Mark* is a 40-something Head Nurse working at a city hospital in Metro Manila. Since starting in 1980, Mark has climbed the ranks to the position he currently holds. He says he is content with his financial situation, having been able to provide for his son who now works abroad. Yet he admits that the only way to achieve upward social mobility in the Philippines with his chosen profession is to drown himself in debt.

Debbie* is also a nurse in her forties, but unlike Mark, she is at the bottom of the nurse hierarchy, at Nurse 1. Debbie has been working at the same hospital as Mark for a year now on what is called a “continuous” basis. She doesn’t know when the hospital will regularize her, at which point she is entitled to double the Php 9,400 she makes today. She says this could take as long as 10 years. Luckily, Debbie’s husband is able to shoulder the family’s expenses. Just like Mark, Debbie believes that her status in life will remain as is as she continues to work as a nurse in the country.

“Hindi talaga ‘yun mangyayari kahit nga sobrang sipag mo pa, kahit mag-double job ka, triple job, imposible. Kasi hindi talaga ganun kalaki ang kikitain mo dito sa atin (This really will not happen, even if you are very hardworking, even if you work two jobs, or three jobs, it is impossible, because what you earn here is not really that much),” says Debbie.

Underpaid health workers  

While tens of thousands of nursing professionals pursue careers abroad, Mark and Debbie have managed to remain in the Philippines. For others, receiving inadequate wages is one of the difficulties that make it untenable for health workers to remain here. In national government-run hospitals and first class cities where Mark and Debbie work, nurses with a permanent position are paid Php 18,549 at entry-level. Even at this amount, nurses are still not properly compensated.

Doctors who work at government hospitals and rural health units in municipalities are not better off as well, as they earn a fixed salary no matter how many patients they see in a day.

“Although they still live better lives than other professions, they’re still at the bottom of the pyramid in terms of income and social status,” says Dr. John Wong, MSc, lecturer at the Ateneo’s Health Sciences Program.

To remedy this, the government passed the Salary Standardization Law of 2015, which increases the wages of government employees over four years. However, Robert Mendoza, president of the Alliance of Health Workers, has decried this law because of the difference in the increase of wages in lower salary grade levels compared to higher salary grades.

According to the law, the president of the Philippines, who belongs to the highest salary grade, will receive an increase of Php 388,096 from the current salary of Php 120,000. Meanwhile, a Nurse 1 who belongs to salary grade 11 will receive compensation of Php 20,754 from Php 18,549 at the end of the four year standardization period.

Mendoza sees this scheme as disadvantageous to lower-level government employees, especially lower-level health workers. Instead, he has advocated for the immediate increase to Php 25,000 for entry-level nurses, which was rejected by former President Benigno S. Aquino III before he left office. Contractualization of health workers

Another problem that government-run health centers all over the Philippines face is the understaffing of health worker positions in government hospitals. In 2014, the Department of Health recorded an average of only 3.5 doctors for every 10,000 Filipinos, whereas the ideal ratio should be one to 1.5 doctors for every 1,000 people.

According to Mendoza, plantilla or permanent positions for all types of health workers in hospitals remain vacant despite claims made by the government to the contrary.

“Ang gobyerno, kunwari naglalagay ng mga health workers, pero ang karamihan diyan is contractuals (The government pretends to add health workers. They do add, but a lot of these health workers are contractual workers),” Mendoza says.

Contractualization does not only create a burden for the financial situation of health workers, but ultimately affects the quality of care they give to the patient.

“Ito [pag-contractualize ng mga health workers] ay nakakabahala dahil hinahanap natin ang quality service na healthcare na binibigay ng health worker. ‘Di na natin maabot dahil ang iba, iba naman ang pananaw ‘pag contractuals compared sa regular, iniisip ng mga contractuals, ‘anyway, hanggang three months or five months lang ako, so bakit ako magmamalakasit para sa ganitong pag-provide ng services para sa mga pasyente?’ (This contractualization of health worker is worrying because we are looking for quality service in healthcare, that is provided by health workers. We cannot reach this goal because some contractual health workers, might think, ‘I’ll be here for only three or five months, why would I provide compassionate service for the patient?’),” Mendoza adds.

Critical role of health workers

Often, nurses accept the contract work offered at these government hospitals, as hospital experience is a requirement to apply for a job overseas. In 2015, nursing professionals were the third highest occupational category of new hires abroad at 22,175.

This number does not include health workers who go abroad and take on different occupations. Karen*, a registered nurse in the Philippines, decided to work as a domestic helper in Hong Kong because her pay was not enough to support her family’s needs. In her current job, Karen says that her nursing skills are not being utilized.

“Alam nila (her employers) na nurse ako sa Pilipinas pero they don’t care. Kailangan nila house help, hindi nurse (My employers know that I was a nurse in the Philippines, but they don’t care. They don’t need a nurse, they need house help),” she says.

Mendoza claims that if pay for entry-level nurses was raised to Php 25,000 with added benefits, nurses, especially those with families, would be encouraged to stay in the country.

Inadequate wages are also the reason why brain drain happens on a local level. Wong says this happens when health workers remain in the Philippines, but do not practice their profession. Instead, they work at call centers where the pay is more substantial.

Wong adds that wage is a huge contributor to the increasing number of health workers affected by this phenomenon. However, all other factors of the health system should be considered to keep nurses from leaving the country or their profession.

“You have to keep them there. You have to provide them [with] perks. It’s not just money. It’s the whole lifestyle,” Wong says.

An effective healthcare system

To Mendoza, it is ridiculous that something as important as health is ignored by the government.

“Dapat priority ito kasi kung malusog ang iyong mga mamamayan, malusog din ang ekonomiya (Health should be a priority. When citizens are healthy, the economy is healthy too),” says Mendoza.

Critical to an effective healthcare system are the health workers themselves. The World Health Organization lists human health resources as one of the six building blocks of the health system, along with service delivery, health financing, health information systems, technology, and governance.

“Healthcare kasi is a service. Even if you have products like medicines, you need people to prescribe them, dispense them. So actually, health human resources is the most valuable resource that you have,” adds Wong.

Despite low salaries and long hours, health workers continue to provide patients with the health service they deserve. For Debbie, the choice to pursue a career in nursing was born out of a desire to follow in the footsteps of multiple family members.

“Nagustuhan ko na rin ‘yung nursing kasi nakita ko sila [nurses] kung gaano sila ka-compassionate sa iba regardless kung maliit ‘yung sweldo. Para sa akin, mas gusto ko ‘yung nakakatulong ako (I liked the nursing profession because I saw how compassionate nurses were, despite their low pay. I preferred being able to help others,” she shares.

Others, like Karen, don’t have such a choice.

Editor’s Note: Names were changed to protect their identities.

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