Rhea Patulay saw the shortage of Filipino nurses up close, sitting by her husband Rico's hospital bed as he recovered from a minibus accident.
"No one there to attend to the patients," she said recently in an interview in Tagalog through a translator. "Doctors usually look after you for operations, surgeries and when they do their rounds, which takes them too long to shows up."
Patulay said one of the nurses working overnight at the hospital near Manila looked like she was still a student. "She said to me 'Ma'am, I am assigned here.'"
The Philippines has traditionally trained more nurses than it needs, knowing they will work internationally and send money back home to support their families.
However, since the COVID-19 pandemic, government health officials say an estimated 40 per cent of all Filipino nurses have left the country or retired.
Philippines has shortage of 350,000 nurses
"We would like to stop the bleeding as soon as we can," Dr. Maria Rosario Vergeire, officer-in-charge of the Department of Health, said in a recent interview, adding that the Philippines has a shortage of more than 350,000 nurses.
"Why is it that the higher-income countries are actively recruiting?" she said. "The countries getting our nurses should also be for some form of exchange so there would be something for our country."
Government officials, hospital administrators and nursing advocates in the Philippines are trying to find ways to make their own health-care system sustainable, even as recruitment delegations — including from Canada — come knocking.
Delegations from Manitoba and New Brunswick just returned from recruiting trips in February.
The Manitoba government said it offered letters of intent to nearly 190 registered nurses, 50 people who are the equivalent of licensed practical nurses and 110 health-care aides.
The New Brunswick delegation interviewed more than 500 candidates and made 241 job offers, said a spokesperson for the province's Department of Health. As of March 1, 164 offers had been accepted.
A delegation from Saskatchewan was in the Philippines in December and has made more than 170 job offers to RNs, continuing care assistants and medical lab assistants.
And that's just Canadian provinces. Countries from around the world are competing to attract nurses from the Philippines.
Western countries 'getting more aggressive'
"That is now the problem," Melvin Miranda, president of the Philippine Nurses Association, said through a translator in a recent interview in Manila.
In the past, Miranda said, nurses sought out international opportunities, but since the pandemic, countries like Canada have come calling, "getting more aggressive in recruitment."
Experienced nurses are being attracted by the "huge pay offer and compensation," he said, noting that the pay is at least double in Canada.
While Miranda said he doesn't want to hold back nurses from opportunities abroad, he also worries about the country's health-care system.
"We feel it in communities, especially in far-flung areas that we cannot reach. The data shows: Why is there high mortality in high-risk pregnancies in provinces and far-flung areas? Because services through sufficient manpower cannot reach them," he said.
"So I think this is alarming. If this will continue, it will continue to increase these cases and we cannot prevent them."
Not to mention the strain and increased workload on those nurses left behind, caring for more patients than is considered safe, Miranda said.
"For example, a nurse is assigned to manage patients in critical levels. They can manage [a ratio of] 1:5 or 1:7 to ensure quality management and monitoring. But if it goes to the point that the number of patients rise beyond that standard ratio, the nurse will not be able to manage, to be honest," he said.
"[If] our nurse will have a high risk of error, it can compromise quality care that the patient deserves."
Torn between opportunity, duty to country
One solution is for Western countries like Canada to help pay for nurse training spots or provide scholarships to students going into nursing, said Dr. Rene De Grano, president of the Private Hospitals Association of the Philippines Inc.
Most countries are recruiting experienced nurses, which leaves a big hole in the Philippine system.
"For example, you are a specialist in dialysis for kidney centres, heart in cardiac centres, ICU," he said. "They have excellent training, so centres abroad really prefer them, [but] we don't have enough of those nurses right now, there's so few of them. If they get them, it's a big problem."
Filipino nurses say they are torn between duty to their country and the much larger paycheques and opportunities that working overseas can provide.
"We are dedicated to our country. We are willing to stay, but we have some requests that our country cannot give to us," Lawrence Vergara said through a translator, during a break on a hospital ward.
Vergara is a nurse who worked in Dubai before returning to the Philippines during the pandemic. She wants to move her entire family to Canada, Australia or New Zealand — partly because of the huge difference in wages, but also to give her children new opportunities.
"That is my ambition. No matter how hard, I will take the risk, for my family and career advantage as well."
Amir Pagadilan has been dreaming of moving to Canada since 2016, studying English and making applications. He's a chemo-dialysis nurse who has been forced to work two jobs to support his family.
Pagadilan is one of the hundreds of pre-screened applicants who received an interview with the Manitoba delegation. He was overcome with emotion after learning he was getting a conditional offer of employment.
"My mom would always say, 'In God's time,'" he said, stopping to wipe his eyes.
"Sorry, sorry. I'm just happy because it feels that it's a God's gift. I have tried so many times since 2016, but it was difficult to get the specific position. It was a lot of patience."
Ethical, economic, safety concerns
Manitoba's minister of labour and immigration, Jon Reyes, said the province needs to fill nearly 2,000 nursing vacancies.
Reyes, originally from the Philippines, said the delegation's goal was to recruit 350 Filipino nurses through an expedited pathway in the next two years.
"We want to make sure this batch that comes has a seamless transition so that they can be gainfully employed right away, and that will benefit Manitobans," he said at a reception in Manila.
But there are growing concerns in less developed countries that wealthy nations like Canada are exploiting those with fragile health-care systems.
"It's the higher-income, richer countries who are going on this global shopping trip to address shortages, which they have failed to recruit enough of their own," Howard Catton, CEO of the International Council of Nurses in Geneva, said in an interview this week.
"They are taking from shelves which are already very, very bare and can least afford to lose nurses from," he said. "You need to absolutely assure yourself that you are not going to do more harm by recruiting from that country."
Catton, who is having meetings in Bangkok this week with organizations from nine countries representing nearly 10 million nurses, said they are all concerned about international recruiting and shortages.
That includes countries like the Philippines and India, which have traditionally exported health-care workers to countries around the world.
An estimated 10 per cent of nurses in Canada and 15 per cent of those in the United Kingdom are internationally trained, a result of "decisions not to educate enough of your own nurses," Catton said.
"That may have worked in the past, where you could recruit overseas is a fairly quick fix to fill those gaps in the short term. But I think for a whole pile of ethical as well as economic reasons ... and also issues of safety and security in the supply of your own health workforce, that's not a strategy to rely on in the future."
