Two years’ experience in an urban hospital? How international nursing recruiters shape flows of Philippine nurses.
Maddy Thompson, Newcastle University
Abstract
The Philippines, as the world’s largest supplier of migrant nurses, unsurprisingly faces various problems concerning its domestic nursing workforce and healthcare provision. From ‘brain drain’ and high staff turnover to a geographical maldistribution of nursing provision, questionable nursing education, and inadequate pay, the problems are diverse and vast.
This paper explores the transformations in the Philippines’ nursing sector which have emerged as a direct result of transnational pressures from overseas skilled health worker recruiters. In particular I examine how norms imposed by global recruitment agencies regarding minimum levels of experience for foreign nurses have contributed to the ‘culture of volunteerism’ prevalent within the Philippine nursing system. This ‘culture of volunteerism’ restricts the opportunities of nurses from a lower socioeconomic status to pursue overseas employment, further entrenching historical class divides and creating additional barriers to overseas markets for nurses who cannot afford the costs associated with volunteerism. This often pushes nurses who cannot afford to volunteer into seeking employment in other occupations, primarily in the business process outsourcing (BPO) industry, which I discuss. This represents a global loss of nursing skills as nurses are no longer just migrating from the Philippines, but are migrating from their occupations. Additionally, the culture of volunteerism is implicated in intensifying the chronic maldistribution of nurses in the Philippines, encouraging internal migration of nurses to urbanised regions.
I call for a re-evaluation of the recruitment practices of those involved in the international recruitment of skilled nursing labour. There is a need to regulate the demands international nurse recruiters place on nurses to ensure they are in line with the job requirements migrant nurses are hired to fill. Nursing shortages in the Philippines and beyond are generally exacerbated in rural, community-based healthcare settings, yet by requiring ‘urban’ experience, international recruiters are complicit in restricting flows of nurse care to underserved rural Philippine regions.
Introduction
Over the past century nursing provision has been increasingly organized and provided on and through the transnational, rather than a national scale (Yeates 2012). Yet the migration of nurses (and other healthcare workers) receives relatively minimal attention by health and medical geographers, perhaps as it tends to be situated within migration or social and cultural geographies. Nonetheless, the migration of nurses impacts a wide range of global health outcomes from nursing provision and distribution in both sending and receiving nations, compatibility of national healthcare credentials, nursing education (in sending countries), labor conditions (in both sending and receiving), and quality of healthcare delivery (Kingma 2006; Walton-Roberts 2015). The literature concerning nurse migration is overwhelmingly focused on how migration affects the capacity of receiving nations to improve the provision of healthcare and the extent to which migrant nurses are welcomed and can integrate into overseas markets (Batnitzky and McDowell, 2011; Smith and Mackintosh, 2007). While researchers occasionally turn to the educational contexts in which migrant nurses are ‘produced’ or trained (Guevarra 2010; Matsuno 2009), the domestic nursing labor practices of sending countries have largely evaded the attention of health and medical geographers.
This paper is based on research undertaken in Metro Manila, the Philippines. The Philippines, which has been hailed as a ‘producer’ of world class nurses, is estimated to provide at least 25% of the world’s migrant nurses (Lorenzo et al. 2007). Nursing has been strongly associated with international migration since the early 20th century, and has been actively marketed by Philippine educational institutions, the media, and state as a way to reach foreign labor markets since the 1970s (Choy 2003). Indeed, as nurses are taught to western medical standards and are fully instructed in English (Masselink and Daniel Lee 2013), it is widely assumed nurses are ‘produced’ for foreign rather than domestic markets (Ortiga 2014; Tyner 2004; Guevarra 2010).
With a few notable exceptions (P. J. Connell 2008; Ronquillo et al. 2011; Walton-Roberts 2015), health geographers have been reluctant to analyze how the international migration of nurses affects health systems in sending countries, beyond offering crude estimations of nurse supply (Kingma 2006). Ronquillo et al (2011), however, in examining the oral histories of Filipino migrants in Canada discovered the exploitative practice of volunteerism in the Philippines and explicitly called for wider engagement with it. I address these concerns by focusing my analysis on what I term the ‘culture of volunteerism’ (volunteerism officially ended for public hospitals in 2011 (Vera 2011)) which is prevalent within Philippine nursing employment. I chart how nurses are expected to pay in order to gain the hospital experience required for international migration – they must pay to leave the Philippines. However, whilst exploring the culture of volunteerism, another phenomenon became apparent, that of nurses leaving their profession for gainful employment within the business process (BPO) industry. In this case, nurses must leave their profession in order to work.
In particular I examine how the demands for skilled nurses which primarily originate from the developed world, widens class divisions within the Philippines’ nursing sphere, replicates and further entrenches global and national health inequities, and impacts the mobilities of nurses beyond that of international migration. I adhere to recommendations from Yeates (2012, 2004) concerning global care chain (GCC) analysis, but also expand GCC analysis to account for healthcare workers who do not migrate, and account for mobility beyond international migration.
I draw on the results of interviews I conducted in Manila from June to December, 2016 with 48 nurse students and graduates, some of whose narratives are documented below. I also spoke informally with numerous other nurses and nurse educators. By focusing on the daily lived experiences of nurses working in Manila, nurses who have not yet or never will seek overseas employment, this research offers a novel perspective on the international forces which contribute to the continuation of global nurse mobility. It reveals how the demands for nurse labor from primarily developed nations creates a unique set of exploitative labor conditions for nurses within the Philippines, resulting in many nurses (particularly from lower socioeconomic backgrounds) leaving the profession.
I begin with a brief overview of the concept of GCCs, highlighting the major weaknesses of this approach. First, that it is too preoccupied with physical mobility across international boundaries. Second, that most applications ignore the central role of labor. Thirdly that GCC analysis is are complicit in reinforcing the link between femininity and care. And finally that GCC analysis must be expanded to account for different types of mobilities, different types of healthcare migrants, and must reorient to focus on labor practices. In doing so, GCC analysis becomes sensitive to the various ways international healthcare demands structure the day-to-day lived experiences of nurses in source countries, regardless of their migratory desires.
Global Care Chains (GCCs)
Global Care Chains (GCCs) were developed from the ‘international division of reproductive labor’ outlined by Rhacel Parreñas (2000)and later modified by Arlie Hochschild (2000, 2002) to include insights gained from global commodity chain thinking, and to more fully account for the fact that care work also involves non-reproductive labor. It is loosely developed on global commodity chain analysis, part of a world-systems approach, which maps global mechanisms of unequal exchange, exploring transnational linkages and relations of exploitation (Yeates 2004; Gereffi 1999). Therefore, central to the idea of GCCs is the idea that care labor is becoming increasingly commodified and internationalized, and that global transfers of care labor can be understood in a similar way to that of material products. To highlight the commodification of healthcare workers, terms such as ‘production’, ‘import/export’ are frequently deployed.
A GCC is commonly defined as a series of ‘personal links between people across the globe based on the paid or unpaid work of caring’ (Hochschild 2000, 131). GCC analysis, therefore, examines how various forms of care work (be that motherly care from nannies, nursing care, spiritual care, domestic duties, etc.) are transferred transnationally to predominantly poor women. The classic example is that of the ‘nanny trade’ from the Philippines to the US (see Hochschild 2002). The stereotype here is of the ‘US woman’ being unwilling to endure the ‘double burden’ of productive and reproductive work, and recruiting someone from a Philippine household to do the domestic duties. The Philippine nanny is then unable to maintain her own domestic duties (such as caring for children), and so either recruits a Filipino women from a lower socioeconomic status (often an internal migrant), or enlists a family member to carry out the care work. As we move down the chain, the ‘value ascribed to the labour decreases [to the stage where it] often becomes unpaid at the end of the chain’ (Yeates 2012, 137). It is also notable that while a global care chain must involve the transfer of care across an international border, it generally also involves the transfer of care within a nation or locality, such as with the example above.
GCC analysis is particularly useful as it is able to examine how global inequities are established and maintained by analyzing relations of inequality between care providers and users within the global care network (Walton-Roberts 2012; Yeates 2004). While previous conceptualizations of the international transfer of care labor have tended to be largely descriptive (such as the concept of brain drain/circulation), GCC analysis is preferable as care chains:
reflect a basic inequality of access to material resources arising from unequal development globally but they also reinforce global inequalities by redistributing care resources […] from those in poorer countries for consumption by those in richer ones (Yeates 2004, 373).
Despite the benefits of using GCC analysis, Nicola Yeates has offered two commentaries (2012, 2004) highlighting the limitations and suggesting ways it could be further developed. A primary concern is that GCCs have been too focused on the mobilities of domestic workers and nannies at the expense of other types of care providers, which serves to limit conceptualizations of care to primarily reproductive and emotional care tasks, and reinforce the notion that care work is women’s work (Walton-Roberts 2012; Yeates 2004; Parreñas 2012; Yeates 2012).
Walton-Roberts (2012) has thus developed the global nursing care chain (GNCC), using Horschild’s initial concept which focused on the international nanny trade, and applying it to nursing. It should be noted that the GNCC is just one type of GCC, and the two should not be considered conceptually different. In doing so, Walton-Roberts (2012) was able to bring attention to the fact that care work also involves highly skilled tasks which require specialized, professionalized knowledge, and notes how the emigration of nurses from Kerala, India has improved the professional and social status associated with nursing.
Secondly, Yeates (2012) argues that ‘fetishizing migrant care workers as the prototypical embodiment of care transnationalization’ (148) carries certain risks. She is concerned that such a narrow focus excludes other forms of care-related migration from analysis, mainly migration of healthcare service users (rather than the providers), sex tourism, and marriage. While I support Yeates’ assertion that the sole focus on migrant care workers is limiting, I do so from a different perspective. I instead believe GCCs must be more receptive to how the transnationalization of care structures the lives of non-migrants, and to move away from privileging the extraordinary experience of migrants over the considerably more ‘ordinary’ experiences of non-migrants (only 3% of the world are migrants, and 10% of Filipinos (Thompson 2016)). It is for this reason that I interviewed nurses who had not (yet) migrated, and actively recruited nurses with no desires to migrate.
Furthermore, while GCCs are able to account for the internal mobility of healthcare workers, Parreñas (2012) among others (Walton-Roberts 2012; Yeates 2012, 2004) notes that GCC analysis is largely preoccupied with how the transnationalization of care entrenches international inequities, omitting local and national inequalities from analysis. The approach must be sensitive to ‘the multiple sites and scales across which the global (care) economy operates and through which power is circulated, concretized and expressed’ (Yeates 2012, 149). Through focusing analysis on the daily lived experiences of nurse students and graduates living in Manila, this research moves away from the traditional site of the destination, considering how the global nursing care chain impacts the daily lived experiences of those who may never themselves embark on an international transference of care.
Finally, Yeates (2004, 2012) notes the inherent differences between the production of manufacturing and health services, arguing that while manufacturing deals in tangible products which can be mobilized to meet international demands, that health services deal in intangible services in which service providers must be mobilized to meet international demands – the product, i.e. care cannot move to consumers, the care provider must move. Related to this, she calls for applications of GCCs to be sensitive to ‘the centrality of labour’ (Yeates 2004, 381), as opposed to capital, in the production and deliverance of care services. However, as Connell and Walton-Roberts (2016) highlight, in their paper entitled ‘What about the workers? The missing geographies of health care’, this a limitation affecting most studies of healthcare worker migration, not just GCCs. Analysis is generally limited to an examination of how migration allows healthcare to be transferred, reducing workers to bodies moving through space.
I instead explore how transnational processes shape the day-to-day lived experiences, not just the migratory pathways or geographical mobility, of healthcare workers. To do so, I examine how the demands of foreign nurse recruiters influence domestic nursing employment practices in the Philippines, structuring nurses’ socioeconomic and occupational mobility, and determining both their internal and international migratory tendencies. Through broadening the notion of mobility, it becomes clear that less privileged nurses are being pushed out of the occupation (rather than the country) due to exploitative working conditions which have arisen as a direct result of international nurse recruitment.
In the remainder of this paper I analyze the domestic employment conditions of nursing in the Philippines, focusing on the culture of volunteerism and the exodus of nurses to the BPO industry. In order to do so, I adopt a GCC approach which is able to account for non-migrant care providers by shifting focus to the sending region, which is sensitive to the centrality of labor, and which expands the notion of mobility beyond international migration.
Working to leave: the culture of volunteerism
The culture of volunteerism involves nurses working in hospitals, in some cases for up to two years, with no or very little pay. The practice is prevalent in both public and private sectors, but where ‘volunteers’ in the public sector may secure some reimbursement for travel and uniform expenses, those in the private sector tend to be charged high fees to gain hospital experience. The experiences of Ian[1] which follow are typical. It is noteworthy that Ian has never desired international migration:
Ian: [I worked as a nurse] for three years. One year as a volunteer at [public hospital] in the ER. It’s a very good experience. It’s a challenge, very challenging really. So that’s voluntary, so I don’t get paid. I pay them, so that they will allow me to volunteer! [Laughs].
Interviewer: How much did you pay them?
Ian: Well I’m lucky, just 500[$10] pesos. And then I got the shirt [uniform], and every meeting I got a free meal […] every three months! So really I got my money back! [Laughs] But there are a lot who would pay 10,000[$201], 15,000, even 20,000[2] [pesos] just to volunteer. It’s not paid.
This ‘culture of volunteerism’ has been allowed to grow due to the arguably arbitrary requirements of overseas nursing recruiters. Despite the fact that migrant nurses are generally recruited to undertake the less glamorous nursing roles of community, end of life, and personal care (Batnitzky and McDowell 2011; O’Brien 2007), they are required to have two years’ experience in a tertiary level hospital. Figure 1 displays an advert for a migrant nurse needed for home care. Despite the advert calling for a home care nurse, two years of hospital experience on high-intensity wards is required. Experience gained from high-intensity wards is not necessary for home care which is typically limited to hygiene, cooking, cleaning, administering medications, changing dressings, and emotional care.
Figure 1: An advert for a nursing position in the UAE displayed on InGulfJob.com (InGulfJob.com 2016).
This is a perfect example of how ‘the economic value of care work diminishes as it gets passed along’ (Parreñas 2012, 269). However, in this GNCC, nurses are not merely drawn to urban areas to replace those who have migrated, they are drawn towards urban centers as that is where the vast majority of hospitals which provide the necessary environment are located. This creates huge surpluses of nursing labor in urban regions, while rural regions are severely underserved(Romualdez Jr. et al. 2011). The huge surplus of urban nurses competing for positions allows domestic employers to suppress wages and working conditions, and maintain a steady stream of unpaid labor to staff their hospitals. As Ball (2004) highlights, it helps to ensure that nurses will continue to seek overseas opportunities as domestic experiences become unbearable:
The depressed state of nursing in the Philippines works to magnify the situation, thus creating an ongoing set of “pushes” to further encourage the labour migration of Filipino nurses (p. 125).