Medical migration as the answer to growing health care needs in Europe

Filipino IV-drip for Flemish health care

Fifteen Filipino nurses have just started a new career in Melsbroek, Ghent and Antwerp. That’s after they waited two and a half years to get a Flemish work permit. Why do they look for a job 10,500 kilometres from home? We went to Manila to find out.

Manila, Makati City, a scorching hot evening at the end of July. Amid the madness of taxis, jeepneys, padyaks and tricycles – Manila is hell on wheels – I say goodbye to Leilani Cruz, Christian Estrada and Kathleen Romasanta. They still have one week left to say goodbye to their families, and then they are leaving for Belgium, to the MS-centre in Melsbroek, after waiting two and a half years. Eleven other Filipino nurses will follow them in September to Ghent or Amsterdam, after an equally long and tiresome road full of obstacles. All fifteen are experienced nurses and they have all been learning Dutch at the Center for Multicultural Studies in Manila.

Leaving is a bittersweet experience for these young people, as Filipinos regard their families as the centre of the universe. They will be away from home for at least five years. ‘I’m very happy after the long wait,’ said Christian Estrada, ‘but also quite sad for my family.’ His family lives in the province of Pangasinan, in the northwest of Luzon, the largest of more than 7,000 islands in the Philippines. Leilani Cruz, who lives with her parents in Parañaque City, has mixed feelings: ‘I’ve never been abroad and I’m going to miss them all terribly. But I’m ready for it.’

Flanders has since 2000 been tentatively looking towards the Philippines, the world centre for the export of nurses, to fulfil its growing health care needs. This is impossible with only Belgian health care workers, no matter how popular the bachelor degree in nursingand theHBO5-track nursing qualification may be at the moment. Exactly how many foreign health care workers Flanders and Brussels will need isn’t clear. There is still no health care register available with recent data. Yet it is clear that it is going to take a lot. Last year Flemish Welfare and Health MinisterJo Vandeurzen mentioned that some 120,000 health care workers would be needed to meet future requirements. At the moment, Flemish facilities are said to be looking for 1,700 nurses and 300 health care assistants.

the water is deep

Most efforts to get Filipino employees to come to Belgium have failed in the past few years. Attempts were made by recruiting agencies such as Medical Express, Randstad and Limarex, which filed for bankruptcy last year, reportedly ‘because the legislation makes it extremely difficult to recruit Filipino migrant workers.’ In the past three and a half years fewer than twenty Filipino nurses have been granted permits to work in Flanders, mainly because foreigners can only work in Belgium if no other suitable Belgian or European Union employee can be found.

Added to that, Belgium’s academic recognition authority decided in May 2010 that the Filipino masters degree in nursing would no longer be considered equal to the Belgian university nursing bachelor degree and instead should be viewed as equivalent to the HBO5 nursing qualification. Indeed, as the NARIC suddenly discovered, the school program in the Philippines differs significantly from the Flemish standards. The Filipino government has recently revised its program and this year extended secondary education from four to six years. In the view of Belgian Federal Health Minister Laurette Onkelinx’s office, nursing migration more or less amounts to a brain drain. ‘Just like the World Health Organisation, we are opposed to engaging employees from third world countries,’ the ministry said.

‘Brain drain is a word from the past,’ according to Dr Kenneth Ronquilo, a Filipino government employee who is director of the Health Human Resource Development Bureau in Manila. ‘We are now focusing on brain circulation. Nurses leave only to return after a few years, with newly acquired skills. These allow them to find a job anywhere here. Brain mobility is a good thing. There are still more nurses available than our country needs.’

shortage of care, excess of caring staff

Gisela de Asas Luna, Dean of St Luke’s College of Nursing at the Trinity University of Asia agrees with the Onkelinkx staff. As a young nurse, she never wanted to work abroad. ‘It was a nationalist impulse. I did not want to work for a different continent, since the Philippines needed health care workers here.’ She regrets the fact that student nurses would rather serve their families than their country, although she is able to put things in perspective. ‘They often have no choice. Eighty to ninety percent of students become nurses on their parents’ orders, in order to better their family’s bad financial situation and to fight poverty. Going abroad means a much better salary and much more pleasant work conditions. Young nurses should be offered that opportunity, but when they’re seasoned veterans they should help their country by coming back. Besides, it’s our own government who is sending those nurses out with its deliberate policy of low wages and striking deals with other countries.’

Nevertheless, De Asas Luna can see the bright side: ‘Fortunately the government is also taking good steps, such as the program that puts unemployed nurses to work in rural, remote areas that need health care badly. They are paid by local governments, but those working outside of Manila, earn a lot less. So it’s understandable that only 10,000 of the 100,000 unemployed nurses have found a job that way.’ According to the Philippines’ 2002 rules, newly qualified nurses who aren’t employed in the private sector should earn 24,887 pesos (497.5 euros) a month. But the reality is quite different. Poor local governments only have to pay 65 percent of the standard salary rate. As a result many regions and poor communities have a health care shortage and a lot of public hospitals are understaffed, despite high unemployment among nurses.

Filipino health care is one of the worst in East Asia. Four in ten Filipinos have never seen a doctor or nurse. Six in ten die without medical care. Dr Ronquilo stresses that progress is being made, but still sees problems. ‘Today more people have medical insurance and access to health care. At the moment maternity mortality is the biggest health issue with 221 deaths out of 100,000 births. In 2009 that number was 162 and our goal was 62 by 2015. In other words, it does not seem like we’re going to get there. The reason is too few health care workers in certain areas, which means many women give birth at home.’ And what Ronquilo does not say, is the very influential Catholic Church is doing everything in its power to oppose a reproductive health bill, which would allow abortions, birth control and population control — another factor to explain why the millennium development goals are not being met.

the daughters’ sacrifice

The nurses I get to know in Manila migrate for economic reasons. The Philippines is a poor country and scores of families are sending their daughters abroad. And it’s the daughters who usually make the sacrifices, with the oldest daughter often expected to alleviate the family’s financial burden. ‘Without our help our families can barely survive and within the Philippines you earn too little,’ says Leilani.

Leilani is 35 and comes from a mixed Filipino-Chinese family. She is accompanying me in Manila for a week to practice her Dutch. She successfully graduated from a five-year course in physical therapy and a three-year course in nursing, with an extra year of training as a surgical nurse. She worked at the Makati Medical Center, one of the most prestigious hospitals in the Philippines, from 2005 to 2010, starting as a regular nurse and leaving as assistant-head nurse for a surgical ward of 22 patients.

‘I was earning less than 250 euros a month, which is too little to provide for a family. On top of that, the work schedule is very hectic. Some days I was working sixteen hours straight. And you don’t get paid for evening shifts or overtime. There is a lot of stress. That’s why I decided to work at a call centre. I would be doing the intakes for nurses who wanted to migrate to Belgium. When I heard about that, I immediately applied. It didn’t matter to me if it was Belgium or any other country.’

Leilani speaks exceptionally good Dutch. ‘Together with sixteen other nurses we took a course in Dutch, which must be the most difficult language on the planet. We were taught by a Dutch and a Flemish teacher from eight till four every day for six months,’ she said. The long wait for a work permitbegan in April 2010. First the Limarex agency accepted her for a job in Hospital Maas en Kempen in Maaseik, just like Christian Estrada. But the hospital pulled out when Limarex could not get a work permitand went broke. Another agency, Medical Express, took over her case. ‘We really started despairing,’ Leilani said. ‘Medical Express paid us a certain amount every month, but still asked us to look for another job before we could leave.’

Originally Leilani’s family was opposed to her leaving the Philippines, but that has changed. ‘They’ll get a better life. I’m happy that I can do something in return for the large financial efforts they made to allow me to study for so long. My mother also deliberately raised me quite strictly. All work, no play: that was her motto. For instance, when I was a child, I always had to study Chinese. That helped me learn other languages. As well as my mother tongue of Tagalog, I can speak English, Chinese and Dutch. And while I’m in Belgium, I want to learn French.’

export numbers

The Philippines have turned the export of nurses into a true brain business. Men go to sea, women head for health care. Filipinos send millions of euros home every year. The government is trying to keep up with the migration trends of its nurses, but that is very difficult. Many go from one country to another. Noel Cadette, the president of the Philippine Nurses Association, headquartered in Malate, gives us the latest numbers. In 2011 the top five countries for migration were Saudi Arabia (12,922 Filipino nurses), Singapore (775), the United Arab Emirates (739), Kuwait (607) and Oman (562). Next come Qatar, Taiwan, Jordan, the Republic of Sudan and the UK (135). In total 17,379 nurses went abroad last year, almost 40 percent more than in 2010.

Filipino nurses’ emigration has in general risen spectacularly since 2000, before falling slightly more recently. ‘Increasing demand from Arab countries has cushioned the fall to some extent,’ said Christopher Dumatol, President of Manpower Resources of Asia. ‘Western countries like the US and Great Britain have made their admission requirements more strict. They are protecting their own nursing industry. In spite of that, the landscape is constantly changing because other countries are signalling more openness, including Belgium, the Netherlands, Canada and Iraq. The improved academic curriculum has definitely played a part in that. In the past, physicians could also work as nurses abroad. That was a politically sensitive point and it’s not allowed anymore.’

the foreign dream

Thousands of people are gathering in and around Manila Cathedral. Many are following the service on one of the TV screens outside the church. In the chapel I bump into Jenny Salvador, 27, a nurse living in Pembo, one of 33 baranggays or districts in Makati. At the Market Market mall in Taguig City we take a tricycle down an untidy alley to her room in a terrible labyrinth of a building. It is pitch black. We have to step over the guard dog, pass under clotheslines and wade through the water that comes up to Jenny’s front door during the monsoon season. A cockroach scuttles off under the sofa. Her living space is a room of two by four meters without a window, a stiflingly small kitchen, a bedroom and a bathroom. No daylight. And she lives here with her younger brother.

After a number of underpaid jobs, such as in one of the enormous pharmacies of a shopping mall, she wants to work in a Manila hospital. ‘That would give me the necessary experience to go and earn a living abroad and provide for my family. My father is a farmer, but because of his heart condition he can’t work anymore. He’s still strong: he washes his own clothes and does his own cooking, but medication is expensive. My mother is a housewife. I also want to give my nephew, who lives with them, the opportunity to finish secondary school. My oldest brother and I will pay for his education.’

At the moment her older brother takes care of the family’s financial needs. ‘He’s working as a sous-chef in a restaurant in Milan. I also want to help my younger brother get a job in the Manila catering industry. That’s why I had him come up from the countryside.’ Every day she goes to an internet café to look for work. ‘Time is running out. I have been saving up money, I live carefully, but I need to find a job this month. Otherwise I can’t pay the rent (120 euros) anymore. Every waking hour the TV drowns out the silence. ‘I’m afraid for the future. My parents don’t have health insurance. If something were to happen to them, they would die. That’s one of the reasons I want to go abroad. But to be honest, I’ve been dreaming of a life abroad since I was a child, even marrying a foreigner. Until now I haven’t opened up to the possibility of a relationship. I’ve had to provide for my family.

the long and winding road to Europe

‘Ninety percent of our former students go abroad,’ says Principal Edna Imperial of the small Mary Johnston Hospital College of Nursing in Tondo, one of the poorest and most densely populated districts of Minal. ‘They are very much in demand. Caring for the elderly is deeply engrained in the Asian culture. Just like hard work. That’s why all those rapidly ageing countries, from Japan to the US and the richer EU countries, will keep attracting Filipinos.’ Despite that, it can be very hard for Filipinos to get a work permit. Christian Estrada first wanted to work in Canada, but after that proved impossible, he chose Belgium. He too was working in a call centre for the last year. Before that he worked at the intensive care unit of Manila’s National Centre for Mental Health for five years.

Christian is a very gentle man, very intelligent and quite big for a Filipino. ‘Honestly, I was disappointed that we had to wait so long for a work permit. It’s been getting more difficult in many countries for a Filipino to work there. People from first world countries have a much easier time migrating than we have,’ he said. Christian thinks it is perfectly normal to work that far from home. For him, it is strange that Flemish nurses prefer to live within a stone’s throw from their work places. ‘Life in the Philippines has everyone looking for a job abroad. With my work in the MS-clinic I can help my younger sister and my brother, who suffers from epilepsy. And I’m getting benefiting from it too. So I’m very curious about the work in the MS-clinic and the relationship with the patients and colleagues. I know it’s a good place from Don and Jeffrey, two other Filipinos working in Melsbroek. Nice colleagues, interesting job.’ The only thing that he doesn’t know is whether he will like the Belgian weather.

Rene Cristobal, President of the Employers Confederation of the Philippines and of Manpower Resources of Asia believes that bureaucrats are creating doubts about the education and the abilities of Filipino nurses to help battle local unemployment. ‘This way they can also control the situation and they don’t have to pay the Filipinos as much as their own countrymen.’ Dean De Asas Luna confirms this, saying: ‘Filipino nurses are just as good at their job as their Belgian colleagues. That so many are working abroad, says it all, doesn’t it? And now other Asian countries are copying the Filipino model. Thailand and Korea are also trying to promote their nurses in an international context. Indonesia is doing the same by sending nurses to Japan, while Vietnam is attempting to set up partnerships with the Philippines.

However the number of students has gone down significantly. De Asas Luna: ‘In this school, 481 students are studying nursing at the moment, from the first up to the fourth year. There used to be many more, even up to 2,500 students. The fact that fewer nurses now find a job abroad has something to do with it. The abundance of nursing schools has saturated the market. Because of that, many nurses are either unemployed or have other jobs: in call centres, supermarkets or take-aways.’

homesick

A month later I’m visiting the four nurses in their apartment in Melsbroek. Their arrival didn’t go unnoticed in the local community. The local priest has started seeing the four young people at his service every week. They even love working as volunteers. Their relationship with their neighbours is excellent, as was their first job evaluation. Not far from their apartment they have even found another Filipino and her wide network of friends. But with every passing plane, homesickness plays up. The four are still in full culture shock. ‘But that passes too.’ says Leilani. ‘When I’m having a difficult time, I go for a walk. I even got lost in a nearby forest once. And there are so many places left to visit. We’ve seen Brussels, now for Bruges.’

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