Better pay crucial to reversing Philippines brain drain

Filipino health workers are leaving the country in droves for higher pay and better opportunities abroad, leading to a critical brain drain. Reforming salaries and working conditions can help retain these talented nurses and doctors.

Filipino nurses and doctors migrate overseas for higher salaries and better working conditions, leading to severe consequences for the country’s health system. Photo: Arthur Uzoagba

Rose Castro’s decision to leave her nursing job in the Philippines’ Cavite province for a similar position in Saudi Arabia came with a dramatic pay rise—no less than a five-fold increase in her income. She could now live more comfortably and send money back to her family, helping finance her siblings’ education. “It made a really big difference,” Castro says.

She chose Saudi Arabia because the country actively recruits early-career nurses, and at the time she had just two years of experience. “Most first-timers go to Saudi Arabia or Singapore,” she explains. “My brother and some other relatives were working here, so I knew I would be safe.”

More than 10 years on, Castro is still living and working in Saudi Arabia. She is a staff nurse at the Prince Sultan Cardiac Center in Riyadh (her “dream hospital”), is married with a son, and has no immediate plans to return to the Philippines.

Castro is one of 10.7 million Filipino people estimated to be living abroad (the country’s total population is 117 million). Of these emigrants, 2.157 million have temporary contracts to work abroad and are classed as “overseas Filipino workers” (OFWs).

Filipino health workers migrate overseas for higher salaries as well as better working conditions and greater professional opportunities. This brain drain—affecting an estimated 20% of the health workforce, most of whom are nurses—has severe consequences for the country’s health system, not only resulting in a significant loss of talent and expertise that affects the quality of care but also eroding morale and fuelling the desire to migrate among those who remain.

Low salaries driving Philippines health worker migration

In 2021, the Filipino Department of Health estimated that 316,000 licensed nurses—equivalent to 51% of the country’s total—had migrated overseas. Low salaries at home are one of the primary drivers of the phenomenon.

Salaries are “way below what is needed to live decently”. “What happens is they get experience for a short time, especially the new registered nurses, and after a while they will opt to leave the country.”

The basic starting salary of nurses in the Philippines is around Php15,000–17,000 (US$255–290) a month. Filipino nurse salaries are the lowest in South-East Asia, with mid-level public hospital nurses earning 57% less than their peers in Vietnam, the region’s second-lowest paying country.

Eleanor Nolasco, national president of Filipino Nurses United, which advocates for the rights and welfare of nurses, says salaries are “way below what is needed to live decently”. “What happens is they get experience for a short time, especially the new registered nurses, and after a while they will opt to leave the country,” she explains.

In rural areas especially, says Nicolito Oba, a nurse at the National Children’s Hospital in Manila, low salaries and limited employment protections leave “many nurses with the mindset of going abroad”. Oba, who left his family in Sorsogon province in search of better paid work in the capital, has seven years of experience and earns Php40,000 (US$681) a month. “In the provinces, they’re still earning Php16,000–17,000 (US$272–289),” he notes of nurses with similar experience.

Doctors, too, are pushed to go abroad due to low salaries. The annual income of a first-year medical resident in the Philippines is around Php720,000 (US$12,260), while their counterparts in the US earn Php3,000,000 (US$51,078).

Dr Janine Patricia Robredo left the Philippines and her role as a physician for the US in 2022 and now works as a research scientist at the Harvard TH Chan School of Public Health. “When I moved here, I was making more as a research associate than as a physician in the Philippines—the discrepancy was quite big,” she says.

Robredo, who co-authored a 2022 paper on the outward migration of Filipino physicians and nurses, says higher salaries allow health workers to send money home to family or explore opportunities for the whole household to migrate overseas. So reliant is the country on overseas remittances—which are a major contributor to the Philippine economy, comprising about 10% of the GDP—that the country trains a surplus of health workers with the intent that they will work elsewhere.

Meanwhile, in the Philippines itself, difficult working conditions, including long hours, heavy workloads, and limited resources, compound the low salaries. Robredo says 30 to 36-hour shifts are common and physicians carry a large administrative load. Many prefer to do their training with more “advanced” technology in other countries. “Then they end up just moving to those places,” Robredo notes.

Nolasco says nurses face “chronic and serious” understaffing, which leads to unsafe nurse-to-patient ratios and burnt-out nurses. “In public hospitals they should be handling only 12 patients per shift, but in most cases they handle beyond what is safe,” she says. The prevalence of “job order” nurses, employed on a contractual basis often at minimum wage, reinforces the sense that nurses are undervalued.

So reliant is the Philippines on overseas remittances that the country trains a surplus of health workers with the intent that they will work elsewhere. Photo: ILO/R. Cabangal

Jobs in Europe, North America, Australia, and the Middle East offer the promise of higher salaries, shorter shifts, and greater financial security for Filipino health workers and their families. Known for providing high-quality patient care and strong English-language skills, the Philippines supplies many of the world’s nurses and doctors, helping combat health worker shortages and care for ageing populations. Filipino health workers comprise 13.5% of immigrant health workers in the US—in part due to the lasting impact of colonial practices—and an estimated 35,000 Filipino nurses work in Europe.

Saudi Arabia leading recruiter of Filipino nurses

Saudi Arabia is among the leading recruiters of Filipino health workers, employing an estimated 130,000 nurses. About 60–70% of the country’s nursing workforce is foreign-born, primarily from the Philippines, India, and Malaysia. During the oil boom of the 1970s, the government invested heavily in infrastructure, including healthcare facilities, which created a strong demand for health workers in the kingdom. Cultural and religious norms have historically led the country to rely on non-Saudi staff in many health professions, particularly nursing.

Dr Glenn Ford Valdez, associate professor in the Department of Nursing Sciences at Shaqra University in Riyadh, left his job as a nurse educator in the Philippines 14 years ago to work in the Middle East. He says there are close ties between Saudi Arabia and the Philippines. “They've seen how Filipino nurses work and how professional they are over a long period of time.”

OFWs are often hailed as “heroes” for their contributions to the Philippine economy through remittances and the sacrifices they make working far from home.

Valdez says pursuit of higher salaries is the “number one” reason Filipino nurses migrate to Saudi Arabia, explaining that, on average, nurses can earn three or four times as much as in the Philippines. “The salaries for nurses in the Philippines are not humane,” he says.

OFWs are often hailed as “heroes” for their contributions to the Philippine economy through remittances and the sacrifices they make working far from home, Valdez explains. “It's a part of our culture to give back, not only to our immediate family members, but also to our parents.”

He says the working conditions for nurses in Saudi Arabia are also better than in the Philippines, such as eight-hour shifts, paid overtime, and adequate rest days. “They really consider the health and overall optimal function of the nurse,” Valdez says.

Castro, the nurse, says the large Filipino community in Saudi Arabia helped her adapt to her new job and the local culture. “I stayed this long because I enjoy working here,” she notes. But because it is not possible to gain citizenship in the country, Valdez says Filipino nurses increasingly see Saudi Arabia as a “jumping-off point” en route to opportunities in other countries. “The mindset is to come here, earn three or four years’ experience, then go to another country where you can be naturalised,” he explains.

Campaigning for higher salaries and better conditions

Most Filipino health workers who migrate overseas do not return, except in some cases to retire after living in countries where they cannot gain citizenship. With the Philippines itself facing a shortage of about 127,000 nurses, especially in rural areas, affecting the quality of care delivered, experts say raising salaries at home may help stem the tide of migration.

Filipino Nurses United is campaigning for an increase to the starting salary for nurses in public and private hospitals to Php50,000 (US$850) per month. “It has to be for all nurses because they do the same job and perform the same tasks,” Nolasco says. The organisation is also fighting against contractualisation and for the provision of more plantilla (permanent) positions, as well as calling for safe nurse-patient ratios.

Filipino Nurses United is campaigning for an increase to the starting salary for nurses in public and private hospitals to Php50,000 (US$850) per month. Photo: Filipino Nurses United

Valdez says increasing salaries will also help to alleviate the problem of health workers who stay in the Philippines but choose to work in higher-paid jobs. “There is an oversupply of graduate nurses who don't want to work in the hospital because of the pay; so they opt to work in areas like call centres,” he explains.

“It's very abstract to invest in healthcare workers. It seems very reflexive, but when you talk to local governments, for them, it's like, ‘why should we invest in this and not in hospitals?”

Robredo suggests that support and guidance be provided to local governments to use special health funds to invest in the health workforce instead of “building more hospitals, providing more beds, or getting more equipment”. “It's very abstract to invest in healthcare workers. It seems very reflexive, but when you talk to local governments, for them, it's like, ‘why should we invest in this and not in hospitals?’” she says.

Robredo also recommends restructuring training programmes to improve health workers’ management and administrative skills or reducing the burden of non-clinical work. “If you want doctors or nurses to just focus on clinical delivery, make sure someone else can absorb the admin work.”

Local and international reforms needed

For the small number of health workers who return to the Philippines after working abroad, reintegration pathways that utilise their skills are crucial—for the workers themselves and the health system more broadly.

Dr Joy Spiliopoulos, a sociologist and research associate at the University of Leicester with expertise in the migration of health workers, says her recent research on returning Filipino nurses found that family crises are one of the most common reasons driving their return. Government repatriation programmes tend to favour lower-skilled returnees such as domestic workers, but Spiliopoulos notes that stable employment helps returning nurses settle back into life in the country.

The various bilateral labour agreements and memorandums of understanding between the Philippines and the countries hiring its health workers are largely one-sided, primarily serving as migrant labour agreements.

“Some were able to find employment in nursing schools as lecturers; another found a job in an office that was responsible for nurse deployment. They might not necessarily practise nursing, but sharing their knowledge and skills, and being recognised for that, is very important,” says Spiliopoulos, who is also a member of the NIHR Greater Manchester Patient Safety Research Collaboration.

She says ‘return’ migration is shaped and encouraged by national and international policymaking that advocates the benefits of healthcare migration for both the sending and receiving countries. At present, Spiliopoulos notes the various bilateral labour agreements and memorandums of understanding between the Philippines and the countries hiring its health workers are largely one-sided, primarily serving as migrant labour agreements.

Higher salaries and stronger workplace reforms may encourage nurses to stay in the Philippines. Photo: SJ Obijo

With stronger reforms and higher salaries, health workers may be encouraged stay in the Philippines. Oba, the nurse working in Manila, says he considered moving overseas for higher pay but ultimately decided to remain in the country to care for his fellow citizens. If nurses are given a “dignified wage” and security of tenure, Oba believes they are more likely to stay.

“The lives of our patients, the Filipino people, are at stake,” he says. “If we, the nurses, can stay here, Filipinos will be healthier than what we are now.”