Nursing and midwifery recruitment practices hurting low-income countries

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Nursing and midwifery shortages are a phenomenon experienced in most countries worldwide. While shortages continue to grow, governments are grappling to fill the shortfall, with many turning to recruitment from low-income countries.


Yet these practices often come at a high cost to the countries they recruit from.

The Philippines, for example, which has long been seen as a source of health workers for other countries, are now experiencing nurse shortagesto support their healthcare system adequately.

Presenting at the International Council of Nurses Congress in Montreal, Canada, earlier this month, Fely Marilyn Elegado-Lorenzo,  professor of Health Policy and Administration at the College of Public Health, and concurrently the Director of the Institute of Health Policy and Development Studies of the National Institutes of Health, said the Philippines was thought of as “the big producer of nurses”.

“But actually, we are in shortage and have difficulty actually meeting the country’s needs,” she said.

“So we don’t know if we have been giving the wrong impression to the world that we are seen as an ethical source of nurses.”

Elegado-Lorenzo suggested that nurse production and retention had changed over the years.

“The environment of nurse production and retention has been globalised since four or five decades ago, but the mobility of nurses across country borders has been more pronounced in the last two decades,” she said.

“Globalised nurse production and retention is now the norm, but its freewheeling to the detriment of source countries.”

The Philippines devised a labour health market plan in 2018 that included training and education for employment distribution across the different healthcare sectors.

The plan included the introduction of scholarships, sustainable production, return service agreements and government job generation. The Philippines also introduced redistribution and regulation laws that mandated national health workers be registered to track where they are working to identify which regions which provinces had health workers shortages.

Elegado-Lorenzo said  pre-COVID, these statistics showed the sector was producing around 670,000 licensed nurses. However, not all of those were in practice, leaving a significant shortfall in the amount of staff required.

“We had [large] attrition rates, [large] number of losses to migration [13,000 per year], and there was also a [significant] number of nurses moving out of the [healthcare] labour force to other industries such as call centres [12,000 per year].

“So if we do a deep dive, it would seem in theory that we produce a lot of nurses, but we have a sizeable health worker outflow,” she said.

As a result, 175,000 nurses were practising in health facilities in the Phillipines which fall short of meeting targets set by the global strategy and human resources for health and the SDG goals.

“The WHO recommends a ratio of 44.5 health workers for 10,000 population and 27.4 nurses in that team, but we still have a gap of 126,000 to meet the nurse requirements accordingly into that standard,” Elegado-Lorenzo said.

Elegado-Lorenzo said this resulted in the  universal healthcare law being passed that aimed to ensure that all Filipinos would have access to quality healthcare in five years.

“We were upgrading our nursing curriculum to meet the standards of target destination countries. We also made a statement in our nursing roadmap that we wanted to be the best for Filipinos and the choice of the world. And this is why there was this effort to show that our nursing training was a par with the standards of the rest of the world,” Elegado-Lorenzo said.

 “We trained excess nurses that the domestic market could not absorb because of massive migration, so we wanted to ensure enough supply. In addition, we trained foreign nursing students. We had Filipino Americans, Chinese and Indonesian students.

“In terms of migration management, we participated in bilateral agreements. We had about 20 forged, but most were not implemented well. We also participated in migration codes, agreements and conventions, frameworks mostly ratified by source countries.

“We also developed strategic plans to ensure long-term health worker needs were developed and trained and collaborated with governments to develop strategies to ensure homegrown health workers and to ensure retention.”

But during the COVID epidemic, all of these initiatives were severely impacted.

“Nursing resources were stretched beyond their limits. Hospitals shifted medical and other resources to care for the critically ill and confined COVID patients. Nurses had limited mobility and no transport services, and so shifting was difficult. Moreover, face-to-face training was suspended for two academic years, and clinical training was not possible. So we had no nurse graduates during that time and no licensed exams.”

During COVID, the Philippines experienced many frontline COVID infections, where nurses exhibited the highest death rates. Many other nurses left the sector for fear of infection and death, which only exacerbated the situation.

Despite the severe shortages at the height of COVID, external migration and recruitment of health workers, especially nurses, continued. To manage the outflow, the government was forced to cap the number of nurses who could leave for international jobs.

Elegado-Lorenzo stressed if this was not done, many hospitals would have been forced to close.

“Special privileges were offered to nurses such as free transport, accommodation, additional compensation so that they would stay.”

But post-COVID, aggressive recruitment occurred as soon as the market opened in late 2020-22.

“Many international and local recruiters went to hospitals directly to recruit, albeit unscrupulously, because this was not supposed to be allowed.

“Some even went directly to nursing schools and offered placements to third-year and senior nursing students, so the government again had to cap the number of nurses who could migrate to job placements abroad.

Severe shortages of nurses in hospitals as well as primary care facilities remained, with some hospitals risking losing their licenses to operate, Elegado-Lorenzo said.

“The quality of care, of course, was threatened due to severe staff shortages. As a result, and because the government was panicking, they suggested that hospitals hire non-licensed nurses to replace nurses to keep hospitals open,” she said.

Finally, after discussions with the nursing profession, the government settled on a two-year bridging program for clinical associates.

“This entailed hiring nurses who did not pass the board exams, but help was given to them to pass the exams while employed,” said Elegado-Lorenzo.

Nurses that were educated under government scholarships or a government institution would also have  to work in the Phillipines two years after graduation before they could travel to job placements abroad.

Elegado-Lorenzo said efforts are now focused on producing more nurses quickly and for healthcare institutions to partner with higher education institutions to ensure the harvesting of their undergraduates. There is also growing awareness of the need to improve retention as well.

While there are many complexities to international recruitment, Elegado-Lorenzo said internationally, more market dynamics would challenge countries that could not afford to compete financially to retain their health workers. “A situation that the Philippines is in and trying to get out of with better economic achievements,” Elegado-Lorenzo said.

“So while improving information and reporting about nurse production, return retention, and exchanges is important, we believe there has to be a collective body who will collect data and have authority to act on it to protect low-income countries. So if they see that certain countries are hurting because of massive migration, they have to help stop temporary or permanent migration.”

Additionally, Elegado-Lorenzo stressed international recruitment needed to be simplified to a few but enforceable international policies.

“We recommend putting up enforceable treaties or frameworks similar to the International Tobacco Framework Convention, where all countries were strongly encouraged to ratify the framework, and unable to opt out of and resources were made available to ensure its implementation.

“At the same time, as many authors have already specified, we need to emphasise the responsibility of each country to develop and retain their workforce to meet the magnitude of their needs and demands by ensuring decent work and positive practice environments within their countries.

“Finally, we need to craft more sustainable nurse exchange agreements that do not cause harm or pain to sending countries and will be beneficial to sending and destination countries.”

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