kanlungan Center Foundation Akbayan Asahi Shimbun College of Nursing, University of the Philippines Manila Committee on Overseas Workers Welfare Administration(OWWA), House ofRepresentatives Public Services Link(PSLink) Kanlungan Center Foundation Office of Senator Gordon, Senate National College of Public Administration and Governance, UP Diliman NCPAG Representative from Batis Center Kanlungan Center Foundation Kanlungan Center Foundation Migrant Forum in Asia Office of Senator Jamby Madrigal, Senate 15 Policy Issues on Skilled Migration: The Case of Filipino Nurses

NAME Marlon Valencia Vince Cruz Filipina Cabaun Atty. Tess Lora Mike Bolos Jhun Aguilar Rene Raya Rep. Etta Rosales Rhodora Abaño Liberty Casco Carrie Tharan Dr. Florian Alburo Dr. Jaime Galvez Tan Dr. Carmelita Divinagracia Anna Navarro Ellene Sana Vim Santos Mila Arbozo Lorie de Lara Bituin Quinto ORGANIZATION Akbayan Akbayan Akbayan National Labor Relations Commission(NLRC) Center for Migrant Advocacy Philippines Filipino Migrant Workers Group Action for Economic Reforms Akbayan Partylist Representative, Congress Center for Migrant Advocacy Philippines Philippine Overseas Employment Administration/DOLE Migrant Forum in Asia School of Economics, UP Diliman National Institutes of Health, UP Philippine College of Nursing, UERMMMC Center for Migrant Advocacy Philippines Center for Migrant Advocacy Philippines Peoples’ Global Exchange People’s Movement for Empowerment and Development(People's MEND) Sarilaya Philippine Alliance of Human Rights Advocates PAHRA) 16 Policy Issues on Skilled Migration: The Case of Filipino Nurses

REFERENCES Aquino, Edna. Working Document on Insights on the Situation of Filipino Nurses in the United Kingdom. London, 2005. Centre for Filipinos. Report on Philippine Nurses and the Nursing Crisis in the United Kingdom . London, 2002. Choy, Catherine Ceniza. Empire of Care: Nursing and Migration in Filipino American History . Ateneo Press, Manila, Philippines, 2003 17 Policy Issues on Skilled Migration: The Case of Filipino Nurses

The Brain Drain Phenomenon and its Implications to Health JAIME Z. GALVEZ TAN, MD, MPH Vice Chancellor for Research, University of the Philippines Manila and Executive Director, National Institutes of Health Philippines September 30, 2005 The Philippines at a Glance Total Population: 85 million (NSO est.’05) Population growth rate: 2.36% (NSO 2000) 2 million added annually; 5,479 a day Average family size: 5 Proportion of population below 15 years of age: 37% Proportion above 65 years old: 3.8% Total labor force: 35 Million Total Unemployment Rate: 10.1%(LFS Oct.’03) Total Underemployment Rate: 15.7%( LFS Oct.’03) Annual average family income: US$2,619(FIES 2000) Poverty incidence: 34% or 25.8 million people(NEDA 2001) Budget deficit 2004: US$5B or 35% of the national budget % of National Budget for debt servicing: 30%-45%(2002-04) 18 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Health Human Resources: The No. 1 Philippine Health Export No. 1 exporter of NURSES “An estimated 85 percent of employed Filipino nurses(more than 150,000) are working internationally.” (Aiken et al. 2004) “70 per cent of all Filipino nursing graduates are working overseas” (Bach, 2003) Source: Aiken, L. et al.(2004). Trends In International Nurse Migration, Health Affairs, Vol 23, Issue 3, 69-77 19 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Health Human Resources: The No. 1 Philippine Health Export No. 2 exporter of DOCTORS “68 percent of Filipino doctors work overseas, next to India.” (Mejia, WHO, 1979) Documented Number of Filipino Medical Doctors in Different Countries Year documented 1999 2002 2004 Country Australia Canada Unites States Number of Doctors 113 261 17, 297 Rank (as supplying country) 11 th 11 th 2 nd Why Such Human Resources Policy? Overseas Filipino Workers(OFWs) Remittances over the Years YEAR 1999 2000 2001 2002 2003 2004 US$ US$ 6.79 US$ 6.05 US$ 6.03 US$ 7.19 US$ 7.64 US$ 8.50 OFW Remittance in Billion US Dollars, 1999-2004 8 7 6 5 4 3 2 1 0 1999 2000 2001 2002 In Billion US$ 2003 2004 (Source: Central Bank of the Philippines, 2005) 20 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Major GAPS of the Philippine Health Human Resources Development Policy Environment • NO official unified national policy on Health Human Resources Development . (14 government agencies speak in different voices regarding HHRD) • NO one government agency responsible for coordinating and leading concerted HHRD planning and management. • NO official national information and data base of HHRD in the country (Source: Sanchez and Batangan 1995) “ PULL ” Factors in Host(North) Countries: “Simply Irresistible” PROPOSALS • Higher compensation and benefit packages (US$180 a month Phil. vs US$4,000 a month USA) • More job opportunities abroad ( More than 20,000 nursing positions available yearly in about 32 countries) • More political, economic, social stability • Better living conditions abroad (offer of migrant visas in the USA) • Better career growth abroad • Better working conditions 21 Policy Issues on Skilled Migration: The Case of Filipino Nurses

“ PUSH ” Factors in the Philippines “ NOTHING COMPARES ; NEVER A HARD CHOICE ” • Low compensation and benefits • Family obligations/security • Political instability (armed communist insurgency, Muslim secessionists) • Graft and corruption • Poor working conditions Massive Filipino Nurse Migration in 2000-2003 vs 1994-1999 • An estimated 100,000 nurses left from 1994-2003, under reporting included • Around 42,000 nurses left in 2000-2003; or 10,500 per year. Only 5, 197 per year passed the Philippine Nursing Board Examinations in the same period. • Clear under reporting of data by the Philippine Overseas Employment Administration(POEA) stating only 91 nurses in 2000, 304 in 2001& 320 in 2002 went to the USA. US-based hospitals directly recruiting nurses bypassing the POEA system. 22 Policy Issues on Skilled Migration: The Case of Filipino Nurses

YEAR 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 TOTAL VOLUME 6,699 7,584 4,734 4,242 4,591 5,413 7,683 13,536 11,911 8,968 8,789 84,150 Note: full USA data not accounted for Source: Professional Regulation Commission, 2004 Large Volume of Nurses Leaving the Country: A Major Trigger Factor Motivating Doctors to Become Nurses Nurses Deployment, 1994-2004 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Volume The Top 5 Countries of Destinations • United States of America • United Kingdom • Saudi Arabia • Ireland • Singapore Source: Philippine Overseas Employment Administration(POEA), 2004 23 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Deployment of Filipino Nurses in the United Kingdom, 1998 –2002 YEAR 1998 UK Data* 52 Philippine Data** 63 % Discrepancy 21% 1999 1,052 934-11% 2000 3,396 2,615-23% 2001 7,235 5,383-26% 2002 5,594 3,105-45% TOTAL 17,329 12,100-30% Average per year (5-year period) 3,466 nurses/year 2,420 nurses/year Underreported 1,046 nurses Sources:* Buchan and Tovlo, 2004;**POEA, 2004 Major Effect of the High Demand for Nurses Overseas= Mushrooming of Nursing Schools • In a matter of 10 months, there was a 47.41 % increase(109 schools) in the number of nursing schools in the country – from 251 in June 2003 to 370 in April 2004. • There were only 40 nursing schools in the 1970’s; 170 in the’90s Source: Association of Deans of the Philippine Colleges of Nursing, Inc. 2004 24 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Consequences of the Rapid Proliferation of Nursing Schools= Deteriorating Performance in the National Nurse Licensure Examinations • The average proportion of nursing graduates passing the Philippine Nurse licensure examinations in the 70’s to 80’s was 80-90% • With 1994 as reference year where passing rate was 61.45%; succeeding years have all been below, even reaching a low of 45% in 2002; current rate is 49.4% not even reaching 50% • The total number of annual licensed nurses have decreased to an average of 4,500(1999-2002) compared to more than 15,000 in the early 1990s; however, it is now again increasing as not only original nursing graduates are taking but also second courses, majority of whom now are nursing medics. Nursing Board Performance, 1994- June 2005 70 60 58.24 61.45 54.22 55.79 53.5 50 50.02 49.86 49.2 48.18 49.68 49.41 44.75 40 30 20 10 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Jun-05 Source: Professional Regulatory Commission, 2005 25 Policy Issues on Skilled Migration: The Case of Filipino Nurses

NURSING MEDICS IN THE PHILIPPINES WHY THE SHIFT IN CAREER? TOP 5 REASONS ON CAREER SHIFT TO NURSING 1 Political instability 2 Poor working conditions 3 Threat of malpractice law 4 Low salary and compensation 5 Peace and order problem (Based on key informant survey results) NURSING MEDICS IN THE PHILIPPINES ”PULL FACTORS” OF NORTHERN COUNTRIES TOP 3 FACTORS INFLUENCING THEIR DECISIONS TO LEAVE 1 More socio-politico- economic security abroad 2 Attractive salaries and compensation packages (High salaries, benefits, compensation) 3 More job opportunities and career growth (Based on key informant survey results) 26 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Other Consequences Decrease in the enrollment of first year medical students for the past two years ranging from 18% to 74%; with an average of 30%. Decrease in the applicants for residency positions in training hospitals Three medical schools already closed down; two more located in the rural areas may follow due to enrollment of less than 20 first year medical students Decreased performance in the physician licensure exam Consequences to Health Care Jess Abrera: PDI 3 Hospitals in Mindanao and 2 hospitals in Isabela have no more doctors and nurses Heightens disparities and inequities Decrease in health services coverage Hospitals across the country lament the loss of senior nurses and less ideal nurse: patient ratios Increasing vacancies of MDs and RNs posts in 8 regions (152- RNs and 219 – MDs as of June 2004) 27 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Increasing Nurse-Patient Ratio IDEAL RATIO 1:'4 Philippine General Hospital Medical Center Manila Manila Doctors Hospital Jose Reyes Memorial Medical Center Davao del Sur(some hospitals) 1:15-26 1:6-12 1:6-7 1:30-40 1:45-55 Nursing Education: Challenges and Directions Dean Carmelita C. Divinagracia UERM College of Nursing President, Association of Deans of Philippine College of Nursing Member, TCNE CHED !" #!#$ %&#! '()*+!(,"-./ 01 '!##+'!,"$ 01/ **+#*," 01 ((+)*,"$ 01 2+3 !+*,$ 2 )+' ,"$ 2 2/ #*+(*,"-./ 28 Policy Issues on Skilled Migration: The Case of Filipino Nurses

#)2 0 2 0 4#,' 0 $! 5$ 4)," 6'+ 6 92 7:)) )+!4, 4), & +7 +8+ % 2 : 7 ; /+ $ ; -<. = /5< /. 29 Policy Issues on Skilled Migration: The Case of Filipino Nurses

>== # ' > &= 2; 5 6 . % 6%@=-/ 6 % >$ / ; & / ? 5 =? @752 2 7 30 Policy Issues on Skilled Migration: The Case of Filipino Nurses

A$& %$ $ -? . B$ $ ?A /A 126@/ Skilled Migration from the Philippines Florian A. Alburo Migration Trends The Philippines is one of few Asian countries that has been experiencing large outflows of workers for more than 20 years. The total stock of Filipino migrants overseas(7.8M in 2003) is almost equally divided between permanent and temporary categories. While in the past the Middle East was the dominant destination the recent years have shown a shift to Asia. 3 31 Policy Issues on Skilled Migration: The Case of Filipino Nurses

NUmber 700,000 Outflows of Workers 600,000 500,000 Philippines 400,000 300,000 India 200,000 100,000 Pakistan S. Korea 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 -100,000 Year back 700,000 Outflow of Workers 600,000 500,000 400,000 Philippines Indonesia 300,000 200,000 Thailand Bangladesh China 100,000 Sri Lanka 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 -100,000 Ye ar Number 32 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Number Outflows of Workers per 10,000 Population 100 90 Philippines 80 70 60 50 40 30 20 10 India S. Korea Pakistan 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 -10 Year Outflows of Workers per 10,000 Population 160 140 Sri Lanka 120 100 Philippines 80 60 40 Thailand Bangladesh 20 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 China 1992 1993 1994 1995 Indonesia 1996 1997 1998 1999 -20 Ye a r Number 33 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Number Registered Physicians and Nurses 35000 4500 30000 25000 20000 Phys ic ians 4000 3500 3000 2500 15000 10000 5000 Nurses 2000 1500 1000 500 0 0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Ye ar Estimated Stock of Filipinos Abroad 2003 Area Africa Asia **Middle Eas t Canada United States Oceani a World, Total Permanent 318 85,570 2,290 359,118 1,979, 408 226,168 2,865, 412 Te mpor ary 53,706 944,129 1,361, 409 30,027 99,815 55,814 3,385, 001 Irregular 16,955 503,173 108,150 2,975 510,000 31,001 1,512, 765 Total 70,979 1,532, 872 1,471, 849 392,120 2,589, 223 312,983 7,763, 178 34 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Brain Drain Evidence and Implications Migration of skilled Philippine workers has had a long history – one survey in 1971 put the number of Filipino MDs in the US at half those registered in the country. Many factors explain this brain drain – the declining absorption of college graduates into the labor force, imbalances in supply of skills, opening up of more opportunities abroad, high unemployment rate, etc. 10 Employment of College Graduates Total Employed Persons College Undergraduate College Graduate and higher Persons with college undergraduate(as percent of total employed persons) Persons with college graduate degree and higher(as percent of total employed pe rson s) Ratio of employed college graduates to total employed persons Ratio of employed college undergraduate to total employed persons 1998 27,689 3,065 3,160 11.07 11.41 1:9 1:9 1999 29,055 3,297 3,455 2000 28,895 3,308 3,449 2001 28,096 3,306 3,636 11.35 11.45 11.77 11.89 1:8 1:8 11.94 1:8 1:8 12.94 1:8 1:8 35 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Employment Rates for College Graduates (1)(2)(3)(4)(5)(6) Persons with Employed Percent of Graduates College Employed College College Year Produced Degree Population Graduates Graduates (000)(000)(000)(000) Employed 1980 1,770 16,443 1,621 92 1990 3,121 22,532 n.a. 1995 4,380 25,698 3,449 79 1996 335 4,715 27,442 3,266 69 1997 343 5,058 27,888 3,128 62 1998 353 5,411 28,262 3,347 62 Migration Flow Employed Graduates 1990-98 (1)(2) Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 College Graduates in Employed Population 2,704 2,757 2,870 2,933 3,020 3,449 3,266 3,128 3,347 TOTAL In Thousands (3) Increase of Graduates in Employed Population 53 113 63 87 429 (183) (138) 219 643 (4) Working Registered Emigrants with College Degree 16.4 15.8 15.7 16.1 15.8 13.4 13.8 12.8 9.2 129 (5) Documented OCWs with College Degree 222 260 268 273 278 245 247 279 274 2,346 (6) (4)+(5) 238.4 275.8 283.7 289.1 293.8 258.4 260.8 291.8 283.2 2,475 (7) (2) –(6) 2,481 2,586 2,644 2,726 3,191 3,005 2,836 3,064 36 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Professionals in the Working Population TOTAL PROFESSIONALS IN WORKING POPULATION CHANGE IN THE NO. OFWORKING POPULATION PROFESSIONALS AMONG Land Based Working OCWs Emigrants Total Outflow Of Professionals 1992 1,392 1993 1,398 1994 1,366 1995 1,428 1996 1,640 1997 1,654 1998 1,697 72 6 65 (32) 74 62 44 212 36 14 52 43 56 8 80 8 73 7 81 6 50 7 43 6 58 4 60 T O T A L 305 399 46 445 In Thousands The exodus of skilled Filipino workers comes mostly from employed professionals, those with experience or responsibility. This can be gleaned from the character of the migrant skilled worker when compared with the average worker in the labor force. This has left a void in the industries where these skilled workers came from – which can not be easily substituted by new graduates. Of course if migration is temporary, they will return, but only to await the next cycle. 15 37 Policy Issues on Skilled Migration: The Case of Filipino Nurses

No. reported by NSO, 1990 Successful Board Examinees 1991-98 1998 Manpower before attrition less: Deaths& Retirements Manpower in 1998 Manpower increase 1990-98 POEA Deployment, 1998 Deployed as percent of 1998 Manpower Deployed as percent of Increase in Manpower 1990 to 1998 TEACHER 443,000 ENGINEER 117,000 119,000 562,000 39,000 523,000 80,000 98 0.02 0.12 40,000 157,000 11,000 146,000 29,000 8,363 5.73 28.84 COMPUTER /ICT NURSE PROFESSIONALS 96,000 15,515 TOTAL 671,515 139,000 235,000 16,000 219,000 123,000 5,399 2.47 4.39 9,916 25,431 890 24,541 9,026 1,066 0.34 11.81 307,916 979,431 66,890 912,541 241,026 14,926 1.64 6.19 P ercen t o f OFW s or Emp lo yed OF WS A ND EM PLOY MEN T BY AG E 45 Ove rsea s Filip in o W or kers 40 35 30 25 20 15 Emp lo yed W o rke rs 10 5 0 15-19 20-24 25-34 Ag e C atego ry 35-44 45 and above 38 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Percent of OFW or Emp loyed F ILIPIN O S EM P LO YED A T HO M E A N D A BR O AD B Y ED U C A T IO N AL A T TA IN M EN T 50 45 Em ployed W orkers 40 Ov erseas Filipino W ork ers 35 30 25 20 15 10 5 0 No gra de Ele me nt ary Hig h Sch oo l Highes t Gra de Compl ete d Co lleg e U nd ergra du ate G ra du at e o r H igh er Brain Gain? Changes in the global economy and in technology may be creating windows to address the brain drain more positively. Advances in ICT open opportunities for new industries that are closing the gap between users and suppliers of skilled work without physical dislocation. Not a few took up the challenge and returned to their country of origin to break ground in fields where their migration mattered. 19 39 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Integration and liberalization of financial markets open avenues by which some of the savings and financial resources of OFW can be channeled for use in the country. Regional cooperation improves prospects of brain drain reversal as expanded reach of services reduce migration incentive. A number of migrant-source countries are establishing retirement/care-giving villages and homes that can absorb skilled workers who would otherwise migrate. 20 Directions Several countries which used to send out hordes of overseas workers are now net importers of these. It is useful to understand how they came to turning points and the Philippines seems far away. For some countries, despite continued rise in migration, the share of professionals has declined suggesting a reverse brain drain. Why is this not taking place in the Philippines? 21 40 Policy Issues on Skilled Migration: The Case of Filipino Nurses

S K IL L M IX o r O C C U P A T IO N A L C L A S S IF IC A T IO N o f L a b o u r M ig r a n ts F lo w fr o m th e P H IL IP P IN E S 1980 1987 1998 P r o fe s s io n a ls A d m in is tr a tive C le ric a l S a le s S e rvic e A g r ic u ltu re P r o d u c tio n O th e rs 1 5.5% 0.5 3.4 0.3 1 4.9 1.0 6 4.4 2 7.6% 0.4 3.6 1.0 3 3.7 0.6 3 3.2 0.1 2 5.3% 0.1 1.3 1.1 2 7.7 0.1 3 4.3 0.6 s o u rce: P O E A BA NG LADES H P r o fe s s io n a ls& S e m i P ro f S k ille d S e m i S ille d U n s k ille d s o u r c e: S M C A tla s 1 9 7 7-8 6 6.5% 3 4.7 7.8 5 1.0 1998 3.5% 2 7.9 1 9.2 4 9.2 T H A IL A N D P r o fe s s io n a ls S k ille d /s e m i s k ille d U n s k ille d S e rvic e O th e r 1981 4 0.5 0% 2 1.5 0 3 8.0 0 T H A IL A N D b y e d u c a tio n a l le ve l:* B e lo w c o lle g e d e g re e C o lle g e d e g re e o th e r s b y o c c u p a tio n:* a c a d e m ic& p r o fe s s io n a l s p e c ia lty m n g t& a d m in c o m m e rce o th e r s SRI LANKA H ig h L e ve l M id d le le ve l S k ille d U n s k ille d H o u s e m a id s 1992 1.0% 5.0 1 8.0 8.0 6 8.0 s o u r c e: S M C A tla s 1997 0.4% 3.4 1 6.4 1 3.6 6 6.2 P A K IS T A N P ro fe s s S e rvic e P ro d u c tio n O th e rs 1990 9.5 0% 2 1.3 6 3.2 6.0 s o u r c e: S M C A tla s 1996 7.1 0% 1 9.7 6 0.0 1 3.2 IN D IA P ro fe s s io n a ls S k ille d /s e m i s k ille d U n s k ille d S e rvic e O th e r 1985 5.2 0% 4 7.0 4 0.1 7.7 s o u r c e: 1 9 8 5 c o lu m n, c o u n tr y s tu d ie s c o m p ile d in T a n( 1 9 8 7) 1999 2000 98% 1.9 0.1 9 7.8 0% 2.1 0.1 2 2.2 1.3 1.2 6.7 8.5 90 8 8.1 PermanentFilipinoMigrants,byoccupational classification 1990, 1995,& 2000 1990% 1995% 2000% ProflmTech'l,&Relatedworkers Managerial, Executive, and Admin Workers Clerical workers Sales workers Service workers Agri,andforestryworkers&fishermen Prodprocess,transport&equipoperators & laborers Members of the Armed Forces 7,858 43 5,416 35 6,154 41 430 2 613 4 791 5 1,807 10 2,270 15 1,625 11 2,715 15 2,524 16 2,324 16 1,331 7 1,230 8 964 6 1,283 7 1,020 7 899 6 2,476 14 2,407 16 2,025 14 285 2 48 0 73 0 Total EmployedEmigrants 18,185 100 15,528 100 14,855 100 41 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Institute policy reforms that accelerates employment generation, raise real incomes, and reduce poverty on a sustained basis. An economic environment of high unemployment rates, inequitable income and wealth distribution, and poor infrastructure is never conducive of keeping skilled workers from migrating or enticing them to return. Advocate better living conditions in social, cultural, and political terms. 24 INSIGHTS ON THE SITUATION OF FILIPINO NURSES IN THE UNITED KINGDOM By Edna Aquino, London United Kingdom(edna_aquino2005@yahoo.co.uk) The following are insights drawn by the author from her involvement in the advocacy for the rights of Filipino nurses in the United Kingdom. This piece accompanies the two papers on the situation of Filipino nurses in the UK and Ireland produced by the Centre for Filipinos where the author had served as the Chair of the Board for Trustees from 1998 to 2003. These papers are also being made available for this Forum. 1. Introduction: The Background of the UK Job Market for Filipino Nurses Policy discussion and debates around the growing out-migration of Filipino nurses abroad in the Philippines tend to center around its impact on the deteriorating health care system in the country. The context of the job market in the receiving countries and its implications to the working and living conditions of our nurses who enter these markets are seldom touched. What are their rights and how are these being protected and guaranteed? Who are responsible for ensuring that these rights are guaranteed? The shortage of health professionals in the UK health care system- particularly in the nursing and auxiliary health workers(e.g. nursing assistants) sectors- is perennial and long-term with its accompanying peaks and flows. Demographic changes such as ageing population, lower birth rates, outbound and inbound migration have always been constant and are typical as in any other country in W. Europe and North America. 42 Policy Issues on Skilled Migration: The Case of Filipino Nurses

One reality that is not often mentioned is the systematic failure by the UK health care system to attract students to enroll in nursing schools over the past few decades and retain those who are already in the system because of its association with low-incentive and low-rewarding jobs. Low pay combined with very demanding working conditions and slow career advancement have been the major disincentives to the locals from joining the nursing profession. Those who are already in the system are drawn to do temp-ing jobs which offer higher salaries and allow them to be more in control of their working hours. Enticement to work abroad where the pay is more lucrative is another factor that has left a gap in the job market in the UK. The first generation of nurses who staffed the hospitals in the Gulf states including Saudi Arabia in the 1970s were British and Americans who were paid very attractive salaries and other perks by multinational companies. British nurses were also in high demand in the US and Canada during the 60s to early 90s. The gaps that the local nurses have created in the UK job market were then filled by nurses recruited from abroad. This has been the trend in the job market in the UK health sector for many years now. The first generation of nurses /care professionals from abroad came to the UK before and shortly after World War II. They were mainly from Ireland and the Caribbean countries. They were followed by those from South Asian countries including those who fled from or were driven out of some African countries because of conflicts and discrimination against Asians. Nurses from S.East Asian countries including the Philippines and Australians came during the late 60s to early 70s. Whatever progressive development in legislation and policies concerning the recruitment and employment of health professionals there are now in the UK owe much to reforms resulting from the experiences of earlier generations of health professionals from abroad and from the advocacy by UK-based unions and Black and Minority Ethnic(BEM) groups working on their behalf. In the absence of explicit legislation and State policies prohibiting racism during that period, earlier generations of foreign nurses in the UK experienced more difficulties in dealing with overt and covert forms of discrimination that manifested in: lower pay, slower or no career advancement at the workplace, lack of institutional support for their adaptation to local English language and culture; lack of recognition to the qualification which they have earned from their home countries; most importantly, their insecure immigration status and inability to bring and be reunited with their families. II. Filipino nurses in the UK According to figures by the accrediting body for nurses and midwives(Nurses and Midwives Council), around 30,000 nurses and midwives have arrived and registered in the UK from overseas as of 2002. Almost 50% of the newly registered nurses are from the Philippines confirming what we know all along that the country remains the main target for recruitment for the UK. The number of nurse registrations from in India has almost doubled in 2004 and are fast catching up with that from the Philippines. The UK health care system would have a huge struggle to work efficiently without these nurses from abroad. 43 Policy Issues on Skilled Migration: The Case of Filipino Nurses

There are now a number of legislations coupled with more explicit, official policies aimed at aligning employment practices with international labor and human rights standards which can work to the advantage of Filipino nurses in the UK. Progressive legislation and policies in the following areas are worth noting:(i) equal opportunities; (ii) anti-harassment at the workplace; and(iii) health and safety. In terms of immigration status, foreign nurses nowadays are recruited principally on the basis of their profession unlike their predecessors who came mostly on a student visa. They are now also entitled to bring their dependents on the basis of their work permits. Once in the country, they're entitled to apply for indefinite stay and eventually for UK citizenship as long as they meet the criteria set by the government required for these. These positive developments mentioned are enjoyed by nurses who go via the route of legitimate recruitment process and by those who are employed in the public sector. Those who are recruited and employed in the private sector- particularly in small private nursing homes- tend to find themselves in very problematic and unregulated working and living conditions: low pay; overextended working hours, no clear job description which means they're subjected to exploitative employment practice; no contracts; and other forms of employment malpractices. Most worrying though is the situation of a growing number of nurses who came via the route of direct hire and illegal recruitment(e.g. entering the country as tourists) and who end up in quite vulnerable situations as there are limits to how much they can be protected by law. Disempowered by the circumstances brought upon them by their problematic entry routes to the country, these nurses tend to become so dependent on the forces that brought them here including their unscrupulous employers who take advantage of their"illegal” status. There is a direct correlation between employers who are willing to take in”illegal" recruits because they regard themselves as beyond the reach of law and their abusive and exploitative employment practices. Despite the positive measures mentioned earlier, discrimination in the workplace still exists in more subtle, institutionalized forms. Slow promotion, slow process in getting their accreditation so that they can work as full-fledged nurses; short and inadequate support during their adaptation period; subtleties in language that are in fact, abusive and discriminatory and overt forms such as bullying by patients and by colleagues are some of the documented problems faced by Filipino nurses at the workplace. The two major nurses’ unions had documented and made representation on behalf of our nurses against a common practice by public and private employers to pay those who are in the process of acquiring their registration and are on supervised practice, a much lower pay and less favourable working conditions than their local colleagues. III. The Impact of the nurses’ migration: is the“export” of our health professionals good or bad for the country? Observations by many colleagues in the Philippines regarding the significant bearing on the Philippine health care system by the growing out-migration of our health professionals are increasingly being picked up by some quarters in the UK government 44 Policy Issues on Skilled Migration: The Case of Filipino Nurses

There is a growing articulation by policy-makers and by the Unions to include a consideration to the impact of recruitment of nurses from abroad on the health care system when choosing a country as target for recruitment. Several of us at the forefront of migrant rights advocacy in the UK share this observation but equally we are unsure about the extent to which this phenomenon is contributory to its deterioration: how would this phenomenon compare, for example, with other factors such as poverty, unabated population growth, impact of globalized economy on health in terms of dependency on foreign /imported drugs, dumping of imported food that have low nutritional value, and corruption for instance. There is a need for some solid evidence to back this up otherwise we might be"barking at the wrong tree" or, worse, we could be unjustly and unnecessarily blaming our health care professionals who have chosen to exercise their basic right to migrate for the poor state of our health care system. It's equally important to look at its effects on the nurses and their families. This is a question that has to be examined thoroughly and from the perspective of the nurses. Advocates like us including representatives of their professional bodies are merely observers of their experiences. The nurses'voice in policy formulation and strategies on matters related to their lives and their future should be given utmost importance by NGO advocates and government authorities. The demands for our health professionals abroad have obvious benefits to the country and to the nurses and families. It is good for the economy in the short-term but is problematic and unsustainable for a number of reasons: 1. The policies and programs of the government and the private sector are predominantly market-driven and short-termed in its vision which, in the long run, reduce the competitive edge of the Philippines in the global job market. Policies by governments on the demand side are increasingly being scrutinized by their stakeholders to look at the ethical implications of their recruitment of health professionals abroad. We are not perceived by these governments and ethical recruiters and employers as being“cutting edge” in this regard because of direct experiences of weak regulation by the government of its overseas workers program. 2. The interests of our overseas Filipino workers and their families are not mainstreamed in other aspects of political governance and economic development programs of the government. The good reputation that our nurses is building for themselves and for the country abroad is being undermined by the absence of an integrated program in the Philippines between the Department of Labor and the Department of Education that will ensure the maintenance, if not the further enhancement of quality education for the next generations of nurses. Our nursing schools are increasingly perceived as fast becoming“diploma factories” driven by the lucrative business of supplying nurses to the job markets abroad. We are increasingly receiving anecdotal statements from the long-staying nurses, the unions, ethical recruiters and community leaders here in the UK about the 45 Policy Issues on Skilled Migration: The Case of Filipino Nurses

“lowering” quality of skills from among the latest batches of nurses from the country. Problematic, too, is the effect of the market-oriented values on the individuals: how their own motivation to earn more and in foreign currencies can easily erode their reputation of service-oriented, caring professionals. Our nurses are increasingly earning the reputation in some quarters of the NHS as generally less aspiring in upward mobility in the career ladder at the workplace thus blocking the advancement of new, incoming nurses. They are said to be reluctant to assume higher positions for various reasons. Firstly, there is no significant difference in salaries between the grade where most of them are currently based and the subsequent higher grades. More senior positions entail more responsibilities and less opportunities to work overtime including taking “moonlighting” jobs in private homes or other hospitals. Our nurses cannot be blamed entirely for this practice: UK is a very expensive country and the demands to maintain their family here and/ or send money home are enormous load on their shoulders. Nonetheless, this a potential disincentive to employers particularly in well-established hospitals in the public sector to recruit Filipino nurses in the long run as pressures to put more resources to train local nurses are mounting. Sources: 1.“Here to Stay – International Nurses in the UK”. April 2003. A publication by the Royal College of Nursing. Obtained from http://www.rcn.org.uk/publications/pdf/heretostay-irns.pdf 2. A Guide for Nurses from Overseas Working in the UK published by UNISON, 2004. 3. Philippine Nurses and the Nursing Crisis in the United Kingdom. A Report by the Centre for Filipinos, London, November 2002, Can be obtained upon request from the Centre for Filipinos c/o mgonzales@centreforfilipinos.org.uk. Philippine Nurses and the Nursing Crisis in the United Kingdom A Report by the Centre for Filipinos London, November 2002 “It is ludicrous that we went to a relatively poor country on the other side of the world to recruit huge numbers of hospital staff – I cannot believe that that makes economic sense,” said Edward Davey, MP for Kingston and Surbiton, in a speech before Parliament last May 24, 2000. Davey and other MPs were then discussing staffing problems for public services in the UK. They estimated that the costs of frequent staff turnovers, expenses in integrating new staff into the work force, and premium rates paid to short-term recruits easily exceed£100 million. Davey lamented that vacancy rates in Kingston Hospital in his constituency“is more than the average rate for England, but less than for London.” Despite their best efforts to recruit locally, the hospital’s management had no recourse but to send a team to Manila to recruit 100 nurses on two-year contracts.(Davey, 2000) 46 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Thus, Philippine nurses, for the moment, are providing a part of the solution to what is perhaps the most serious staffing crisis ever in the UK’s National Health Service. Whether this solution is to be viewed as good or bad is the subject of much debate. A growing number of MPs are worried that the UK’s crisis is merely being passed on to a poorer country like the Philippines. Public sector unions point out that, in effect, a poorer country like the Philippines is subsidising the education and training of nurses in the British health service. Davey observes that the“overall long-term sustainable capacity of the(UK) health service is not enhanced by having to resort to such measures.” But for the Philippine nurses and their families, working in the UK away from their families is a sacrifice they are willing to make. As Filipino medical activist, and former Secretary of Health, Jaime Galvez Tan explained,“with nursing salaries in the USA and UK five to 20 times what Filipino doctors and nurses are receiving, it is unrealistic to expect Philippine salaries will ever be able to match these even in the far future.” The issue is a bitter pill for the different stakeholders concerned. For the UK’s National Health Service, recruiting nurses from countries like the Philippines brings an immediate solution to their staffing problems, but may do even more serious damage to the longterm sustainable capacity of the British Health Service. For the Philippine nurses involved, working in the UK brings enormous economic benefits especially when the sterling pounds they earn is converted into pesos back home. But that means enduring separation from family and the social support systems of home, leading very frugal lives in the UK, and adjusting to a new culture and life in exile. For the Philippine government, it means income for a national economy that is increasingly reliant on repatriation from overseas workers. But it also brings the long-term consequences of a nursing brain drain. Since June 2001, the Centre for Filipinos, a London-based and registered charity, has been working with the key players in the provision of health care services in the UK and Ireland, in order to influence policy towards a) the development of standards of good practice in the recruitment and working conditions of Filipino nurses and b) establishing a referral and monitoring system for the resolution of problems that occur both in the Philippines and in the country of destination. To this end, the Centre(CF) initiated a series of workshops and policy forums to discuss the issue in greater depth and explore the different aspects of the debate. The first objective of these workshops was simply to understand the problem and get more information. As Davey and other MPs themselves complained during their May 5, 2000 meeting in Parliament, there was a lack of systematic information on relative staff shortages, how shortages were distributed between London and its environs, what were the impacts of recruitment from abroad, and so on. What they had were merely anecdotal evidence. For Filipino groups in the UK, the urgent objective was to address immediate worries regarding the recruitment, placement and employment of Filipino nurses into the UK and Ireland. The Centre for Filipinos had processed cases of Philippine nurses illegally recruited and employed under onerous conditions, often by unscrupulous employers that have taken advantage of the NHS crisis to employ staff who are subsequently denied minimum labour standards. This report is based on three forums and a series of working group discussions held from June 2001 to June 2002. The first forum on nurses was held on 17 th June 2001 at School 47 Policy Issues on Skilled Migration: The Case of Filipino Nurses

of Oriental and African Studies Main Building in London. This involved representatives from the Philippine Overseas Employment Administration, the then UKCC, the Philippine Council of Representatives(UK and Ireland), the RCN and UNISON, the Philippine Embassy, the Redemptorist Mission for Migrant Workers in the UK as well as a number of Filipino community and health organizations. In her keynote address, Mrs. Edna Aquino, CF Chairperson, stressed the need to establish a number of key guidelines which would light the way towards first, establishing a common policy framework on which good or best practice may be based. Of major importance, she said, was to draw inspiration from the liberal and democratic traditions of the UK to ensure that the applicants and workers were made conscious of their rights. The forum came up with key recommendations in the areas of no-fee collection, proper orientation and induction of applicants, a review of the adaptation process, and the application of the equal opportunities policy in the work place. Suggestions covering the process of contracts verification and authentication of placement agencies both in the Philippines and in the UK were also discussed at length. At the end of the forum, the Action Group for Filipino Nurses was formed to pursue discussions with the NHS and the Independent Healthcare Asociation(IHCA) primarily as well as to monitor progress on the recommendations made. The Action Group was to be coordinated by CF and would involve the Philippine National Council of Representatives, the Redemptorist Mission for Migrant Workers, the newly organized Association of Filipino Nurses, the KAPIS in East London, and the Filipino British Association of Croydon and Coulsden. This was followed by a working group meeting on 28 June 2001 at the Kensington Town Hall, which heard inputs from the Director and Co-ordinator of International Recruitment of the National Health Service. As the largest employer of Filipino health workers, the NHS’ role in setting out a Code of Practice as well as updating existing rules on overseas recruitment, was crucial. The Kensington Forum provided the CF and the Filipino community the opportunity to work with NHS management in threshing out such a landmark policy document. The new CODE OF PRACTICE was published in November 2001. It is a testament to the mutual commitment of both NHS management and the Filipino community to creating the proper policy framework for the recruitment of health professionals from overseas. Two other forums followed, both held at the Centre for Filipinos office at the St Alban’s Community Centre in Hammersmith, London. In both instances, discussions were held with the IHCA(the largest grouping of independent agencies in the UK). The highlight of these discussions was the presentation by the IHCA of their own newly updated Code of Practice – which hewed closely to that of the NHS. It is notable that, in all of these discussions, individual nurses had occasion to relay their personal experiences. 48 Policy Issues on Skilled Migration: The Case of Filipino Nurses

Background on the Issue The Centre for Filipinos initially became involved in the nurses’ concerns in 1999 when a group of 10 Filipino nurses decided to leave their employer in Bristol. In the documentation of their cases, they cited three main issues for leaving. First and most serious was contract substitution – the contracts they signed upon recruitment in Manila were changed with a new contract on arrival in the UK, where they have little free choice. Then, there were the exorbitant additional fees, such as“induction fees” that they were told to pay in order that they can get regular appointment. They also complained of poor working and living conditions, such as spending a Christmas Day shift with only a boiled egg to eat. CF provided temporary accommodations for these nurses in London. After a few months and with CF’s intervention, these nurses eventually found employment with other hospitals in the NHS. Since then, CF came into contact with nurses who faced similar problems. These nurses came from all over England, but most were concentrated in the London area. The Philippine Embassy has reported a sharp increase in the number of Filipinos being recruited by UK-based employers. British Ambassador to the Philippines Paul Dimond, in a meeting with the local media in Iloilo City in the Philippines last June 28, 2002, said that in 2001, the British Embassy in Manila processed nearly 30,000 visa applications, and that the acceptance rate was 95%. Many Filipinos going to the UK eventually end up getting employed. Philippine Ambassador to the UK Cesar Bautista estimates that since 1998, some 35,000 nurses have been recruited into the UK. This‘deluge’ of migrant nurses naturally came with problems, as not all of them came under the auspices of decent employers. Recurring problems emerged from the stories they told that CF documented. These included: Exorbitant fees in both the Philippines and the UK. Poor orientation process in the Philippines. Poor or no support and facilities in the UK to ease their adjustment to new working and cultural conditions. Overextended working hours and no overtime pay. Being asked to perform menial non-skilled work not covered in the contract Substitution of contracts No clear and consistent entitlement to statutory services. CF was not the only organisation that monitored such cases. The Philippine National Council of Representatives, a network of Filipino-British community associations throughout the UK and Ireland came into contact with nurses with such problems. Initially the approach adopted was similar to fire fighting-- deal with the cases as they come spontaneously, and bring it to the attention of the concerned authorities. Dialogues were held with private sector employers, and in a handful of cases, legal action was initiated. As the cases increased, Filipino community leaders decided that a coherent strategy was needed to address these concerns. They also saw the need to build on the positive experiences and best practice in order to set and enforce the proper standards. Similarly, the Redemptorist Mission for Migrant Workers and local associations such as the Filipino-British Association in Croydon and Coulsden had been playing an important 49 Policy Issues on Skilled Migration: The Case of Filipino Nurses

role in providing temporary housing as well as referral work for nurses in distress. The Filipino-Irish Association in Dublin had been actively lobbying the Irish authorities for a greater measure of protection for recruited nurses, even as they brought legal suit against what they termed as unscrupulous recruiters. The Nursing Crisis and the NHS Response According to Georgina Dwight, the NHS Director for international recruitment, the reliance on foreign nurses takes place in the context of a serious decline of people joining the nursing profession while the demand for nurses is on the rise. In 1995, the NHS was already experiencing a 35% staffing shortfall. This was attributed to the previous Tory government policy of threats of closure of big hospitals, mergers and privatisation of the health care system that led to a decline in students going into the nursing profession. Emergency recruitment drives abroad, like in Finland, were undertaken by some local health authorities. Under Labour, the government commissioned a report in 1998 to look at the continuing trend of nursing shortages. In Summer 2000, the government unveiled“The NHS Plan” which included efforts to undertake a massive expansion of the NHS. International recruitment is not a recent phenomenon in the NHS. It can be recalled that in the late 60s and early 70s, the UK recruited thousands of nurses as well in the Philippines. Many of this‘batch’ of recruits ended up settling in the UK, and brought their families over. It is mostly these settled Filipinos who started setting up various community organisations across the UK. The post of Director of International Recruitment is however, a newly created post in response to the need to strategically address the shortage this time around. There are several International Recruitment Coordinators assigned to the regions to take charge of coordinating the recruitment of nurses by NHS Trusts all over the UK. In early 2001 the UK was recruiting nurses from 25 countries around the world to cover for 4,000 vacancies in the NHS. There is a government-to-government agreement with Spain covering the recruitment of Spanish nurses that the NHS is keen to apply in their negotiations with other countries. The NHS maintains a policy that the recruitment of nurses from abroad should not affect the health care system of the sending countries. The NHS considers the coming of Filipino nurses as very positive. Ms Dwight said that they are doing extremely well and are very competent, have adjusted well, and show strong potential for staying on the job for the long term. This compatible with the NHS desire for stability, and given the huge investments they are putting into the recruitment of nurses. But the NHS has also grown concerned about the stories of nurses’ problems picked up from the media and feedback from UNISON, RCN, UKCC, community groups and the Philippine Embassy. While they are aware that most of the problems seem to occur in private nursing homes, it is an issue for the NHS as well. The international recruitment 50 Policy Issues on Skilled Migration: The Case of Filipino Nurses

director stressed the need for documented evidence, in order that complaints can be received and acted upon by the NHS. UNISON reported that they were receiving an average of 30 to 50 calls from distressed nurses a week, with complaints ranging from ambiguity of contracts, punitive financial handcuffs, breaches of the working time directive, and employers keeping passports. In these cases, UNISON reported offenders to the Overseas Labour Service, and got quick action on many cases. But there were also nurses who were threatened with dismissal if they spoke to a trade union. UNISON believes that the Philippine government should be assisted by both the UK’s Department of Trade and Industry and the Home Office in considering the guidelines of the NGS. The Barnet and Chase Farm Hospital NHS Trust provided information on their experience in the recruitment and placement of overseas nurses. With vacancy rates of 15% along with the opening of new beds, they were compelled to recruit abroad. They recruited through a recruitment agency, which they selected based on the agency’s appreciation of the ethical and professional issues, having a policy of non-collection of fees from the nurse applicants, capacity to provide adequate UK-specific orientation and preparation, and the capacity to support the nurse recruits for up to three years of the normal contract. The nurse recruits come in at“C grade” while doing their supervised practice. The Trust ensured that their mentors would have an understanding of the culture, history and social conditions in the Philippines. The operative concept employed by the Trust is that the nurses are not only settling into the health organisation; they were also settling into the community. A Catholic priest was made available to the new recruits. Several initial problems such as housing were easily resolved by working closely with the recruiting agency. They have also put in place a career development program. Independent Private Sector Health Providers While the NHS is the public health body, there are many independent private sector sector health providers in the UK. UNISON notes that many of the complaints come from private sector employers. The largest group among them is the Independent Healthcare Association(IHCA), which has about 211 hospitals and health units and 70,000 beds in the nursing home sector. Nursing homes are an important factor in the recruitment of nurses, particularly because they are more difficult to regulate and monitor. Not all nursing homes belong to a trade association like the IHA. The IHA has worked with the RCN and have drafted a Supervised Practice Programme for internationally registered nurses. Included in this programme are the following guidelines: • That the independent health sector will not use recruitment agencies that charge fees to nurses; • That mentors will be provided • That the salary would be the same as the NHS. 51 Policy Issues on Skilled Migration: The Case of Filipino Nurses

BUPA The BUPA(British United Provident Association) is one of the largest, if not the largest, private sector health service provider in the UK. With over 260 hospitals and care homes under its management, it was crucial that the BUPA participate in these discussions. Since March 2002, the CF and the Action Group have been holding a series of discussions with key officials of BUPA. The agreement is to continue this dialogue on a quarterly basis. Over 3 meetings(one in Leeds and 2 in London), focus has been on the resolution of practical concerns through concrete action for implementation by BUPA. These concerns reflect BUPA’s actual experience on the ground and they principally involve: 1. the prevention of contract substitution and the standardization of contracts all across the BUPA network; 2. the setting up of a practical grievance procedure where problems from nurses are coursed through a centralized complaints system for quicker resolution; 3. a more rights-based and UK-oriented orientation program to be executed by BUPA at both the recruitment and employment ends of the placement process; 4. a review of procedures in the adaptation process while ensuring that BUPA’s institutions are duly accredited to provide adaptation; 5. the setting up of a liaison position within BUPA’s recruitment office, to help new nurses and care givers the proper support for a more trouble free adjustment within the UK and within the workplace. 6. the establishment of a system of referral between BUPA and members of the Action Group so that qualified nurses may be placed within the BUPA system, should there be suitable positions for them. Currently, CF and BUPA are working on organizing nurses’ round table discussions in order to pin down actual experiences and establish means of addressing problems on the ground. Discussions with the UKCC The UKCC participated actively in the June 2001 forum. As the government agency principally responsible for supervising adaptation process for nurses and issuing as well as renewing nurses’ registrations, it plays a crucial role in the entire recruitment and placement process. It has been renamed as the NMC, the Nursing and Midwifery Council since early in 2002, and given even broader powers. Overall, the NMC is charged with establishing and improving the standards for education practice and its conduct with the primary aim of protecting the public, and not professional interests. Specifically, its key tasks include maintaining a register, providing 52 Policy Issues on Skilled Migration: The Case of Filipino Nurses

advice, dealing with misconduct and lack of competence, ensuring quality in nursing education as well as providing guidance to Local Authorities. It is now reviewing registration processes, particularly of overseas members and developing standards for adaptation programs. In the summer of 2002, the discussions between the CF and the NMC came up with the following recommendations, in response to problems relating to the adaptation process and the consequent registration of nurses from overseas: the NMC needs to improve/formalize the standards for the adaptation programme so that it does not exploit the nurses. There should be no difference in the adaptation programme of the NHS and the IHCA so that whether it is the NHS or the private sector, the quality is the same all throughout. The NMC’s website has a list of nursing homes that are registered and accredited to undertake adaptation programs and mentoring. It should also include those that have been struck off. The Philippine Embassy needs to be informed of this, so that unscrupulous nursing homes( which have no accreditation and therefore cannot undertake adaptation programmes) are not given the chance to hire nurses and exploit them. The NMC must inform nurses of the status of the nursing home that they are working for, so that the nurses are made aware of whether the nursing home in question has the capacity and is authorized to run the supervised nursing practice. This has been the source of much heartache as recruits find out they cannot get their PIN numbers since their“adaptation program” is not accredited by the NMC. Nurses and other agencies must have a way to report problems directly to the NMC as well as those who issue work permits in the UK The NMC must make a firm statement that the English test is not necessary for nurse applicants coming from the Philippines, The NMC needs to set guidelines of practice for those involved in implementing the adaptation programme, including the role of mentors. It should also supervise supervisors of the adaptation process to ensure that these guidelines are followed strictly. As this report is being drafted, the NMC has begun to make significant adjustments to the adaptation programme in order to plug the gaps. For example, nursing homes as well as hospitals need to go through an audit prior to their accreditation. Furthermore, in order to ensure quality control, a ratio of one mentor to one adaptee is to be observed. While this more stringent set of rules will definitely reduce the inflow of new overseas recruits and possibly lengthen the placement process, it does cut at the roots of the many initial problems that overseas applicants have encountered after entering the country. In response, the Philippine Embassy now seeks to ensure that working permits are duly accompanied by documents stating that there are indeed adaptation positions 53 Policy Issues on Skilled Migration: The Case of Filipino Nurses

available in the nursing home or hospital recruiting Filipino applicants. As follow up, the CF and allied organizations are requesting the NMC to come out with a register of accredited nursing homes which may can be usable to all concerned, not the least, the nurse applicants themelves, to make sure that positions offered to them do indeed exist. The Philippine Nurses CF and the Filipino community have gone through great lengths to look at the conditions and problems of the nurses. They talk of‘push’ and‘pull’ factors affecting the migration of nurses. Poor social conditions in the Philippines are considered as the powerful‘push’ factor that compel skilled personnel like nurses to work and live abroad, with all the attendant social costs back home. Promised pay and working conditions on the other hand constitute the pull factor that draws Filipinos abroad. Part of the UK’s particular attraction lies in the fact that it has had a long tradition of legal and practical adherence to equal opportunities and a legacy of respect for human rights. There is consensus that the positive contribution of nurses in their destination countries can only be realised if there are legal and operational mechanisms in place that would protect their rights and protect their long term interests. They are known in particular for their high level of skill and professional service standards. Hence, there is a mutuality of interests among the nurses, their home country and the receiving countries which can only be enhanced through continued cooperation, openness and accountability. Within these, the Filipino community in destination countries can be a potent source of support and resources. The media also plays a role not only in exposing anomalies and malpractices but also in helping set the proper standards and to monitor enforcement. CF has also taken the problems of the nurses to the attention of the Philippine Overseas Employment Authority. Memorandum No. 5 issued in May 2000 continued to be the guiding document governing the processing of Filipino nurses in the Philippines. A comprehensive review of these guidelines will be made in order to minimise problems. As contained in the Memorandum, once documents are complete, the POEA can now issue the relevant overseas employment certificates within eight hours. Recruitment agencies considered as having good standing are allowed to undertake self-processing. The Philippine Embassy is encouraging newly arrived nurses to register with the Labour Attache’s office, which is there to help workers with problems and which maintains a fund available for taking legal action. Under the UK Recruitment Agency Act of 1973, the charging fees for directly or indirectly helping someone get a job is specifically prohibited. The Global Recruitment Agency, which participated in the CF meetings, does not charge a placement for getting a job in the UK. Instead, they get a share of what local agencies in various countries they work with. Global provides comprehensive services, including advising nurses on the terms and conditions of their employment in the UK, a thoroughgoing orientation process, costs and types of accommodation, the meaning of national insurance, income 54 Policy Issues on Skilled Migration: The Case of Filipino Nurses

taxes, and so on. One observation that emerged is the alignment of policies between the UK and the Philippines-- POEA’s guidelines relate more to recruitment in areas like the Middle East. Key issues of Philippine nurses in the UK: • Contract substitution – A typical practice involves nurses being asked to sign at least three different employment contracts. The first is signed in the Philippines upon confirmation of recruitment, and which is sent to the POEA and used as the basis for applying for a UK visa. The second contract is kept solely by the Philippine-based recruitment agency, which contains an acceptance by the nurse to pay fees. A third further contract is drawn and signed upon arrival in the UK with terms and conditions totally different from the first contract. • Exorbitant charges and placement fees – Can they be stopped or minimised, and can refunds be made for nurses who have paid such exorbitant fees that sometimes amounts to 6 months’ full pay? There was strong support for a no fee policy. However, there were inconsistencies on the regulations, like the UK Employment Act of 1973 excludes nurses from a no policy. The main problem is that there is no mechanism for monitoring, especially fee charging. It is also not clear whether it should be employers, the workers, or the government, who should pay for such a mechanism to be put in place. The nurses believe recruitment should be based on competence and qualifications, not ability to pay the placement fee. • Monitoring systems – have to be established not just to monitor fees, but also terms and conditions in contracts, work and life conditions, the adaptation process and career opportunities. • Accountability – Questions were raised on who goes after the after bad recruitment agencies, how both governments can share responsibilities for stopping problems. Individual nurses have to be made more aware of their entitlements, and their associations and institutions strengthened to be able to put out information, raise awareness, and facilitate solidarity amongst nurses. • Problems in the attitude of NHS staff towards Filipinos – there appears in many cases disregard for culture-specific needs of the nurses, and that the NHS had no initiative to make contact with the Filipino community to consult them or tap their support. Oftentimes, mentors for the nurses were inexperienced and there is a lack of clarity on the final point of accountability between mentors and newly-arrived nurses when conflict arises. The Appeal processes available for when a nurse fails are not clear. • Adaptation courses have sometimes tended to be too basic and fails to take into account the level of experience of the nurses being inducted. Checklist of Recommendations: 55 Policy Issues on Skilled Migration: The Case of Filipino Nurses

The CF forums have come up with a list recommendations to address the problems. This includes: (11) The adoption and enforcement of a no placement fee rule(Memorandum No. 16), in both the Philippines and the UK. (12) Facilitation of direct hire processes, rather than having to go through recruitment agencies. (13) The NHS will conduct further investigation into the practice of contract substitution. (14) Implementation of a UK-focused pre-departure induction program. (15) The NHS employing a Filipino link person. (16) The replacement of AB998, and the NHS looking into the nursing curriculum of the Philippines to see if Filipino nurses could be immediately registered with the UKCC registration. (17) Changing the concept of‘adaptation’ to‘supervised practice’ that puts more emphasis on greater understanding of responsibility in the UK context, like getting nurses more familiar with UK ward standards and policies. (18) Implementation of a new Code of Practice for international recruitment, that also addresses grading issues. Once this new Code of Practice is adopted, it would become the basis of international recruitment. Based on the foregoing, the Codes of Practice recently updated with inputs from the Filipino community and organizations such as the CF, go a long way to meeting this need. Conclusion The various Codes of Practice are in place. The process of better regulating the adaptation programme for the benefit of the public as well as the nursing applicants has progressed apace. The POEA has updated its rules especially in those areas relevant to countries such as the UK and Ireland. The training program for Filipino community leaders to assist in monitoring complaints and grievances and referring them to the proper authorities is ongoing. Active information exchange with the trade unions involved in the medical profession continues. Various sectors within the Filipino community have come forward to offer their support. A system for referring nurses to other places of employment is slowly being developed. These are some of the developments that have occurred these past 2 years. The wonder of it is – most of these have been nudged forward by the efforts of volunteers, within the Filipino community. There is still a lot of work that needs to be done as the old truism goes. Within the debates on whether the migration of Philippine nurses is a boon or bane to any or both countries, there are the very real concerns about addressing problems they face as a result of this migration. While conscious of the fact that much still remains to be done, the Centre for Filipinos is glad to have contributed to providing the initial infrastructure for policy reform as well as intervention crucial to the recruitment, employment and the professional development process. 56 Policy Issues on Skilled Migration: The Case of Filipino Nurses

In the end, however, as the Chairperson at the first Forum in June 2001 commented, “the nurses themselves are in the best position to address their own very real concerns. ”In fact, this campaign would not even have gone off the ground, were it not for the initial batch of nurse applicants who had the courage to air their grievances and inform the community of their plight. 57 Policy Issues on Skilled Migration: The Case of Filipino Nurses