Regulating the Regulating the Movement of Doctors –Movement of Doctors –Supply and Demand: Supply and Demand: The PhilippinesThe Philippines

Jaime Z. Galvez Tan MD, MPHJaime Z. Galvez Tan MD, MPHProfessor, University of the Philippines Professor, University of the Philippines

College of MedicineCollege of Medicine

Health Human Resources:Health Human Resources: The No. 1 Philippine Health Export 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)(Aiken et al. 2004)

“70 per cent of all Filipino nursing graduates are working overseas” (Bach, 2003)(Bach, 2003)

No. 2 exporter of DOCTORS“68 per cent of Filipino doctors work overseas, next

to India.” (Mejia, WHO, 1979)(Mejia, WHO, 1979)

The Diaspora of The Diaspora of Filipino DoctorsFilipino Doctors Filipino Doctors are practicing in Filipino Doctors are practicing in

at least 80 countries in the worldat least 80 countries in the world Majority are in the USAMajority are in the USA Others are in the Middle East, Others are in the Middle East,

Pacific Island countries, Africa, Pacific Island countries, Africa, Southeast Asia, Australia, New Southeast Asia, Australia, New Zealand, Canada, Taiwan, EuropeZealand, Canada, Taiwan, Europe

The Out-of-the-Box The Out-of-the-Box Phenomenon in the Phenomenon in the PhilippinesPhilippines

Doctors have been becoming Doctors have been becoming Nurses in the last 7 yearsNurses in the last 7 years

At a rate of 1,200 per year, at At a rate of 1,200 per year, at least 9,000 Doctors are now MDs-least 9,000 Doctors are now MDs-RNs or “Nursing Medics”RNs or “Nursing Medics”

At least 6,000 Doctors are now in At least 6,000 Doctors are now in the USA working as Nursesthe USA working as Nurses

Schools for Nursing Schools for Nursing MedicsMedics At least 45 Philippine nursing schools At least 45 Philippine nursing schools

offer abbreviated 1 ½- to 3-year courses offer abbreviated 1 ½- to 3-year courses for doctors to become nursesfor doctors to become nurses

Classes are every weekend; enrolment Classes are every weekend; enrolment ranges from 50 to 500 doctorsranges from 50 to 500 doctors

Doctors go through the capping Doctors go through the capping ceremonies and nursing duties in ceremonies and nursing duties in hospitalshospitals

The total tuition costs range from The total tuition costs range from US$1,500 to US$3,500US$1,500 to US$3,500

Source: Source: Key Informant Interviews; Preliminary results, Galvez Tan, et al., 2004

Nursing Medics: Who Are Nursing Medics: Who Are They?They?

They come from all kinds of specialtiesThey come from all kinds of specialties Their age range from 25 years old to 65 Their age range from 25 years old to 65

years oldyears old Years of practice as a physician range Years of practice as a physician range

from zero to 40 yearsfrom zero to 40 years Near equal male and female ratiosNear equal male and female ratios They come from all regions of the countryThey come from all regions of the country Around 80% of public health physicians Around 80% of public health physicians

have taken up or are enrolled in nursinghave taken up or are enrolled in nursing

Source: Source: KII, Personal Study 2004

Nursing Medics in the PhilippinesNursing Medics in the Philippines

WHY WHY

THE SHIFT THE SHIFT

IN CAREER? IN CAREER?

Nursing Medics in the Philippines Nursing Medics in the Philippines WHY THE SHIFT IN CAREER? WHY THE SHIFT IN CAREER?

TOP 5 REASONS ON CAREER SHIFT TO NURSING

11 Political instability Political instability 22 Poor working conditions Poor working conditions 33 Threat of malpractice law Threat of malpractice law 44 Low salary and compensationLow salary and compensation55 Peace and order problemPeace and order problem

(Based on key informant survey results)

Nursing Medics in the Philippines Nursing Medics in the Philippines ”PULL FACTORS” OF NORTHERN COUNTRIES”PULL FACTORS” OF NORTHERN COUNTRIES

TOP 3 FACTORS INFLUENCING THEIR DECISIONS TO LEAVE

11 More socio-politico- economic security abroad More socio-politico- economic security abroad (Migrant visas for nurses & spouses & children)(Migrant visas for nurses & spouses & children)

2 Attractive salaries and compensation packages2 Attractive salaries and compensation packages(High salaries, benefits, compensation)(High salaries, benefits, compensation)

3 More job opportunities and career growth 3 More job opportunities and career growth

(Based on key informant survey results)

The Supply of Doctors The Supply of Doctors in the Philippinesin the Philippines There are 36 medical schools There are 36 medical schools

(only 7 are government-run)(only 7 are government-run) 2,000 doctors annually pass the 2,000 doctors annually pass the

Philippine National Licensure Philippine National Licensure Exams (out of 3,000 that Exams (out of 3,000 that graduate yearly)graduate yearly)

However in the last 3 years, there However in the last 3 years, there has been a 50% decrease in has been a 50% decrease in medical school enrolment medical school enrolment

The Demand for The Demand for Doctors in the Doctors in the PhilippinesPhilippines There are 120 rural municipalities There are 120 rural municipalities

that have been doctor-less for a that have been doctor-less for a decade or moredecade or more

There are 600 vacancies in rural and There are 600 vacancies in rural and urban hospitals (public and private)urban hospitals (public and private)

In the last 3 years, there has been a In the last 3 years, there has been a 30% decrease enrolment in hospital 30% decrease enrolment in hospital residency specialty training residency specialty training programsprograms

Consequences of Consequences of the Mass Migration the Mass Migration of Filipino Doctors of Filipino Doctors and Nursesand Nurses

Positive and Negative Positive and Negative ConsequencesConsequences Increase in US$ remittances from US$6 Increase in US$ remittances from US$6

Billion in 2000 to US$10.2 Billion in 2005 Billion in 2000 to US$10.2 Billion in 2005 (Source: Central Bank of the Philippines 2006)(Source: Central Bank of the Philippines 2006)

However, little of these remittances are However, little of these remittances are returned as investments in health nor in returned as investments in health nor in health human resources developmenthealth human resources development

Decrease in the proportion of deaths Decrease in the proportion of deaths medically attended from 50% in 1995 to medically attended from 50% in 1995 to 30% in 2003 30% in 2003 (Source: National Statistics Office 2006)(Source: National Statistics Office 2006)

1965 1970 1975 1980 1985 1990 1995 2000 2002

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%P

erce

nt

Year

Death by Attendance in 5-year I ntervals, Philippines 1965-2002

Unattended

Attended

Source: National Statistics Office, 2006

Negative Negative Consequences Consequences

200 hospitals have closed down 200 hospitals have closed down within the past two years – no more within the past two years – no more doctors and nurses doctors and nurses (PHA, November 2005)(PHA, November 2005)

800 hospitals have partially closed 800 hospitals have partially closed (with one to two wards closed) – lack (with one to two wards closed) – lack of doctors and nurses of doctors and nurses (PHA, November 2005)(PHA, November 2005)

Decreasing Trend in NMAT (National Decreasing Trend in NMAT (National Medical Admission Test) Examinees Medical Admission Test) Examinees since Yr. 2000since Yr. 2000

NMAT Examinees (1994-2005)

50495360

5814 5730 5948 6121 6245 61925853

44754070

2912

0

1000

2000

3000

4000

5000

6000

7000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Less and less young Filipinos wanting to become medical doctors with a decrease by 53% of NMAT Examinees since Year 2000 from 6,245 to 2,912 in 2005, the lowest in 12 years.

What has been the What has been the response of the response of the Philippines? #1Philippines? #1 Develop Health Business Develop Health Business

Models that will generate Models that will generate foreign investments in healthforeign investments in health((the aim is for Filipino health the aim is for Filipino health professionals in the Philippines to professionals in the Philippines to earn foreign currency while earn foreign currency while practicing in the countrypracticing in the country))

Philippine Response Philippine Response #1.1#1.1 Medical tourism has been launched as a Medical tourism has been launched as a flagship program of the government in flagship program of the government in January 2006January 2006

The Department of Foreign Affairs has The Department of Foreign Affairs has commissioned the design of business commissioned the design of business models for health:models for health: (1) creation of an (1) creation of an international zone of health for health and wellness international zone of health for health and wellness combining medical tourism, spa health, eco-tourism and combining medical tourism, spa health, eco-tourism and retirement villages (2) health human resources retirement villages (2) health human resources development network with the top nursing and medical development network with the top nursing and medical schools/hospitals in the Philippines as investment areas schools/hospitals in the Philippines as investment areas (3) health crewing for specific health services, including (3) health crewing for specific health services, including tele-health, medical transcriptions, health research and tele-health, medical transcriptions, health research and developmentdevelopment

Philippine Response Philippine Response #2#2 Increase physician scholarships Increase physician scholarships

in underserved areas with 200 in underserved areas with 200 new scholars starting 2006new scholars starting 2006

The Philippine Health Insurance The Philippine Health Insurance Corporation is considering Corporation is considering doubling reimbursements for doubling reimbursements for physicians practicing in rural physicians practicing in rural areasareas

Philippine Response Philippine Response #3#3The Development Bank of the The Development Bank of the Philippines is designing a US$40 M Philippines is designing a US$40 M program to provide low interest loans program to provide low interest loans to physicians intending to practice in to physicians intending to practice in rural areasrural areas

Legislation of a National Service ActLegislation of a National Service ActDevelopment of a coherent Health Development of a coherent Health Human Resource Development PolicyHuman Resource Development Policy

Philippine Response Philippine Response #4#4 Recently updated the 25 year Recently updated the 25 year

Master Plan for Health Human Master Plan for Health Human Resources Development (2006-Resources Development (2006-2030) by the Dept. of Health with 2030) by the Dept. of Health with the National Institutes of Health-the National Institutes of Health-Philippines and WHOPhilippines and WHO

Philippine Response Philippine Response #5#5(private sector/civil society)(private sector/civil society) The Philippine Medical Association The Philippine Medical Association

held a Philippine Medical Summit in held a Philippine Medical Summit in Sept 2005 for resolute actions on the Sept 2005 for resolute actions on the issueissue

The Philippine College of Physicians The Philippine College of Physicians launched its campaign for retention of launched its campaign for retention of doctors in the Philippines through the doctors in the Philippines through the Movement of Idealistic and Movement of Idealistic and Nationalistic Doctors (MIND) in 2005Nationalistic Doctors (MIND) in 2005

What Else Needs to Be What Else Needs to Be Done by the Done by the Philippines?Philippines? Tame the mass exodus to the North Tame the mass exodus to the North Achieve a rational programmed Achieve a rational programmed

departure or our health professionalsdeparture or our health professionals Secure a win-win situation for the Secure a win-win situation for the

Philippines and the receiving countriesPhilippines and the receiving countries Achieve brain gain and brain Achieve brain gain and brain

circulation for Filipino health circulation for Filipino health professionals abroadprofessionals abroad

Note: These do not aim to prevent health Note: These do not aim to prevent health professionals from leaving the countryprofessionals from leaving the country

One: Initiation of High-One: Initiation of High-level Bilateral level Bilateral Negotiations with Negotiations with Northern Countries Northern Countries Importing Filipino Importing Filipino Health ProfessionalsHealth Professionals(similar to the South Africa-(similar to the South Africa-UK and Poland-Netherlands UK and Poland-Netherlands Agreement)Agreement)

One …One …

The Government should negotiate with The Government should negotiate with the top importing countries for bilateral the top importing countries for bilateral agreements that can lead to agreements that can lead to development of a National Trust Fund development of a National Trust Fund for Health Human Resource for Health Human Resource Development to help improve training, Development to help improve training, education and working conditions of education and working conditions of local health workers, provide local health workers, provide scholarships and even salary incentives.scholarships and even salary incentives.

Two: Convene the health Two: Convene the health human resources human resources development agenda of development agenda of the General Agreement on the General Agreement on Trade and Services (GATS) Trade and Services (GATS) of the World Trade of the World Trade Organization (WTO)Organization (WTO)

Two:Two:

Health services and health Health services and health professional services can be professional services can be treated like commercial goods and treated like commercial goods and services that can be traded across services that can be traded across and among countries in need of and among countries in need of additional health care services. It additional health care services. It is in the interest of physicians to is in the interest of physicians to be represented in the WTO be represented in the WTO negotiations.negotiations.

Three: Joint Research Three: Joint Research AgendaAgenda Forge a joint or multi-country Forge a joint or multi-country

research agenda and action program research agenda and action program on health human resources on health human resources development among importing and development among importing and exporting countriesexporting countries

At the very least there should be a At the very least there should be a partnership in the regular sharing of partnership in the regular sharing of health human resources data and health human resources data and policies among these countriespolicies among these countries

Finally: A Call of the Finally: A Call of the Philippines to the Philippines to the Receiving CountriesReceiving Countries Create Health Human Resource Create Health Human Resource

Development (HHRD) policies that would Development (HHRD) policies that would be humane and compassionate to the be humane and compassionate to the PhilippinesPhilippines

Increase bilateral aid specific for HHRD in Increase bilateral aid specific for HHRD in the Philippinesthe Philippines

Encourage private investors in your Encourage private investors in your country in invest in health in the country in invest in health in the PhilippinesPhilippines

Enact legislation on ethical recruitment of Enact legislation on ethical recruitment of health professionalshealth professionals

The Challenge for All The Challenge for All

The need for global and The need for global and national solidaritynational solidarity

Matched by political will and Matched by political will and actionaction

The time to act was The time to act was yesterday.yesterday.

Thank You Very Much!!!Thank You Very Much!!!

As we say in the Philippines,As we say in the Philippines,““Mabuhay” and “Salamat Po”Mabuhay” and “Salamat Po”

Jaime Z. Galvez Tan MD, MPHJaime Z. Galvez Tan MD, MPHjzgalveztan@gmail.comjzgalveztan@gmail.com