2. Rey Vivo, MD Assistant Professor of Medicine Texas Tech University Health Sciences Center The Philippines

3. The Islands 7,107 islands making up an archipelago Climate: Tropical Area: 115,831 sq mi #72 in the world Population: 91 million #12 in the world Capital: Manila Currency: Peso (PhP47 = US$1)

5. 6 9 1118

6. The History Negritos – Malay aboriginals 13 th century – Islam 1521 – Ferdinand Magellan “discovers” the islands Manila is established as capital of the new Spanish colony Christianity 1880s – Propaganda Movement, Katipunan 1898 – US defeats Spain; “First Philippine Republic” 1935 – Philippine Commonwealth; then WWII 1946 – Independence from US The Marcos dictatorship, People Power revolution(s)

7. “300 years in the convent and 100 years in Hollywood”

8. The People Manila is 11 th most populous metro in the world Literacy rate: 93% Language: Filipino and English; >180 dialects Labor force: 34.2 million 11 million (11%) overseas; largest diaspora

9. The Culture Spanish: names, language, religion/customs, food, architecture “…a Latin American country transported to the Orient…” American: fast food, music, movies, pop culture “Brown Americans”

10. The Culture Harmonious social interaction Debt of gratitude Colonial mentality Hospitality

11. Healthcare Issues

12. Health and healthcare Top causes of mortality: cardiovascular, cancer, accidents, pneumonia, tuberculosis 1940s-1980s: infectious diseases led all causes PhilHealth – national health insurance program Out-of-pocket share emphasizes inequality 75% pharmaceuticals imported

13. Diaspora 2001 – 2004: >5,000 physicians left 30 medical schools 2000 – 2003: 51,850 nurses migrated 350 medical schools Approx. 1,000 hospitals have closed in the last 5 years Crisis

14. Physicians Top countries of medical education for IMG physicians CountryTotalPercentage India47,58119.9% Philippines20,8618.7% Mexico13,9295.8% Pakistan11,3304.8% Dominican Republic7,8923.3% American Medical Assn., 2007

15. Why leave? Harsh realities: Compensation/month for resident MDs $300 $1,000 $4,000 PhilippinesSouth AfricaUSA

16. Why leave? Other limitations Poor working/training conditions, quality of life Gov’t budget for health MD to person ratio: US……… 1:150 Cuba…. 1:225 Phil…... 1:>10,000 Poor job prospects, difficulties in establishing practice Specialties Research Local political/economic forecast

17. Challenges USMLE Cost Visas/Immigration laws Post-training employment opportunities Healthcare differences Disrupted families/relationships

19. Diaspora 2001 – 2004: >5,000 physicians left 2000 – 2003: 51,850 nurses migrated Nursing schools are mushrooming everywhere 40 – 50% of nursing students are “second-coursers” At present 6,000 doctors are enrolled in nursing schools, all wanting to leave for “greener pastures” abroad >50,000 caregivers have trained; about half have left for jobs overseas

20. Percent of Hospitals Hiring Foreign-educated Nurses by Country from which They Recruited, 2006 Nurses American Hospital Assn., 2007

21. Nurses’ compensation $200 USACanadaPhilippines Daily Daily Monthly

22. From MD to RN 2000 – 2004: 5,000 MDs left to work abroad as RNs 2004 – 2005: >2,400 MDs took the nursing boards Currently, >4,000 MDs enrolled in nursing schools Generalists and specialists; aged 25-60 years “Retrogression” Alliance of Health Workers

23. Pros and Cons Remittances from overseas workers Reduced unemployment Technology transfer Healthcare cultural diversity Expedited but suboptimal training Demoralization of MDs “Brain drain”

24. Brain drain Filipino-born nurses and Indian-born doctors each represent about 15 percent of all nurses and doctors in the Organization for Economic Cooperation and Development (OECD). “The migration of doctors and nurses from the developing to the developed world has only a limited impact on the crisis in health care in poor countries.” AFP

25. Gov’t solutions Manage migration Mandatory government service Career advancement programs Knowledge exchange

26. JAMA. 2008;299:1753-4.

27. http://www.youtube.com/watch?v=YdBANriBrlw

28. Thank you