Presentation by: Federico M. Macaranas, Ph.D. Executive Director, AIM Policy Center

1. “Policy Alternatives for Ethical Management of Migration in the Philippines” Presentation by: Federico M. Macaranas, Ph.D. Executive Director, AIM Policy Center Asian Institute of Management Member, National Competitiveness Council NATIONAL HRH POLICY FORUM RIGODON BALLROOM, MANILA PENINSULA 15 NOVEMBER 2007

2. Summary Global migration is a long-term phenomenon that requires HRH planners to think beyond the Philippines. We must have a global HRH system perspective and situate our health care crisis in the imbalances of Global Demand and Supply of HRH. Hence the Ethical Aspects of Migration must be viewed simultaneously from the utilitarian (individual benefits and costs summing up to total social welfare), liberal (individual starting points), and communitarian perspectives (global community).

3. Presentation Outline • I. Introduction: • Global Migration Issues • The Philippine and Global Brain Drain/ Flow • Imbalances in Global Demand and Supply II. Ethical Aspects of Migration • Six (6 )migration principles • Case of Filipino nurses’ migration • III. Policy Options

4. INTRODUCTION: Global Migration Issues • Demographic structures force cross border movement of younger human resources from developing economies with fewer employment opportunities/room for better governance (NY Times, June 24, 2007) • Scale, scope & complexity of global migration has grown (Report of Global Commission on Int’l Migration, Oct 2005) • Bilateral arrangements may be a second best solution; a more comprehensive approach must be designed to correct the global imbalance in allocating scarce human talent.

5. The Philippine and Global Brain Drain/Flow • 175M people (2.9% of world population) were living outside their country of birth in 2000 (compared to 1.8% or 100M in 1995); with 1.5M professionals from developing countries • Migration of skilled health professionals directly affects the health system, and hence also population health outcomes and health workers remaining in the country. (Human Resources for Health, Vol 1, 2003)

6. The Philippine and Global Brain Drain/Flow • EFFECTS OF MIGRATION ON HEALTH WORKERS WHO REMAIN IN PUBLIC HEALTH SYSTEMS– they suffer from added stress and greater workloads; poorly motivated due to low pay, poorly equipped, inadequately supervised and informed and have limited career opportunities (USAID Bureau for Africa paper, Office of Sustainable Development 2001)

7. The Philippine and Global Brain Drain/Flow • Remittance flows are the second-largest source, behind FDIs, of external funding for developing countries. • Workers' remittance receipts of developing countries stood at $ 72.3 billion (2001) – much higher than total official flows and private non-FDI flows – even exceeding total global development aid for the last decade (Dilip Ratha: Global Development Finance: Striving for Stability in Development Finance, http://www.worldbank.org/prospects/gdf2003/tocvol1.htm)

8. Imbalances in Global Demand and Supply of Human Talent • The skills gap in developed vs. developing countries is most problematic where education and training costs of a mobile workforce are borne solely by the source country. • For developed countries, markets solve shortages in health care, IT, etc. as global recruitment plays the arbitrage game – buy where it is cheap, sell where prices are high (Utilitarian ethics) • For developing countries, long-term supply of quality talent is jeopardized by lack of foresight and investment in advanced training facilities; these are provided by host countries albeit in more expensive environments.

9. Global Demand and Supply Imbalances of Human Talent: UK (1) CLASSIFICATION OF WORK PERMITS: (The UK Experience) India South Africa

10. Global Demand and Supply of Human Talent: UK (2) CLASSIFICATION OF WORK PERMITS IN UK: ( Philippines)

11. UK-South Africa Health Agreement • MOU on the Reciprocal Educational Exchange of Healthcare Concepts and Personnel (October 2003) • areas of co-operation in enhanced department-to-department communication and in sharing skills and expertise; • provides a means for time-limited placements for British and South African health professionals in each other's countries (2 years for South African health professionals; • British health professionals to work in rural and underserved areas in South Africa to gain exposure to health challenges in developing countries; • assistance to the Red Cross Children's Hospital in Cape Town. (Joint Communiqué of the 6th Meeting of the South Africa-UK Bilateral Forum, Cape Town, South Africa 25-26 August 2004)

12. Ethical Aspects of Migration • Three Alternative Ethical Perspectives: 1. Utilitarianism: judge a policy by its consequences thru an examination of the effects of a decision on the sum total of individual well-being in society (markets-based) 2. Liberalism: focus on the rights and opportunities of individuals, and on where they start and not where they end up (rights-based) 3. Communitarianism: what matters is the kind of society that public policy helps to create and the kinds of individuals who live in it (global community?) ( Roberts, Marc. J., William Hsiao, Peter Berman, and Michael R. Reich,Getting Health Reform Right, Oxford University Press, 2004)

13. Ethical Aspects of Migration • Key questions 1. Should poor nations restrict the flow of their skilled human resources? 2. Should governments of source nations be solely responsible in the training of their own people who will leave for foreign jobs anyway? 3. Should host governments continue to attract skilled workers from poor developing countries that require their talent for their own development? 4. What global programs can be developed to ensure fair and equitable deployment of human talent?

14. 6 ETHICAL PRINCIPLES OF MIGRATION • Migration out of choice • Reinforcing economic and development impact • Addressing irregular migration • Strengthening social cohesion through integration • Protecting the rights of migrants • Enhancing governance Global Commission on International Migration, October 2005)

15. “The global migration dossier urgently needs more poetry and plumbing” – GCIM Commissioner Sergio Marchi, March 2007 As the world’s largest supplier of health workers, the Philippines, with the help of its international partners, must challenge every global stakeholder to re-examine the ethics of managed migration.

16. HEALTH CARE-RELATED MIGRATION FACTORS ( in the HOST COUNTRY ) • Demand driven issues : aging population; lowered fertility in OECD; relatively poor health care in nearby Asia-Pacific nations • Supply driven issues : overly expensive health care services due to poor cost controls; more expensive technologies; ill-focused treatments; lack of quality health care facilities and workforce; lack of international professional accreditation (GTZ Philippines, Health Brief: Global Health and International Negotiations, 2005)

17. Human Health Resources MIGRATION FACTORS ( in the HOME COUNTRY ) • Demand driven issues : young population with high fertility; relatively poor health financing that depresses HRH compensation packages, and costly inputs to health care; long work hours and poor job conditions; • Supply driven issues : deliberately planned production of nurses which the local market cannot absorb; global imbalance which younger countries can fill up (Various sources, e.g., TWG # 1, 2 3 HRHN; Jose Galvez-Tan, op cit)

18. GLOBAL DEMAND FOR FILIPINO NURSES • Nurses employed locally – 32,593 • Nurses deployed overseas -- 123,683 (Emigrant nurses: 20,950) (Source: PNA 2003/CFO 2004), 100,000 left between 1994-2000, another 50,000 between 2002-03, 180,000 more to be deployed between 2006-2010 • Doctors turned nurses – 10,000 • Nurse shortfall (by 2010) estimated to be at: • 275,000 (US) to 800,000 (by 2020) • 53,000 (UK) • 40,000 (Australia) • 50,000 each (Europe and Middle East) • 77% of developed countries have shortage

19. GLOBAL DEMAND FOR FILIPINO NURSES • Traditional Markets for Filipino Nurses – Saudi Arabia (55%), UK and Ireland (17%), USA (12%), UAE, Kuwait, Libya • Emerging Countries of Destination -- Chad, Algeria, Italy, Qatar, HK, Brunei, Mongolia, Taiwan, Papua New Guinea, Marianas & Saipan

23. Crisis Affecting Philippine Human Resources for Health • The Philippine human resources for health (HRH) • crisis is a combination of increasing global • demand, declining domestic demand, and less • love for the Philippines. • This combination makes the impact of HHR • out-migration on unmet needs more serious • This combination also severely restricts the • range and effectiveness of policy interventions

24. Global Pull  Hospital Crisis • 200 hospitals have closed down within the past two years – no more doctors and nurses (PHA, November 2005) • 800 hospitals have partially closed (with one to two wards closed) – lack of doctors and nurses (PHA, November 2005) • Nurse to patient ratios in provincial and district hospitals now 1:80-1:100 (PNA Nursing Summit, 2007) • Loss of highly skilled nurses in all hospitals across the country • Source: Jaime Galvez Tan,The Challenge of Managing Migration,Retention and Return of Health Professionals

25. Global Pull  Health Care Crisis • Proportion of Filipinos dying without medical attention has reverted to its 1975 levels of 70% of deaths unattended during the height of nurse & nursing medics migration 2002-2003. (NSO 2003) • Health services coverage declining e.g. immunization coverage down (NDHS, MCH Survey, NSO 1993-2003) Source: Jaime Galvez Tan, The Challenge of Managing Migration, Retention, and Return of Health Professionals

26. Proposals Addressing the Crisis in Philippine Human Resources for Health (1) • Carefully choose doable and incentive- • compatible policy interventions, such as: • Targeted and performance-linked compensation subsidies • Tax activities directly related to out- migration (travel, passport, work permits, placement, certification) • Introduce domestic service requirements in the context of basic training • Expand NHP coverage and improve benefits and payment systems to increase effective demand • Secure availability of trainers (subsidize teachers not students)

27. Proposals Addressing the Crisis in Philippine Human Resources for Health (2) • Ethical recruitment and reciprocity / • mutuality of benefits (TWG on Exit and • Re-entry, HRHN) • Bilateral arrangements for ethical • recruitment (ILO rights based framework – • compare with utilitarian, liberal and • communitarian approaches) Benefit packages in the form of resources or technical support Scholarships In-service trainings Facilities improvement (SUCs, public health system) Common trust fund Interim visits and re-integration

28. Policy Responses to High Skilled Emigration: The “Six Rs” • Retention through educational policies -skills matching (TWG #1, HRHN – Supply side of the market) • Recruitment of international migrants – POEA’s management vs. corporate approach (TWG #2- Demand side of the market) • Restriction of international mobility – mission critical skills, in-country service (TWG#2 - Supply side) • Reparation for loss of human capital (tax) (TWG#2- Supply side of the market) Source: Lowell and Findlay, International Labor Office International Migration Paper #44, “Migration of Highly Skilled Persons from Developing Countries: Impact and Policy Responses”, Geneva, Dec. 2001

29. Policy Responses to High Skilled Emigration: The “Six Rs” • Return of migrants to source country – Balik Scientist, UNV TOKTEN, STAC, management advice from retirees, retirement villages (TWG # 3 - Supply side of the market) • Resourcing expatriates (diaspora options)– Brain Gain Network, non resident Indian schemes, bond flotation,alumni bequests (TWG# 3 - Supply side) • Retention through economic development -- $ incomes for HRH – medical tourism/billing, labs, SMEs (TWG #3 - Demand side of the market) Source: Lowell and Findlay, International Labor Office International Migration Paper #44, “Migration of Highly Skilled Persons from Developing Countries: Impact and Policy Responses”, Geneva, Dec. 2001

30. PENDING LEGISLATIVE BILLS ON MIGRATION IN THE PHILIPPINES • Bills to strengthen the Philippine Overseas Employment Administration (POEA) =14 • Bills on Amendments to the OWWA Charter = 3 • Bills on Protection of Rights & Provision of Services to OFWs = 6

31. PENDING LEGISLATIVE BILLS ON MIGRATION IN THE PHILIPPINES • Bills on Regulating Nurses’ Employment Abroad = 2 bills • An Act Requiring all Filipino Registered Nurses to Render at least 2 yrs service within the Philippines prior to any employment abroad • An Act Requiring all Nurses to Serve in a Private or Government Hospital for at least 3 yrs as pre-requisite for employment in foreign countries & providing penalties for violation thereof

32. Ethical Aspects of Migration • Key questions and some answers: 1. Should poor nations restrict the flow of their skilled human resources? NO (utilitarian, liberal) , YES (communitarian, national perspective) NO (communitarian, global perspective) 2. Should governments of source nations be solely responsible in the training of their own people who will leave for foreign jobs anyway? YES (utilitarian, communitarian, national perspective), NO (liberal, communitarian, global perspective) 3. Should host governments continue to attract skilled workers from poor developing countries that require their talent for their own development? NO (utilitarian, liberal) , YES (communitarian and global perspectives) 4. What global programs can be developed to ensure fair and equitable deployment of human talent? (Six R’s – retention through skills matching and economic development; recruitement for global jobs; restriction of mobility; reparation for loss of human capital; return or re-entry programs)

33. THANK YOU and GOOD DAY!!! THANK YOU and GOOD DAY!!!