As Canada recruits Filipino nurses, those left behind struggle to care for patients
More than half of licensed nurses in the Philippines are practising overseas
In Manila's Pasay neighbourhood, people knock on nurse Irene Bernabe's door at all hours of the day.
"I'm used to it for 20 years," she said of her role as the volunteer community nurse.
Bernabe also works full time at a private hospital and as a part-time clinical instructor. But she may soon leave her family, community, and jobs behind to work abroad to earn more so she can send her three boys to university. Her youngest son Vincent, 13, cries at the thought of not seeing his mom every day.
"You know the saying, 'Without mother, the home is broken,'" said her 15-year-old son, Alfred.
Neighbours and friends are encouraging, but say they worry about what will happen to the community.
"Good luck to every one of us," said Odette Luangco, a friend and colleague, in Tagalog.
Thousands of nurses like Bernabe leave the Philippines each year for better career opportunities in countries like Canada. More than half of licensed nurses in the Philippines are practising overseas.
But when the nurses leave, it causes a ripple effect on those left behind. Families are separated from loved ones, hospitals can become short nurses and colleagues are often forced to deal with increased workloads.
"When you look at it historically, there are the knock-on effects," said Ivy Bourgeault, a professor in the University of Ottawa's sociological and anthropological studies department, who has studied nurse migration in the Philippines. She's also the lead of the Canadian Health Workforce Network.
Recruitment efforts from countries such as Canada are fuelling that nurse migration, Bourgeault and others say. In the last year, several provinces have been to the Philippines to recruit nurses, hoping to alleviate some of their own staff shortages.
And Canada is one of at least a dozen countries looking to the Philippines to fill that gap. With the demand for Filipino nurses high, hospital directors say countries have been recruiting less-experienced nurses, a pool of staff local hospitals rely on for their own staffing.
Dr. Jose Rene de Grano, president of the Private Hospitals Association of the Philippines, pleads with other countries to allow Filipino nurses to practise in their home country for a few years before recruiting them away.
"Because if we just let the first-world countries to really get all of our nurses, what will happen to the health-care delivery system [here]?"
The nurses left behind
Cristy Donguines says she misses having family dinner with her husband and two teenagers. Instead, she spends three nights a week sleeping at the hospital after her long shifts as one of two nurses caring for 70 to 80 patients.
She says her workload has increased because of the many colleagues who have recently left. When she does go home, her 13-year-old son often begs her to stay for longer, and she wishes she could.
"He cannot convince me to stay home because I know this is my job and this is what I stand for," said Donguines, who is also involved with the Philippines-based Alliance of Health Workers.
Emergency room nurse Ronald Richie Ignacio also has an increased workload due to a staff shortage. He can care for up to 20 patients at once — some of those acute.
That nurse-to-patient ratio should be lower, he says. The Philippines Department of Health stipulates a 1:12 ratio of nurses to patients for general wards, where patients require a minimum level of care.
"Patients are severely impacted. We have to turn down patients because of lack of nurses, lack of rooms," said Ignacio, who is also the spokesperson for the United Private Hospital Unions of the Philippines.
The current exact figure of the Philippines shortage of nurses varies. In March, Dr. Maria Rosario Vergeire, officer in charge of the Philippines' Department of Health (DOH), told local media that the Philippines needs more than 350,000 nurses.
A few months later, local media reported Vergeire as saying 178,000 nurses are needed and that it could take up to 12 years to fill the shortage. DOH did not respond to multiple interview requests.
In Canada, B.C. will become the first province to adopt minimum nurse-to-patient ratios, with its Ministry of Health saying work is still underway.
In 2021, Canada had a higher nurse-to-population ratio than the Philippines, sitting at 102.7 nurses and midwives per 10,000 people, according to World Health Organization data. The Philippines had less than half that, with 47.55 nurses and midwives per 10,000 people.
"It's important to recognize the precarity of the health system in the Philippines and the density of nurses per population is only one indication," said Bourgeault.
She says there's "complexity" as to why the density of nurses is lower, but the push for nurses to leave for abroad is a contributing factor.
Union representatives in the Philippines told CBC News that better salaries and working conditions would help to keep some nurses in the country.
'Not working for us'
Patricia Yvonne Caunan, undersecretary of policy and international co-operation in the Philippines Department of Migrant Workers, says provincial leaders are made aware of the "local demands" for nurses when they visit to recruit nurses and other health-care workers.
"We have our own needs, so we put this in the conversation and we're very open about this with not only provinces in Canada, but other countries," she said.
Hospital directors in the Philippines told CBC News that they're used to nurses leaving their hospitals after they gain some experience, usually after two to three years. But now they're increasingly having to compete against richer countries for newer nurses.
"Those recruitment strategies are working for those countries, but not working for us," said Dr. Erbe Bugay, director of Ospital ng Lungsod ng San Jose Del Monte in Bulacan, about 40 kilometres north of Manila.
Saskatchewan is one of the provinces that visited the Philippines recently to recruit.
Job postings shared on social media by one of the recruiters who worked with Saskatchewan advertised "preferred experience" to be one-to-three years of recent nursing experience in the last five years in three areas, including primary care, and at least one year experience as a full-time RN.
A spokesperson with the province's health authority said in an emailed statement that those who apply must meet the requirements for licensing through the College of Registered Nurses of Saskatchewan.
Tracy Zambory, the president of the Saskatchewan Union of Nurses, says she's worried these nurses are coming at a time when the Saskatchewan health-care system is "nothing short of a pressure cooker."
"We're putting people in untenable situations where there could be harm that they can't reverse because they don't have the expertise ... and they don't have the mentorship and preceptorship to be told 'We need to help you through this situation,'" Zambory told Dr. Brian Goldman, host of CBC's White Coat, Black Art.
In 2009, she mentored a nurse from Manila who came to work at a long-term care home.
"He came from one of the biggest hospitals there, but yet when he got to Saskatchewan, he was like a brand-new grad," she said.
Since then, Saskatchewan started a new 14-week bridging program that the government says will help internationally trained nurses integrate into the workplace. A spokesperson with the province's health department says the first cohort started last month.
What's the solution?
Zambory says she was grateful for the Filipino nurses that came in 2009, but says it was a lot of work to train and introduce them to the Saskatchewan health-care system on top of her workload as an RN.
She's concerned nurses today will be asked to do the same thing.
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Several Canadian experts say international recruitment is — and always has been — a quick fix.
Provinces should focus more on proper health workforce planning, hire talent already in Canada and streamline bridging programs before recruiting abroad, said Margaret Walton-Roberts, a professor in Wilfrid Laurier University's geography and environmental studies department.
Until they focus their efforts on retaining and recruiting in Canada first, Bourgeault says relying on international recruitment in times of need will continue to affect both Canada and the Philippines.
"The consequences of the reliance on this approach is continued instability in Canada and knock-on instability in the Philippines health-care system."
The reporting of this story was made possible by the R. James Travers Foreign Corresponding Fellowship. Jim Travers, who died in 2011, believed it was crucial for Canadian reporters to "bear witness" because in our interconnected world, foreign news is local news.
Special thanks to Guill Ramos, Jayson Pajarillo, Rodney Ramos, Geric Cruz and Jilson Tiu