by Eleanor Macagba*
Introduction
The COVID-19 pandemic illuminated many flaws in the American healthcare industry, including the lack of social and economic infrastructure and support for frontline workers. Yet it wasn’t until this pandemic that researchers began exploring the disproportionate impacts felt by Filipino-American healthcare workers. As of June 2021, Filipino American nurses accounted for around 25% of COVID-19 deaths among nurses in the United States, despite representing only 4% of the nursing workforce (Constante, 2021). This is due to the fact that Filipino nurses make up a large portion of the lower-level nursing workforce that would lead to increased exposure to the virus (Nolen, 2022).
The health crisis of Filipino nurses in the United States is not a recent issue, extending back to the AIDS crisis, where Filipino nurses were also on the frontlines with increased exposure to infections and illnesses. This relationship can be traced back even further to the late 19th century, when the United States colonized the Philippines. The United States established American nursing schools on the archipelago and began allowing Filipino nurses to come work abroad temporarily, therefore filling in any healthcare gaps the United States had (Cachero, 2021). In 1965, the Immigration and Nationality Act was passed, allowing migrant nurses to petition to stay in the country permanently. Due to the economic hardship felt by the Philippines post-colonization (by both the Spanish and later the United States), the export of nurses was capitalized on, and the Philippines grew to be a global leader in exporting nurses to the United States.
The reason for my interest in this topic is not only because of its relevance in light of the current global health crisis, but also because of my own family background. Many of my family members are in the healthcare industry, currently operating a hospital and a nursing school based in Luzon, in the Ilocos region of the Philippines. My focus for this essay will be on the nursing school industry, as I am interested in how the Philippines contributes to and profits off of its current culture of exporting nurses, specifically through its education system. Through this paper, I aim to answer the following: how do Philippine nursing schools contribute to a globalized nursing system, and what are their socio-economic impacts in the Philippines? In order to explore this, I begin with a literature review on the Philippine’s healthcare worker export culture more broadly. Then, I discuss the push and pull factors to the United States and cover the issue of remittances. Finally, I focus on Philippine nursing schools, through a historical analysis and a contemporary analysis of their curricula and testing practices.
Globalization, postcolonialism, and neocolonialism
Common definitions of globalisation, more often than not, do not delve into its social-historical construction and its relations to colonization. Thus globalisation is presented almost as a natural phenomenon where all involved parties are somehow interconnected, but where questions of unequal power distribution and dependancies are ignored. There are of course exceptions: In his paper “Globalization, Power and the Politics of Scale in the Philippines,” Kelly, whose research specializes in migration and labor studies in the Philippines, defines globalization as “a social construction that is employed as a convenient spatial metaphor to understand, explain, and legitimize experiences” (1997, p. 154). This helps to understand globalization as a constructed social phenomenon, rather than inevitable. In the specific context of the Philippines, globalization is complicated by its prior history of colonization. Though the Philippines employed a system of trade with others around the archipelago before colonization, Kelly argues that American colonialism facilitated an export culture in the Philippines through acts “allowing preferential access to the U.S. market for Philippine primary products” (p. 156). Postcolonial cultural markers have also aided in the Philippines’ export-focused, globalized economy. This includes the “influence of Western, mostly American, media; the cultural distinction invested in foreign brands and images; and, the aspiration of working abroad that has been realized by so many Filipino men and women” (Kelly, p. 156). The allure of work abroad will be expanded on further in the following literature review, but this idea of globalization and a postcolonial economy and culture is essential to understanding the existing relationship between the United States and the Philippines, and the cultural and systemically constructed economic means through which healthcare workers feel encouraged to work abroad.
Edward Said, founder of the academic field of postcolonial studies, describes colonial discourse itself as “the systemic practices, policies, and forms that were engendered through the tropes of knowledge and power for colonial domination and representation of the Orient” (Burney, 2012, p. 181). The terms postcolonial and especially neocolonial thus emphasize the existing hierarchies that have lingered and continue to be maintained by neocolonial policies and culture. The issue “Introduction: The Politics of Postcoloniality” argues for the importance of postcolonialism as an area of academic study, stating it is “the only methodological framework strongly committed to a critique of the global conditions of domination and oppression to which the ‘civilizing mission’ has given rise” (Jefferess et al., 2006).
The term neocolonialism in particular emphasizes how colonial relationships remain through economic and political control. Kwame Nkrumah, a revolutionary and former President of Ghana, defines a neocolonial state as one in which “its economic system and thus its political policy is directed from outside” (1965). In this case, the United States has continued control over the Philippines’ economic state through the system of remittances, which center on the export of healthcare workers. In turn, this has affected policy to facilitate this export.
The frameworks of postcolonialism and neocolonialism will aid me in directly connecting the Philippines’ colonial past to its current ramifications—demonstrating that the Philippines’ current healthcare system is not an accident nor a result of solely its own policies, but a result of American colonial intervention and its neocolonial manifestations.
The Export of Healthcare Workers and Its Effects
Much of the current literature on Filipino healthcare workers has a US-centric perspective, with a recent focus on the disproportional effects of the COVID-19 pandemic felt by these individuals and their families. The New York Times itself has published at least ten articles with a mention of all the following: “Philippines”, “healthcare workers”, and “COVID-19”. Out of these, only two of them specifically concern the disproportionate health impacts suffered by Philippine healthcare workers, with the rest surrounding the pandemic status in the Philippines itself, or healthcare workers’ in the United States across more broad demographics.
On the other hand, the current research on Philippine nursing schools and the export of healthcare workers is scarce, with no mentions in any popular media that I could find. My research was thus limited to scholarly articles, which are divided along two lines—one perspective analyzing the effects of globalization and the export of nurses on the Philippine’s own healthcare system, and the other analyzing (mostly quantitatively) the current status of Philippine nursing schools as a means to optimize them.
To begin exploring this topic, one must first understand the greater pattern of health worker exports from low-income nations to richer ones, which extends beyond the Philippines. According to Sinead Carbery, president of an international recruiting firm, around “1,000 nurses are arriving in the United States each month from African nations, the Philippines and the Caribbean” (Nolen). This has only been exacerbated by the recent pandemic, although this pattern of an insurgence of immigrants due to a health crisis is not a new one, going all the way back to the AIDS crisis as mentioned prior. This is because European and North American countries have “immigration fast-tracks for health care workers, and have expedited processes to recognize foreign qualifications” (Nolen).
A main critique of the health care worker exports is that they weaken the domestic health care workforce. According to the Manila-based Health Alliance for Democracy, in 2006, “80% of doctors working in the Filipino public sector had applied or intended to apply to work overseas and 90% of municipal health officers were set to leave to work abroad” (Cheng, 2009, p. 111). This export of healthcare workers has been an increasingly dire issue with the advent of the recent pandemic, as the rise in export of nurses to the United States has meant a weakened healthcare system in the Philippines. This means that while there has been an increase in the amount of nurses being exported to the United States, the Philippines health system has suffered from a lack of healthcare workers. According to the article “When the ‘heroes’ ‘don’t feel care for’: The migration and resignation of Philippine nurses amidst the COVID-19 pandemic,” in the beginning of October 2021, “about 5% to 10% of nurses working in private hospitals have resigned,” and an unnamed hospital director in the Philippines noted that “their nursing staff had decreased from 200 to 63 over the past year,” more than half of their existing staff (Alibudbud, 2022). Reasons cited for these resignations include “chronic understaffing, low wages, unsafe working conditions, and deployment bans” (Alibudbud). According to 2022 data from the World Health Organization, the United States had more than double the density of medical doctors, and almost triple the amount of nursing and midwifery personnel (see Figure 1). While these can be due to any number of factors, including differences in government expenditures on healthcare (of which the United States has more than double the percentage), combined with the other data conducted on Philippine hospital staffing, the information seems to point to an uneven distribution of healthcare support.
| Density of medical doctors (per 10,000 population) | Density of nursing and midwifery personnel (per 10,000 population) | |
| The Philippines | 7.7 | 54.4 |
| The United States | 26.1 | 156.8 |
Figure 1: 2022 World Health Organization healthcare force density comparison between the Philippines and the United States (World Health Organization [WHO], 2022).
The deployment bans, as stated for one of the reasons for resignations, are particularly significant. Deployment bans are put in place to cap the amount of workers who can work overseas. In the Philippines, deployment bans were enacted following a complete ban on overseas work at the height of the pandemic in 2020. President Ferdinand Marcos Jr. raised the deployment ban cap to 7,500 healthcare workers per year, still maintaining the aim to keep nurses within the country. This demonstrates the extent to which the export of nurses in the Philippines has harmed the country. According to a speech given by Marcos in September 2022, the government “had already disbursed 25.82 billion pesos [approximately 1.43 billion U.S. dollars] worth of assistance to nurses as of August this year,” but stated that “‘We’re a little short on funds, so that’s all that we can give you right now’” (Cepeda). The deployment ban and ensuing rise in funding displays the effects of a healthcare crisis on the issue of migration and healthcare development. This calls into question how sustainable nurse migration from countries as the Philippines is, especially with the rising frequency and urgency of global health crises. Through the United States’ reliance on migrant labor for their care work, not only are they endangering Filipino nurses abroad, but weakening the healthcare system in these countries.
Push and Pull Factors; Remittances
In order to understand the export of healthcare workers, one must first understand the push and pull factors that lead Filipino nurses to migrate to places such as the United States. According to a qualitative study conducted by the World Health Organization, the main push factor for nurses leaving was low salary, but also other key factors were listed as reasons for leaving, including “poor working conditions, outdated health-care technologies and lack of employment opportunities” (Dayrit et al., 2018, p. 148). As for pull factors, nurses listed “higher salaries, higher-quality working conditions and technologies, and numerous job openings” (Dayrit et al., p. 148). Additionally, migration is seen as an enticing opportunity due to visa provisions, which allow families to be reunited with the migrating health worker in the destination country.
Another major pull factor is remittances, and it is a main reason why Filipino nurses are encouraged to work abroad by family and the government, even with the harm it causes the local healthcare force. Remittances allow the Philippine economy to benefit from the export of healthcare workers, even as they do not directly participate in the local economy. Remittances are “the portion of migrant income that, in the form of either funds or goods, flows back into the country of origin, primarily to support families back home” (Hertlein, 2006). In 2022 alone, personal remittances reached an all-time high of $35.14 billion, increasing by 3.6% by the prior record of $34.88 in 2021 (Agcaoili, 2023). These remittances accounted for 8.9% of the country’s gross domestic product (GDP). Possible reasons for this increase is the lifting of COVID-19 quarantine and lockdown restrictions, allowing for an expansion of the economy, as well as the fact that migrants may have needed to send more money home due to the effects of increasing inflation (Agcaoili).
The history of the Philippines’ remittance-focused economy begins in 1974, when President Ferdinand Marcos passed a decree that created three government institutions within the Ministry of Labour: the Overseas Employment Development Board, the Bureau of Employment Services, and the National Seamen Board. These institutions systematized the outflow of Filipino workers, and was issued as a result of increasing social unrest from joblessness and poverty, as well as a desire for overall economic growth (Labour Export Policy, n.d.). Amendments and additions to the policy were issued in 1980, 1982, and 2021, to add protections for migrant workers and to cope with the increasing number of overseas Filipino workers. This has culminated in the current structure of the Philippine Overseas Employment Administration, which combines the original three institutions of 1974, and the Department of Migrant Workers, which consists of seven separate offices (Labour Export Policy).
The original implementation of the decree by Marcos in 1974 was meant to be a temporary measure for improving the livelihood of Filipinos, but the subsequent expansion of the decree and of the number of migrant workers shows how much the Philippines now depends on remittances. There have been additional systematic shifts to expand the remittance program, with at least 50% of financial tech companies in the Philippines providing e-remittances, an innovation created to ensure that remittances “reliably and immediately” reach the earnees (Debuque, 2022). Even within the media, the Philippines encourages Filipino workers to seek overseas employment, with advertisements stating “your cap is your passport” appearing in Philippine nursing publications since the early 1960s (Masselink & Lee, 2010, p. 167).
The situation is complicated by the fact that remittances drastically change the quality of life for many Filipinos—even though it is at the expense of the local healthcare system. According to a United Nations report, “over 50% of global remittances are sent to households in rural areas, where 75% of the world’s poor and food-insecure live” (Debuque). Additionally, “remittance-receiving households have demonstrably better educational participation than non-recipients, and invest about one tenth of their income educating their children” (Debuque). While studies have displayed that remittances in poor countries are primarily used for personal consumption purposes, they allow families to indirectly invest in the economy through increased educational opportunities, as well as an overall increase in disposable income (Semyonov & Gorodzeisky, 2008). However, findings have also shown that remittances increase economic inequality between households with and without migrant workers (Semyonov & Gorodzeisky).
Philippine Nursing Schools
Returning to the prior information on the density of medical doctors and nursing and midwifery personnel in both the United States and the Philippines (see Figure 1), it is important to acknowledge this data alongside the number of nursing schools and graduates, which have steadily increased over time. The Philippines has “233 nursing schools,” and produces “more than 20,000 graduates per year since 1999” (Elmaco, 2022). This does not seem congruent with the data and the workforce shortages as stated by the interviews, displaying the Philippines’ systemic overproduction of registered nurses. In creating a surplus of registered nurses, these nurses can be exported into the international market.
This systemic overproduction of nurses and the globalized nature of Philippine nursing schools can be traced back to its colonial relationship with the United States, as nursing did not exist as a profession until American colonization. Nursing schools started opening in the Philippines in 1907, approximately nine years after the United States officially acquired the Philippines as a colony (Choy, 2003). These schools were integrated with American medical training as part of their design to train Filipinos for nursing careers in the United States rather than the Philippines. One example is the Philippine General Hospital, built in 1907 as a large modern hospital. Victor Heiser, the American director of health at the time, stated that such a hospital would demonstrate “‘the sincerity and helpful purposes of the American government’” (Anderson, 2009, p. 157). However, the shift of many Filipino healthcare workers from their old regimens and frameworks to the dominating American ideals of the time was difficult. In “Modern Sentinel and Colonial Microcosm: Science, Discipline, and Distress at the Philippine General Hospital,” Dr. Anderson summarizes this phenomenon, stating that “even surgery and specific therapeutics were subordinated in the modern hospital to training in bourgeois rules of propriety and the discipline of hygiene” (p. 165). Ultimately, colonizing relations shaped the hierarchies of healthcare, with native healthcare methodologies and frameworks being looked down upon and forcibly replaced with American ones. This also did not always prove effective—with doctors and scientists employing methods of guesswork and rough experimentation when faced with unknown tropical diseases that they were not otherwise familiar with prior to coming to the Philippines or other tropical countries (Anderson, p. 161).
These colonial legacies continue in current nursing school curricula, aimed at training Philippine nurses in Western healthcare practices. Due to the Philippines’ high number of nurse exports, the subject of the quality of Philippine nursing schools’ educational programs is highly contested. The quality of education is often determined by the capability of this knowledge to be transferred to careers in other countries, or, essentially, whether Philippine hospitals are globalized enough to properly export nurses to other countries. Philippine nursing schools use their globalized curriculum and education style as an advertising method, with some schools’ mission statements emphasizing a “globally competitive” education, and with mottos such as “We nurse the world” (Masselink & Lee, p. 167). The focus on a globalized education system displays the existing neo-colonial relationship in the Philippines, wherein schools are tailored for exportation purposes. This globalized curriculum has the chance to harm students’ wellbeing and potential, with some nursing schools having been shown to take on double the workload due to the fact that they have to learn different standards and practices both locally and internationally (Ortiga, 2018, p. 68). For example, some nursing students had to learn high-tech electronic charting for fully automated hospitals in the United States while also learning how to fill out manual charts for underfunded hospitals in the Philippines (Ortiga, p. 68).
Overall, the quality of nursing education has deteriorated from the increase in demand for nurses, and this can be measured by results from the Nurse Licensure Examination (NLE). There are two possible reasons for this, both of which work in conjunction with each other: the disproportionate increase in nursing schools, and the increase in the number of students. As stated prior, the number of nursing schools have steadily increased in the Philippines, seemingly incongruent with the data on the number of nurses in the Philippines. This increase in schools are aligned with the high international demand for nurses, yet a reason why these do not seemingly produce enough nursing graduates is because the more recently established nursing schools were found to be “constantly underperforming in nursing licensure examinations, an indicator of low-quality education” (Dayrit et al., p. 150). The pressure to produce more nursing schools has led to subpar education, which has harmed the nursing industry in the Philippines. The increase in nursing enrollment as a whole also contributes to this decrease in the quality of nursing education, as nursing schools are unable to support the large number of students. The Philippine Commission of Higher Education guidelines require a 1:12 teacher to student ratio, so with the influx of nursing students, nursing schools began hiring instructors en masse (Ortiga, p. 70). This has led to the recruitment of instructors who may not meet all the qualifications for nursing education. As many nurses are also being exported to other countries, the number of qualified nursing instructors is restricted (Ortiga, p. 70).
There have also been instances of corruption with shared business interests between schools and review centers. In 2006, officials from three review centers leaked NLE questions, and at another point, the owner of a prominent nursing school and review center bribed officials from the Professional Regulation Commission’s Board of Nursing in order to gain advanced copies of the exam. After this latter instance, U.S. officials threatened to refuse entry of examinees, to which the Board of Nursing replaced two of its implicated members and offered a retake of those tests that were affected (Masselink & Lee, p. 171).
Overall, according to a study supported by the University of the Philippines’ Center for Integrative and Development Studies, while NLE passing rates have improved since 2013, there has been an overall downward trend since 2010 in the number of takers and passers. NLE passing rates were associated with higher-education institutions’ “location, size, type, year of establishment, and student-faculty ratio,” so the factors that affected the results varied greatly. The study also acknowledges the shortage of nurses working in the Philippines, citing a 2017 report from the Department of Health stating that “there were only 90,661 nurses deployed locally and 269,761 more are required to achieve the country’s health care needs” (Bautista et al., 2018, p. 264). Therefore, the system of education in the Philippines feeds into an aggrandizing cycle, wherein the pool of qualified nurses decreases, and from this limited pool, few stay in the country.
Conclusions
This paper provides a preliminary glimpse into the colonial relationship between the Philippines and the United States in terms of global care work exportation, specifically within the nursing industry. Through the combined examination of curriculum and remittances, I hope to add to existing literature on the nursing exportation industry, which is still lacking. In my own research, it was difficult to find literature directly equating the nursing education system and the globalized Filipino nurse with neo-colonial relationships, so I am hopeful that this can be the beginning of research at the intersections of colonialism, migration, and care work, specifically within the Philippines. This research is important not only because of its pressing current implications for the failing Philippine healthcare system, but also because it highlights the complexity of moving past colonial relationships as a whole. As stated in section 4, many Filipinos rely on remittances as a form of livelihood, allowing them to support themselves and their families and allowing the Philippines’ economy as a whole to benefit. The Philippines’ current state of poverty is tied back to its long colonial history, and this has meant that it has had to rely on nations like the United States, even as their prior colonizer, as a means of survival. In analyzing this neo-colonial relationship within the healthcare system specifically, one can begin to see how pervasive this relationship is, and how invisible it is in the way it has been woven into the educational system itself.
There are also topics I have not been able to touch on within this essay that should be considered in any future research. This includes the gendered politics of nursing work. Nursing as a profession is traditionally regarded as women’s work (i.e. care work), and this gendered relation in regards to the Philippines and export of nurses still has yet to be explored. Additionally, there is still research to be done on the economic benefit of remittances, as there is still discourse on how beneficial they truly can be to a country’s economy if they also contribute to economic inequality.
Overall, socio-political analyses such as this one must be combined with economic research in order to figure out the best possible solution to the Philippines’ healthcare crisis. Is it possible for the Philippines to revert its globalized healthcare system when it is so entrenched in the culture and politics of the educational system, and when there are so few local economic opportunities for Filipinos? As this is a systemic issue and not an individual one, with a long history that dates back to colonialism, it is difficult to come up with an easy solution that will not harm the Philippines. Still, research like this helps to shed light on invisible and structural inequalities that are embedded into the structure of life and work in the country, and thus helps to start conversations on how neo-colonial countries can begin decolonizing their existing structures.
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*Eleanor Macagba (they/them) is a rising junior with a concentration in environmental and decolonial studies. They are originally from Brooklyn, New York, and they spent the Spring 2023 semester at NYU Berlin. As a half-Filipino person who comes from a long line of healthcare workers, having the opportunity to do this research was rewarding, and they hope to be able to expand on their findings in their future academic career.