Nursing the western world

In the Philippines, thousands are training as nurses in order to get jobs in Ireland and elsewhere - but are we gaining at the expense of the Asian country's own health service, asks Clifford Coonanin Iloilo

There are people in nurse uniforms everywhere in Iloilo, whizzing to training hospitals on spectacularly decorated Jeepney minibuses, clamouring together, giggling on the streets outside the scores of recruitment agencies downtown or rushing to class laden with medical text books.

The Philippines is experiencing a nurse training bonanza as people seek ways to escape dire poverty and work abroad; 15,000 Filipinos will leave the southeast Asian country this year to nurse the sick and the aged in the West, and many of them will come to Irish hospitals.

"Going abroad is something everyone thinks of here. That's why everyone wants to learn to be a care-giver, they know it's a skill they can use abroad," says Maureen Parra, 32, a trained physiotherapist with an MBA.

Sitting in a recruitment agency in this bustling urban centre, where many of the country's top training facilities for the caring profession are located, she says her nursing class had three doctors, 10 medical technologists, four physiotherapists and five dentists. A nursing degree takes four years, competition for places is intense and all the teaching is through English.

Parra is working as a volunteer nurse, earning no pay, to gain the valuable experience she needs to work abroad.

People are the Philippines' biggest export - nine million of the country's 82 million citizens live outside the country and they send home nearly €700 million a month in remittances through the banking system, 12 per cent of Philippine gross domestic product (GDP).

In one shocking statistic, Philippine health secretary Francisco Duque has estimated that 85 per cent of the country's nurses have left the Philippines. About 3,000 people emigrate every day.

SR CAROL AGRAVANTE, director of the St Paul University and Hospital Iloilo, runs a tight ship. The nursing training facility is one of the best in the country, with a fantastic reputation. As she whisks us through the well-equipped school, the impeccably dressed and polite students stop to say "Hello, Sister" and smile. I've never seen a more polite university and the college is far cleaner than most hospitals.

They start class every morning at 6.45am with prayers and hymns. This is top-notch education, Philippine style - the rest of the world should beware.

"I've seen so many changes in the nursing profession in the Philippines," says Agravante, who has worked as a nurse herself. "Going abroad is what everyone wants to do. Probably the parents want them to go. Their motivation is to help their families."

St Paul University is extremely difficult to get into and takes only 200 students a year, with nearly all of them getting through the nursing board exams at the end of their studies.

"We're very selective in terms of grades and motivation, and are the top school for passing the nursing board exams," says Agravante. She is scathing about the mushrooming of ill-qualified schools training nurses, a sad fact which is reflected in the low percentages passing the nursing board exam.

A big fear for people who have sold the family farm to pay for a child's education is that unscrupulous agencies will rip them off. The main protection is the phenomenal grapevine that exists among the applicants. Word-of-mouth quickly exposes the fraudsters and the offices of the Overseas Workers Welfare Administration (OWWA), have posters with details about cheating agents.

James Mendiola, officer in charge at the OWWA, says that illegal recruitment was one of the most serious crimes you can commit.

"If you are caught, then they take away your bond money; there's no bail - you go straight to jail."

Ireland is one of the most popular destinations, because of the Catholicism, the shared colonial past, plus the fact many were educated by Irish missionaries. And the money isn't bad.

Liam Doran, general secretary of the Irish Nurses Organisation (INO), attests to the importance of Filipino nurses in Ireland, where they account for more than 10 per cent of the total number of 50,000 nurses.

"It is a reality, not readily acknowledged by Irish health employers, that this country would now be forced to close literally thousands of beds if we did not have the significant cohort of Filipino nurses now working in our Irish health service," says Doran.

Circe Brillantes, 34, applied for something in Europe so she can spend more time with her husband, a seaman, with whom she has spent one year out of the seven years they have been together.

"Ireland has a good reputation among the applicants here. Classmates of mine in Ireland applied for citizenship and it looks like they'll get it," says Brillantes, who needs to find work abroad to finish building her house, after their last home was eaten by termites. So far there has only been enough money to replace half of it.

Brillantes' case illustrates how Ireland could soon be losing the battle to attract healthcare workers. She has approval to go to Finland, and the word on the street in Iloilo is the Finns, who are just starting to accept Filipino nurses, offer better conditions. The language is difficult, sure, but people in the western Visayas region cope with 15 dialects plus English, and cold weather might make a nice change.

Canadian hospitals are recruiting Filipino nurses from Ireland, promising them better pay, fast-track visas - for them and, crucially, for their families - and even low-interest loans. Irish nurses are moving to Canada too. Swedish recruitment firms are also looking at Irish hospitals for nurses. Websites offering advice for Filipino nurses who want to come to Ireland say that the new Irish "Green Card" rules are not clear on some areas about families.

All the students are constantly on the lookout for what is known as a "retrogression" - when a country closes its doors to Filipino nurses.

THERE ARE STILL about 1,000 nursing vacancies in Ireland, mostly in Dublin, but there are restrictions on employment imposed by the HSE since the 2008 Health Service Budget, which the INO's Doran believes has complicated the situation, in terms of planned recruitment.

"But there are still vacancies and there will still be a need into the future," he says.

The talk among the 3,000 nursing students on the campus at the Central Philippine University is of where the latest openings are.

"Most people want to go to the US, where they earn more money. But the agencies will tell us about what is open and inform us. And when we go abroad it is important there is a Filipino community to help us adjust wherever we go," says 18-year-old first-year student, Florevy Diana.

Her teacher Maria Habardass spent 13 years working in an intensive care unit in the Middle East.

"The students can adapt so easily. They are multi-experienced," she says, proud of her charges.

Then we ask the class how many want to go abroad. They look at Habardass guiltily, and then all raise their hands.

"This is our tragedy. What will happen to us when all of our trained professionals have left the country?" she says.

Later we drive to Maureen Parra's house in the suburbs, which doubles as her father's general practice; her old-school VW Beetle, still a common sight in the Philippines, sits in the driveway.

"Filipinos are really adaptable," says Parra. She was valedictorian in her class and her father Nestor, who was an anaesthetist at a hospital, is fiercely proud of her. He and his wife Adele are sad their daughter is following her sister in taking the emigration path - Maureen's elder sister, a gynaecologist, is in Australia - but proud of her ambition. They don't need her money but they want her to do well.

"It's the sad plight of our profession here, that we receive a low salary for our job. I stayed here because I wanted to serve the people, but it's easier to leave as a doctor," he says, wistfully.

The exodus of nurses means a brain drain on an unprecedented scale, as the nursing schools of places such as Iloilo fill a growing need for health professionals among the greying populations of the rich Western countries - European countries are expected to need 50,000 nurses a year based on current rates of ageing and dependency ratios.

Poorly paid doctors are retraining as nurses to seek their fortune at hospitals abroad. At the same time, the World Health Organisation (WHO) is worried that the resulting exodus of skilled health workers is putting pressure on the already strapped Philippine health system.

The shortage of doctors and other medical staff is felt acutely in rural areas, as most of the city hospitals can always find trainees to do the work.

Iloilo's vice-mayor Jed Mabilog says the Philippines' high birth rate, combined with widespread English language skills, makes it possible to train so many skilled workers.

"Of course, it's sad for us because we lose a lot of good nurses and specialised labour but we have a lot of people. Even doctors here are taking up nursing courses to go out of the Philippines to work as nurses. There is a brain drain but we continually produce people who can replicate the skills," says Mabilog.

WHO country representative Jean Marc Olive believes that the exodus of nurses will continue until 2015, with annual demand for medical workers in the US and Europe estimated to be about 800,000.

Maureen Parra summarises the hope and the need to look on the bright side amid constant retrogressions and changes in the rules.

"You need a sense of humour. Otherwise you go quietly insane."