PHILIPPINE CASE STUDY ON NURSING MIGRATION
Fely Marilyn Elegado- Lorenzo, RN, DrPH Institute of Health Policy and Development Studies National Institutes of Health-Philippines UP Manila , Health Sciences Center
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Methodology
Study Design: Analytic Case Study Design Data Collection Methods
• Review of Literature • Review of Records • Focus Group Discussions • Key Informant Interviews
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Methodology
Study Population
• 56 registered nurses out of a sample of 218 health workers from study areas:
Loag City, Ilocos Norte Cebu City, Cebu Tagum City, Davao del Norte Manila Valuenzuela City, Valenzuela
• Other health workers included doctors, PTs, OTs, MTs, and midwives • Recruitment Agencies and Review Centers
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Methodology
Study Population for Stakeholders Analysis
• Government Agencies:
• Professional Organizations
Civil Service Commission (CSC), Commission on Filipinos Overseas (CFO), Department of Budget and Management (DBM), Department of Labor and Employment (DOLE), National Economic and Development Agency (NEDA), Philippine Overseas Employment Agency (POEA), Professional Regulation Commission (PRC), Technical Education and Skills Development Authority (TESDA) PNA (Philippine Nursing Association) PMA (Philippine Medical Association)
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Philippine Employment and Health Care System Context
Philippines composed of 7,150 islands organized into 3 main island groups Population : 82 million growing annually by 2.3 % Productive age group estimated to be 42% of 34.2 million Labor Force is 67% of all Filipinos in reproductive age Only 8.83% are estimated to comprise human health resources
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Philippine Employment and Health Care System Context
Rapidly growing population , steady employment rates (Figure 1) Unemployment rates around 12 1 out of 5 Filipinos underemployed Job opportunities have not increased correspondingly with pop. increase Labor productivity stagnant over last 12 years Every year about 800,000 young people begin looking for work in a contracting and job-scarce economy
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Philippine Employment and Health Care System Context
Devolved health care system since 1995 DOH lead agency that safeguards health and maintains specialty hospitals, regional hospitals, and medical centers All other hospitals and field health units maintained by local governments Private sector involvement in health care is enormous – 60% of 1,600 hospitals in country are private Problems of access and equity: hampered by high costs and physical and socicultural barriers
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Philippine Employment and Health Care System Context
Health Sector Reform launched in 2000 covering :
• Hospital • Local Health Systems Development • Public Health Programs • Health Regulation • Social Health Insurance
No attention given to development of Health Human Resources
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Stock and Outflows of Nurses
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Stock of Philippine Health Human Resources
Philippines health sciences programs produce 23 categories of health workers (professionals and subprofessionals) From 1910-1950 producing health workers for domestic needs
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Figure 1. Trend in Deployment of Filipino Nurses Abroad, 19922003
Number of Filipino Nurses
13536 11911 8968 6744 6699 5747 4734 4242 4591 7584 5413 7683
Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr Yr 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
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Source: Philippine Overseas Employment Administration (POEA)
Table 1. Number of Filipino Nurses Deployed Abroad Per Year, 1992-2003 1992 1993 5747 6744
1994
1995 1996
6699
7584 4734 4242 4591 5413 7683 13536 11911
1997
1998 1999 2000 2001 2002
2003
Total
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8968
87852
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Source: Philippine Overseas Employment Administration (POEA)
Figure 2. Trend of Deployment of Health Workers Abroad, 1992-2003 20000 18000
DENTISTS
16000 14000
Population
DIETITIANS AND PUBLIC HEALTH NUTRITIONISTS DOCTORS MEDICAL MIDWIVES PROFESSIONAL NURSES PROFESSIONAL OPTOMETRISTS AND OPTICIANS PHARMACISTS PHYSIOTHERAPISTS AND OCCUPATIONAL THERAPISTS 13 TECHNICIANS MEDICAL XRAY
12000 10000 8000 6000 4000 2000 0
92 93 94 95 96 97 98 99 00 01 02 19 19 19 19 19 19 19 19 20 20 20
Source: Philippine Overseas Employment Administration (POEA)
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Table 2. Number Of Selected Health Workers Who Left The Country And Worked Abroad 1998-2003
1992 Dentists Dietitians And Public Health Nutritionists Doctors Medical Midwives Professional Nurses Professional Optometrists And Opticians Pharmacists Physiotherapists And Occupational Therapists Technicians Medical XRay Caregivers And Caretakers 27 1993 22 1994 38 1995 48 1996 36 1997 52 1998 32 1999 56 2000 33 2001 57 2002 62 2003 40
nd
nd
nd
nd
nd
nd
98
66
45
64
98
134
86 246
91 295
57 126
69 161
47 142
82 113
55 149
59 66
27 55
61 190
13536
129 312
11867
112 276
5747
nd 52
6744
nd 32
6699
nd 32
7584
nd 54
4734
nd 57
4242
nd 42
4591
68 47
5413
96 55
7683
80 30
8968
58 74
83 64
123 57
542
608
645
581
426
289
317
147
235
330
517
371
nd nd
nd nd
nd nd
nd nd
nd nd
nd nd
409 nd
249 nd
223 nd
285 465
359 5383
384
18878 14
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Source: Philippine Overseas Employment Administration (POEA)
STOCK OF NURSES
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Total Number of Nurses in the Country
Total Registered Nurses (1960-2003) = 333, 581
Estimated Deaths = 1, 375.20
Estimated Current Stock of Nurses = 332, 205.80
SUPPLY AND DEMAND:
Supply Demand
= 332, 206 = 193, 223
Oversupply = 138, 983
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Table 6. Estimated Number of Employed Filipino Nurses By Work Setting, 2003 Work Setting I. Local/National A. Service 1. Government Agencies 2. Private Agencies B. Education II. International Total 19, 052 8, 173 2, 241 163, 756 193, 223
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Number 29, 467
Percentage 15.25%
9.86% 4.23% 1.16% 84.75% 100.00%
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Estimated HRH Production Trends
Nurses (10,000-15,000/year) from 441 nursing colleges Doctors (2,000/year) from 30 medical colleges Midwives (1,500/year) from 129 schools Dentists (2,000/year) from 31 dental schools Pharmacists (1,500/year from 35 pharmacy colleges Physical Therapists (1,000/year) from 95 PT/OT colleges Occupational Therapists (200/year) from 95 PT/OT colleges
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STOCK OF NURSES
Geographical Distribution
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Region I (Ilocos Region) CAR (Cordillera Administrative Region) Region II (Cagayan Valley) Region III (Central Luzon) NCR (National Capital Region) Region IV-A (CALABARZON) Region IV-B (MIMAROPA) Region V (Bicol Region) Region VI (Western Visayas) Region VII (Central Visayas) Region VIII (Eastern Visayas) Region IX (Zamboanga Peninsula) Region X (Northern Mindanao) Region XI (Davao Region) Region XII (SOCCSKSARGEN) Region XIII (Caraga) ARMM (Autonomous Region in Muslim Mindanao)
The Political Map of the Philippines
Bellagio Nurse Migration Source: http://islandphilippines.com/map.htm (accessed June 23, 2005)
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Table 7. Distribution of Nurses Passing the Licensure Examination by Region, 2001-2003
Number of Nurses Passing the Licensure Examination By Year Region Region I Region II Region III Region IV Region V Region VI Region VII Region VIII Region IX Region X Region XI Region XII Region XIII (NCR) Region XIV (CAR) Region XV (ARMM) Region XVI (CARAGA) TOTAL 2001 356 99 214 250 280 327 214 60 198 170 149 158 1547 179 19 60 4280 2002 355 132 247 284 253 306 333 41 195 140 139 70 1367 166 6 45 4079 2003 502 519 462 576 299 659 546 102 256 308 279 147 2358 354 4 59 7430 Total 1213 750 923 1110 832 1292 1093 203 649 618 567 375 5272 699 29 164 21 15789
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Source: Compilation of Statistics on Performance of Schools in Various Licensure Examinations 2001-2003
Table 9. Distribution of Doctors According To Region, 2002
Region XIV CAR XIII NCR I II III public 85 658 158 175 297 private 1968 15238 3659 4053 6878 total 2053 15896 3817 4228 7175 % 2.81% 21.78% 5.23% 5.79% 9.83%
IV
V VI VII VIII IX X XI XII XV ARMM XVI CARAGA Total
350
190 226 229 153 90 99 79 84 69 79 3021
8105
4400 5234 5303 3543 2084 2293 1829 1945 1598 1829
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8455
4590 5460 5532 3696 2174 2392 1908 2029 1667 1908 72981
11.59%
6.29% 7.48% 7.58% 5.06% 2.98% 3.28% 2.62% 2.78% 2.28% 2.62% 100.00%
22
69960
Source: Philippine Statistical Yearbook (National Statistics Coordination Board)
Countries of Destination
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Table 3a. Deployment of Filipino Nurses by Major Country of Destination, Philippines 1992- 2003
Year Saudi Arabia Num 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Total 3279 4202 3332 3249 3071 3794 4098 4031 4386 5045 5704 5740 49931 % 57.06% 62.31% 49.74% 42.84% 64.87% 89.44% 89.26% 74.47% 57.09% 37.27% 47.89% 64.01% 56.84% United States Num 1767 1987 2853 3690 270 11 5 53 91 304 320 196 11547 % 30.75% 29.46% 42.59% 48.66% 5.70% 0.26% 0.11% 0.98% 1.18% 2.25% 2.69% 2.19% United Kingdom Num 0 0 0 1 0 0 63 367 295 5383 3105 1544 % 0.00% 0.00% 0.00% 0.01% 0.00% 0.00% 1.37% 6.78% 3.84% 39.77% 26.07% 17.22% Num 269 721 15 380 809 175 89 18 17 9 414 52 2968 Libya % 4.68% 10.69% 0.22% 5.01% 17.09% 4.13% 1.94% 0.33% 0.22% 0.07% 3.48% 0.58% 3.38% United Arab Emirates Num 271 47 270 94 137 209 279 378 305 243 405 226 2864 % 4.72% 0.70% 4.03% 1.24% 2.89% 4.93% 6.08% 6.98% 3.97% 1.80% 3.40% 2.52% 3.26% 24
13.14% Nurse Migration12.25% 10758 Bellagio Meeting
Source: Philippine Overseas Employment Administration (POEA)
Table 3b. Deployment of Filipino Nurses by Major Country of Destination, Philippines 1992- 2003
Year Ireland Singapore Kuwait Qatar Brunei
Num
1992 1993 1994 1995 1996 1997 1998 1999 2000 0 0 0 0 0 0 0 0 126
%
0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 1.64%
Num
0 0 0 79 264 228 224 154 292
%
0.00% 0.00% 0.00% 1.04% 5.58% 5.37% 4.88% 2.85% 3.80%
Num
320 139 455 59 269 25 143 53 133
%
5.57% 2.06% 6.79% 0.78% 5.68% 0.59% 3.11% 0.98% 1.73%
Num
0 0 6 10 6 14 21 12 7
%
0.00% 0.00% 0.09% 0.13% 0.13% 0.33% 0.46% 0.22% 0.09%
Num
0 6 5 7 5 32 2 1 0
%
0.00% 0.09% 0.07% 0.09% 0.11% 0.75% 0.04% 0.02% 0.00%
2001
2002 2003 Total
1529
915 207 2777
11.30%
7.68% 2.31% 3.16%
413
337 326 2317
3.05%
2.83% 3.64%
182
108 51
1.34%
0.91% 0.57%
143
213 242 674
1.06%
1.79% 2.70% 0.77%
1
9 2 70
0.01%
0.08% 0.02% 0.08% 25
2.64%Nurse Migration2.20% 1937 Bellagio Meeting
Source: Philippine Overseas Employment Administration (POEA)
Markets
Traditional Markets: Middle East, North America New Markets: Europe especially UK, Netherlands, High Income Asia Emerging Markets: Japan and Nurse Education abroad
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Profile of Nurse Migrants
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Profile of Filipino Nurse Migrants
Predominantly female Young - 20’s -30’s Middle Class Mostly with basic professional education ;some with masters’ degrees Specialized in Critical Care nursing, OR, DR and /ER and rendered 1-10 years of service before migration
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Profile of Nurse Migrants: Results of FGD
Mostly Women Age Range of 20-30 years old Middle-Income Group Basic Professional Educ/with Master’s Degree Specialized in areas ICU, ER, and OR Served 1-10 years before migration
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Profile of Nurse Medics
Increasing number – about 1000/year from 2000 to 2003- estimated to triple in 2005 From survey of 100 volunteer respondents (doctors currently taking nursing courses) in different regions of the Philippines: Gender Distribution – 45% female, 30% male, 25% no info Marital Status - 24% single, 76% married Age – 37 years old and above Annual Income Bracket – P 120, 000 to P 480, 000 Specializations – Internal/General Medicine (30%), Pediatrics (14%), Family Medicine (13%), Surgery (8%), Pathology (6%), Others (29%) Bellagio 63% were practicing Nurse Migration Meeting doctors for more than 10 30 years
INFLOW/OUTFLOW
Reasons for Migrating/Returning
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Reasons Why Filipino Nurses Leave the Country
Push Factors
Economic: low salary at home, no overtime and hazard pay, low coverage of health insurance Job-related: work overload or stressful working environment, slow promotion Socio-political and economic environment: limited opportunities for employment, decreased health budget, peace and order situation in the Philippines
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Reasons Why Filipino Nurses Leave the Country
Pull Factors
Economic: higher income, better benefits and compensation package Job-related: Lower nurse to patient ratio, more options in working hours Individual/Family-related: Chance to upgrade nursing skills, acquisition of immigrant visa and opportunity for family to migrate, opportunity to travel and learn other cultures, influence from peers and relatives
Socio-political and Economic environment: Advanced technology, better peace and order situation
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Reasons Why Doctors Migrate as Nurse Medics
PUSH FACTORS very low compensation and salaries, feeling of hopelessness about the Philippine current situation, political instability and graft and corruption, poor working conditions and the threat of malpractice law PULL FACTORS more socio-politico- economic security abroad, attractive salaries and compensation packages (High salaries, benefits, compensation) more job opportunities Migration Meeting and career growth. Bellagio Nurse
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Reasons Why Filipino Nurses Return:
Personal Reasons
• • • • • •
To get married To raise children in homeland To take a vacation Homesickness and depression To retire To get family
Professional Reasons
• To share expertise • For professional stability
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Reasons Why Filipino Nurses Return
Financial Reasons
• Nurse has saved enough money • To set up a business at home
Job-related Reasons
• To buy a house or a car
Social Reasons
• Contract has expired • Plans to retire back home
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Stakeholder Analysis
Viewpoints of Stakeholders on the Impact of Health Worker Migration
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Impact of Health Worker Migration: Government Agencies Perspective
A. 1. 2.
On Family Positive: Increase family Income Better quality of life for family
1. 2.
Negative: Loss of family values Social cost
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Impact of Health Worker Migration: Government Agencies Perspective
B. On Health Care System
1.
Positive Transfer of technology
Negative Loss of senior, competent staff Compromised health care due to inadequate pool of skilled workers The HR becomes more expensive Some hospitals have closed down because there are not enough nurses and no applicants for various residency programs Increased patients to nurse ratio
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1. 2. 3. 4.
5.
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Impact of Health Worker Migration: Government Agencies’ Perspective
C. On the Health Professions Positive 1. Encourages Filipinos to take up health courses and add to stock of potential HWs 2. Ease in stock of HWs because of oversupply when the demand went down in the past 3. Exposure to different culture, work ethics, technology if they come back to echo them 4. Career advancement because of better technology and available studies/training in host countries 5. Top students go into nursing
1.
Negative repercussions of other professionals moving into nursing (incompetent and unproductive nurses)
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Impact of Health Worker Migration: Professional Organizations’ Perspective
1. 2. 3. 4. 5.
POSITIVE Dollar remittance in the country Knowledge are shared by those who are coming back in the country The nurses are recognized for more compassion and dedication in their work There is a less competition among the health workers that are left behind Technology transfer from the migrants on vacation NEGATIVE Depletion of the skilled staff and the loss of rapport between the staff and the patients Submission of fake documents posts a bad image on the Filipino health workers Good image of the nurses is lost when the newly graduates or the less experienced/skilled workers go abroad.
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1. 2. 3.
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Social Net Benefits
Winners –
• Nurse migrants and their familiesgreater child schooling, reduced child labor , increased educational expenditure, • Economy – remittances, raise hours worked in self-employment and lead to relatively capital-intensive enterprises by migrants’ hoouseholds
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Social Net Benefits
Losers –
• Health Care System
Loss of skilled trained health staff Rendered health system fragile Social support Ability to renew and further nursing development is hampered
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• Extended Families
• Philippine Nursing
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Policy Analysis
Policies affecting domestic nursing education and training -Many Policies affecting domestic nursing processional practice - Updated Policies on external and international demand for nursing services-None from domestic arena, all external
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Policy Analysis
Policies that Affect Equity, Access Work Conditions and Career Path Development Policies that provide employment and deployment opportunities for health providers through a national insurance system Policies that provide for HRH development International Policies that affect Philippine Health Worker Migration
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Policy and Program Initiatives
Declaration of Nursing Crisis More Effective Regulation of Nursing Schools
• Nursing School report Card • Regulate opening and closure of schools • Moratorium of new nurse program opening
Proposal of an EO to closely coordinate national government agency functions with regards to nurse supply and demand development Innovative Health Sciences Education Experiments Retention Strategy Experiments
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Policy and Program Initiatives
HRH Master Plan 2005-2030
• Workforce planning and migration management (20052010)
• HRH Systems Development Pilot Phase (2010-2021)
Returnee positions provisions and development Nursing Educational Development from Receiving countries HRH research Local Health Systems Development Recruitment, retention, career development, compensation and benefit development Roll Out , Monitoring and Evaluation
• HRH Systems Development Expansion Phase (20212030)
• Establishment of HRH Development Network (Commission)
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Future Directions
Regional Policies (ASEAN Mutual Recognition Agreement) Bilateral Policies and Arrangements Hospital Tourism Health Zone Establishment Remittance Management
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Important Considerations
Temporary migration most beneficial for sending country Permanent migration beneficial to individual migrants and families and receiving country Nursing most popular profession now due to job and career opportunities Nursing and HRH development are on national policy agenda -controversial
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Important Considerations
Nursing development has not benefited from rollercoaster trends of migration Health Care system has not benefited from migration related transactions Nursing and health sectors need to manage relationships with trade and economic managers in private and government sectors Philippines has not utilized remittances to leverage job creation and domestic employment development
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Important Considerations
Philippines major exporter of nurses with competitive edge that we need to protect We will form partnerships with systems and countries that will help us uphold this quality and value this resource to ensure global quality!
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Total Number of Nurses in the Country
AGE GROUP 22-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
YEAR
2001-2003 1996-2000 1991-1995 1986-1990 1981-1985 1976-1980 1971-1975 1966-1970
AGE SPECIFIC DEATH RATE 1.3 1.7 2.2 3 3.9 5.7 7.9 11.4
NO.OF REGISTERED NURSES 8,658 44,119 113,877 32,815 33,663 50,586 25,252 14,081
ESTIMATED DEATHS 11.26 75.00 250.53 98.45 131.29 288.34 199.49 160.52
60-64
65 TOTAL
1961-1965
1960
17.7
25
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9,058
1,472 333,581
160.33
36.80 1,375.20 53
Table 4. Distribution of Nurses Deployed Abroad by Gender and Year, 1992-2003 Year 1992 1993 1994 1995 1996 1997 1998 1999 Male 680 729 1, 013 1, 160 665 671 666 839 Female 5, 067 6, 015 5, 686 6, 424 4, 069 3, 571 3, 925 4,574 No Information 0 0 0 0 0 0 0 0 Total 5, 747 6, 744 6, 699 7, 584 4, 734 4, 242 4, 591 5, 413
2000
2001 2002 2003 Total
1, 273
2, 269 1, 615 981 12, 561
6, 410
11, 267 10, 295 7, 986
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0 1 1 2
7, 683
13, 536 11, 911 8, 968 87, 85254
75, 289
Source: Philippine Overseas Employment Administration (POEA)
Table 8. Number of Government Nurses by Region (1980-2002)
YEAR XIV CAR nd nd nd nd nd nd nd nd nd nd 576 558 573 nd 166 25 488 159 140 138 138 140 159 XIII NCR 1,568 1,444 1,487 1,748 1,759 1,617 1,597 2,095 2,095 2,122 618 632 5,417 627** 113 242 685 504 838 849 861 823 745 I II III IV V VI VII VIII IX X XI XII XV ARMM nd nd nd nd nd nd nd nd nd nd nd nd 217 nd nd 87 nd 149 134 78 142 80 99 XVI CARAGA nd nd nd nd nd nd nd nd nd nd nd nd nd nd nd 60 119 147 83 148 109 134 130 2721 2694 5663 4096 4389 4945 4724 4819 4720 TOTAL
1980 1981 1982 1983 1984 1985 1986 1987@ 1988 1989 1990 1991 1992 1993 1994*** 1995 1996 1997 1998 1999 2000 2001 2002 LEGEND:
955 981 1,028 1,310 999 1,051 1,035 1,138 1,138 1,138 738 665 683 627** 177 153 1,473 178 227 217 216 214 203
579 642 670 764 768 686 692 777 777 777 588 576 425 50** 135 334 271 282 158 202 210 206 267
774 842 855 1,028 1,031 868 883 1,041 1,041 1,041 1,006 1,007 1,016 789** 215 232 436 178 295 605 349 372 382
1,410 1,390 1,398 1,457 1,468 1,302 1,315 1,310 1,310 1,310 1,263 1,260 1,360 2,725** 207 281 500 760 620 613 653 638 648
580 666 678 705 706 686 710 737 737 737 753 756 786 765* 158 200 260 241 257 279 276 326 338
759 798 815 901 1,008 834 866 962 962 962 956 956 786 648** 332 206 381 351 385 424 411 467 433
665 668 771 794 800 780 796 922 922 899 633 633 633 582 368 381 406 439 431 423 399 416 379
607 671 686 714 698 693 718 857 857 857 839 814 769 796** 166 85 53 168 203 217 221 226 233
369 418 445 504 486 476 517 582 582 582 567 585 480 471** 142 164 174 182 180 173 204 205 196
510 562 577 600 512 594 606 678 678 678 709 717 717 524 208 150 114 107 124 152 172 242 189
368 237 440 519 525 451 471 603 603 603 539 523 582
282 325 380 411 405 386 406 464 464 464 485 435 409 245**
9426 9644 10230 11455 11165 10424 10612 12,166 12166 12170 10270 10117 14853
223 50 200 92 160 301 244 198 161
111 44 103 159 154 126 119 132 158
* Combination of retained at the RHO and devolved health personnel in the LGUs. ** Devolved/absorbed health personnel by the LGUs.
@ Data for 1987 same as data for 1986.
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*** Retained personnel only. Devolved personnel not included.
SOURCE: 1991 – 2004 Philippine Statistical Yearbook National Statistical Coordination Board