From Brain Drain to National Hemorrhage The Global Migration of Philippine-Trained Nurses: Causes, Impacts and Future Prospects Erlinda Castro-Palaganas PhD, RN University of Ottawa, Nov. 3, 2008 References Several researches on the PHILIPPINE NURSING MIGRATION by Dr. Fely Marilyn Lorenzo, Dr. Jaime Galvez Tan, PNA, ADPCN, HEAD, PHM Outline of Presentation Philippine Health Care Context Philippine Basic Indicators The Government Responses: - Privatization as a Government Policy - Labor Export Policy Nurses and Migration - Migration Situation - Migration Issues and Concerns - Policy Implications Challenges What could be the reason/s? Philippine Health Care System Context Philippines composed of 7,150 islands organized into 3 main island groups Population : 87million 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 Philippine Health Care System Context Rapidly growing population , steady employment rates Unemployment rates around 12% 1 out of 5 Filipinos underemployed Job opportunities have not increased correspondingly with population 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 Philippine 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 soci-cultural barriers Philippine 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 Philippine Basic Indicators 4 million unemployed and 7.3 million underemployed in 2006 in the past six years, 11.3% unemployment rate and 18.5% underemployment rate 70% of Filipinos consider themselves poor (IBON survey) around 3,000 Filipinos daily forced overseas to work source: IBON Philippine Basic Indicators P100 billion estimated government deficit P278 billion target raised through higher taxes, fees, rates & public service charges P721.7 billion target to be repaid to creditors in ’06 or P6,391 per Filipino Real public spending per Filipino on education is P1,296; health P120 Source: “2006: The Economics of Hype”, IBON Foundation, published in bulatlat.com, Philippine Basic Indicators The Philippines ranked 83rd of 177 nations (down from 77th in 2002) in the quality-of-life survey (GDP, life expectancy, adult literacy, growth in school enrollment, environmental protection) - 2004 UN Human Development Index Privatization as a Government Health Policy Health Sector Reform the Philippines Health Sector Privatization “Health Sector Reform Agenda” “Fiscal autonomy” for govt hospitals Promote health insurance schemes with private sector Tokenism in “public health programs”, “community health” and “development of local health systems” “FOURmula ONE for Health” (2005-2010) Integrated public health into hospital services Medical tourism “Innovative financing arrangements” Health Services for Sale: Medical Tourism Principally being promoted by the Philippine government using the public health care system Linked to the issue of organ trade (i.e. sale of kidneys for US$3,000- 4,000) Expected revenues: US$ 10B in 5 years “Medical Terrorism”: Growing military presence Labor Export Policy This decline in the quality of life is due to the worsening economic and political crisis in the country. Due to widening unemployment, the Philippine government has resorted to a Labor Export Policy (LEP) to: (1) defuse social tension by exporting its vast numbers of unemployed and underemployed people abroad (2) to rake in the much needed dollar remittances to prop up a falling peso, pay balance of trade deficits and onerous foreign loans. “The fact that millions of Filipinos are forced to work abroad is proof of government’s economic failure.” - Manila Archbishop Gaudencio Rosales, July 2004 Labor Export Policy The Philippines’ Labor Export Policy is rooted in the failure of its government to chart its own economic and political development through genuine agrarian reform and the creation of a modern industrial base to make the local market vibrant, prosperous and stable. This resulted into dependence on foreign technology and markets, political subservience to foreign policy dictates of the dominant economic powers. Without a sustainable and self-reliant domestic economic base, the Philippine government will perpetually export its human resources to foreign masters in exchange for much-needed revenue at the expense of the rights and welfare of its workers. The development of the labor export program (LEP) • Since 1974, when the Labor Code was first revised, the “export” of Filipino workers overseas has intensified and become increasingly systematic • Creation of successive government agencies that institutionalized and intensified the export of Filipino workers overseas • Overseas Workers Welfare Administration, Philippine Overseas Employment Administration • Government target of 1 million workers overseas per year Organized Philippine Overseas Deployment System Goals: Maximize gains of overseas employment for migrants and sending countries Monitoring and Protection of OFW welfare Components: Managing overseas deployment: Finding , managing new markets, maintaining current partners; Welfare Protection: Ensuring rights are protected during recruitment, pre-departure and in overseas workplaces Migrant workers’ reintegration into society Organized Philippine Overseas Deployment System Six major government agencies involved in migration process : 1.DOLE- Department of Labor and Employment 2. POEA- Phil. Overseas Employment Administration 3. OWWA- Overseas Workers Welfare Administration 4. BSP- Bangko Sentral ng Pilipinas (Central Bank) 5. DFA – Department of Foreign Affairs 6. CFO- Commission on Filipinos Overseas Key Migration Management Tools Migrant and Overseas Filipinos Act (RA 8042) Contains policies, rights , obligations, sanctions and regulations that govern overseas employment. POEA- handles documentation of land-based and sea- based contract workers recruited mostly by private recruiters, regulates recruiters; manages information on migrant and remittance flows to assist with policy formulation OWWA- responsible for promoting welfare of OFWs and dependents through implementation of welfare programs for migrants and dependents; includes health or repatriation assistance, livelihood loans, skills training, scholarships, and reintegration incentives POLOs – Philippine Overseas Labor Offices attached to Phil. embassies and consulates Labor Export 2006 Top 10 OFW destination countries: • 36,000 Filipinos were 1. Saudi Arabia 223,359 “deployed” to other 2. UAE 99,212 countries in 1975. 3. Hong Kong 96,929 • In 2006, the Arroyo 4. Kuwait 47,917 administration exported 5. Qatar 45,795 a record 1.08 million 6. Taiwan 39,025 Filipinos and received 7. Singapore 28,369 US$14 billion in 8. Italy 25,413 remittances of overseas 9. UK 16,926 10. Korea 13,984 Filipinos. Others 151,041 • Of the 308,142 deployed Landbased 788,070 OFWs as new hires, Seabased 274,497 184,454 or 60% were Total 1,062,657 females compared to Source: POEA, 2006 123,688 males in 2006. Top Ten Occupational Group by Sex For the Year 2006 Male Female Total % share to total 1. Household & related workers 1,590 89,861 91,451 29.7% 2. Factory & related workers 39,544 12,690 43,234 14.0% 3. Construction workers 40,178 2,862 43,040 14.0% 4. Medical & related workers 2,650 15,081 17,731 5.8% 5. Hotel & Restaurant related workers 6,210 9,483 15,693 5.1% 6. Caregivers & caretakers 842 13,570 14,412 4.7% 7. Building caretakers & related workers 2,103 10,191 12,294 4.0% 8. Engineers & related workers 10,754 415 11,169 3.6% 9. Dressmakers, tailors & related 375 7,456 7.831 2.5% workers 10. Overseas Performing Artists 709 6,722 7,431 2.4 Total deployment – new hires 123,688 184,454 308,142 100.0% Intensified export of Filipino migrants “Overseas Filipino Workers should stay where they are and not think of coming home.” President Gloria, August 2002 during dinner with OFWs in Kuala Lumpur. Labor Export Policy For the last 30 years, the Philippine economy, and all administrations have been propped up by the remittances of overseas Filipinos. The country’s economy is saved from eventual collapse by the remittances of Filipinos abroad. Last year, close to 10 million Filipinos overseas remitted a total of US$12.8 billion to the Philippines, US$2.2 billion higher than the US$ 10.6 billion total of 2005. This is aided by the government’s pursuit of its labor export program that targets one (1) million Filipinos deployed annually. State exactions & dollar remittances Annual remittances: 1984 US$659 million State exactions: 1989 US$973 76 Signatures P 7,600 million (P100/signature) 1994 US$2.9 Passport P 550 billion POEA fee P 7,500 1999 US$6.97 OWWA fee (US$25 P 1,375 billion per contract) 2003 US$7.2 Medicare (annual) P 900 billion Total P17,925 2004 US$8.5 billion P17,925 x 3,000 P19.6 OFWs = P53.77 billion 2005 US$10.7 million daily per year billion 2006 US$12.8 Source: Central Bank; COURAGE 7/7/2011 billion 27 Lucrative labor export program 2005 Remittances of US$10.7 billion (P545.7 billion) amounted to: • More than the five top 2005 merchandise exports • More than ½ of the 2005 national budget (P907 B) • 100 times more than all Foreign Direct Investments • 10% of the GDP • 9.5% of the GNP • 3 times more than 2001 US military aid 7/7/2011 28 Overseas Filipinos • More than 8.5 million or 10% of Philippine population are in over 196countries • Mostly from peasant and worker families • Overseas Filipinos include immigrants and naturalized citizens; undocumented workers; refugees; and contract workers (est. 3.5 million, DFA) Exporting Health Human Resource No. 1 Exporter of Nurses “An estimated 85% of employed Filipino nurses (more than 150,000) are working internationally.” (Aiken et al 2004) “70% of all Filipino nursing graduates are working overseas.” (Bach 2003) No. 2 Exporter of Doctors “68% of Filipino doctors work overseas, next to India.” (Mejia, WHO 1975) (NIH 2004) Hemorrhage of Human Resources: Nurses 13,536 nurses left the country in 2001. 2000-2003: approx 50,000 nurses left. “Data casts doubt on the underreporting of the Philippine Overseas Employment Agency (POEA) that shows only 91 nurses left for the USA in 2000, 304 nurses in 2001, and 320 nurses in 2002.” (Tan et al 2004) Source: Philippine Overseas Employment Administration (POEA) Source: Philippine Overseas Employment Administration (POEA) 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 = 332, 206 Demand = 193, 223 Oversupply = 138, 983 Table 6. Estimated Number of Employed Filipino Nurses By Work Setting, 2003 Work Setting Number Percentage I. Local/National 29, 467 15.25% A. Service 1. Government Agencies 19, 052 9.86% 2. Private Agencies 8, 173 4.23% B. Education 2, 241 1.16% II. International 163, 756 84.75% Total 193, 223 100.00% Estimated HRH Production Trends Nurses (10,000-15,000/year) from 475 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 Top 5 Destinations of Filipino Nurses United States of America United Kingdom Saudi Arabia Ireland Singapore (NIH 2004) Markets Traditional Markets: Middle East, North America New Markets: Europe especially UK, Netherlands, High Income Asia Emerging Markets: Japan and Nurse Education abroad Profile of Nurse Migrants 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 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%) 63% were practicing doctors for more than 10 years Hemorrhage of Human Resources: Doctors MD-NURSES: More than 9,000 MDs have already left as nurses in 2002-2005. Around 80% of public health physicians have taken up or are enrolled in nursing. Obstetricians and anaesthesiologists are fast depleting, followed by pediatricians and surgeons. (NIH 2004, PMA 2005) Hemorrhage of Human Resources: Doctors In some areas, the local PMA chapter facilitates the nursing education of its members Decrease in enrollment of first year medical students of 10% to 55% in the last 2 years. Decrease in applicants for residency positions (NIH 2004, PMA 2005) Hemorrhage of Human Resources: Other Professionals At least 37 Philippine nursing schools offer abbreviated 2-year courses for doctors to become nurses. More than 60% of nursing schools are geared mainly for “second coursers” (non-health professionals who want to take up nursing, e.g. engineers, accountants, teachers, soldiers). (HSA 2005, PNA 2005) Hemorrhage of Human Resources: Other Professionals HEAD estimates that there are between 30,000- 40,000 “second-coursers” currently taking up nursing. TESDA has trained over 50,000 caregivers in the last 5 years and over 24,000 have been deployed abroad. (HSA 2005, PNA 2005) 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 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 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 and career growth. 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 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 Perceived Impact of Migration Health Care System and Quality of Health Care o Positive Effects Health care is enhanced. Availability of more aggressive staff replacements who are eager to learn. o Negative Effects Continuity of programs/services is adversely affected. Quality of care is compromised. People in the community are deprived of health services. Improvement of the hospital is delayed when resources are used to train staff replacement. Perceived Impact of Migration Economy o Positive Effects Economy improves with the remittances from workers abroad. Philippines posts 5th largest remittance earnings globally (WB) projected to be $30 B Unemployment is reduced. o Negative Effects Loss of government resources used in education and training. Resources are spent on training of staff replacements. Reduced government income of the province and country from taxes of health professionals. Social Net Benefits Winners – Nurse migrants and their families- greater 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 Social Net Benefits Losers – Health Care System Loss of skilled trained health staff Rendered health system fragile Extended Families Social support Philippine Nursing Ability to renew and further nursing development is hampered Deteriorating Quality of Nursing Education The number of nursing schools have increased 1970s: only 40 1990s: 170 June 2003: 251 April 2004: 370 June 2005: 441 June 2006: 470 In the last 3 years, there has been an 87% increase in nursing schools nationwide (NIH 2004) Deteriorating Quality of Nursing Education Decreasing proportion of nursing graduates who pass the national nursing licensure examinations 1970s and 80s: 80%-90% 1991: below 61% 2001-2003: 44%-48% 2004: 55.9% 2005: 49.7% 2006: 41% (NIH 2004, PRC 2006) Deteriorating Quality of Nursing Education In 2001 116 nursing schools: passing rate of <50% 124 nursing schools: passing rate of >50% In 2002, 150 nursing schools had a passing rate <50%, which was already 63% of the 237 nursing schools then. In the last 3 NLEs, at least 20 nursing schools consistently had a 0% passing rate. (NIH 2004, PRC 2006) Source: PRC, 2005 Nurses and Severe Exploitation and Discrimination Canada: the Live-in Caregiver Program (LCP) for nurses United Kingdom: £ 2,000 payment to employer or recruiter, yet start at the lowest rung (~ healthcare assistant) Saudi Arabia: the visit of DOLE Sec. Patricia Sto. Tomas pushed for lower wages for Filipino nurses in order to maintain “competitiveness”. (AHW 2004, MIGRANTE INT’L 2005) Exploited Health Human Resources Health workers and professionals are overworked and underpaid. “Average monthly wages for nurses is between Php 5,500 to 16,500 and for doctors is between Php 9,700 to 23,500.” (Lorenzo et al, 2004) Exploited Health Human Resources Doctor to patient ratio (population) Cuba 1:225 USA 1:450 Philippines 1:10,000-26,000 WHO (Ideal) 1:600 Nurses to patient ratio PGH 1:15-26 per shift Davao del Sur 1:44-45 per shift Ideal 1:4 per shift Philippines 1:16,000 (population) (AHW 2004, HealthWrights 2004) Reasons for the Continuing Exodus Commercialized health education. “The average tuition fee for a 5-year medical course is Php 500,000 for school fees alone.” Labor export policy. “The national government earned USD 7.6B from OFW remittances in 2003 and USD 8.5B in 2004. It expects to earn an estimated USD 10B in 2005.” Reasons for the Continuing Exodus Economic and political instability. “The fiscal crisis and the ballooning national debt; the unbridled corruption and lack of accountability; and the political crisis that worsen daily amid the incapacity of government to address these with long-term, definitive solutions.” Globalization policies. “The phenomenon of human trafficking across states, even under the guise of globalizing labor and human resource development, is still within the framework of privatization, deregulation, and liberalization.” The Unhealthy Philippine Health Care System “A health care system that cannot maintain its own health human resource is not healthy at all.” “Health is a basic human right. It is the responsibility of the state to ensure that the people have access to quality health care.” RIGHT TO HEALTH OF THE PEOPLE Worsening State Neglect 40% government 49% out of 11% Shared-Risk Schemes pocket Including National Health Insurance (PhilHealth) Total Health Expenditure P0.25 per Filipino per day Increasing private burdens Decreasing Spending on Social Services Debt payments: increased by 101% Health: decreased by 19% Military: increased by 11++% Nota: “%” ay inflation-adjusted per capita, tsart ay nominal Administrative Costs and 10% Regulatory Functions 10% 80% Public Health Interventions Individual Healthcare (Romualdez, 2008) HEALTH has become a commodity: subject to TRADE and PROFITS National Governments have ABANDONED their responsibility to ensure the HEALTH of their PEOPLE. In these trying times, WHAT ARE WE TO DO? 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 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 Health Worker Migration Policy Issues Areas that need attention: recruitment, retention, policy, education and strain on current nurses Funding of the education and training of health workers Employment situation within the source country and the degree to which health professionals would have been gainfully employed in their home country Consequences for the workers that remain in the country as their colleagues depart for employment abroad Whether movements reflect temporary or permanent shift in location Policy Analysis Local Policies – mainly regulate and manage domestic employment Many incompletely implemented or not implemented Does not manage outflow of workforce Does not adequately clarify standards of staffing and compensation Policy Provisions International Policies Provides models of regulating scope of practice and licensure, recruitment, entry Safeguards quality of health systems and health care in destination countries Few contain safeguards from source countries Migration has to be managed by: Addressing protection of both health and human rights. - Dampening push forces by retaining talent in sending countries - Reducing pull forces by aiming for educational self sufficiency in destination countries JLI Secretariat 2004 Managed Migration Should facilitate both - development goals of source countries and - efficiency goals of destination countries Involves national - policy reforms - international agreements - cooperative education program by source and destination country institutions Health sector development projects (Commonwealth Secretaiat, 2005) Migration Related Policy Categories Recruitment, Entry, and Citizenship Policies Welfare and Human Resource Development and Retention Re-entry of Migrants (Brain Gain) - Permanent - Temporary (Brain Circulation) Licensure and Scope of Practice Skill Mix Poverty Alleviation and Social Development Policy Development Criteria Mutually Beneficial - economic standpoint (social return) - development status (professional and social) - financial (private returns) - cultural - health systems Should achieve equity and efficiency Promote policy coherence Protection and safety human outcomes Policy Goals Equity – Nurse Distribution Effectiveness Efficiency Security/Safety – ensuring local/domestic health outcomes Policy Recommendations International Policies Bilateral Migration Management Policies Provision of Progressive Incentives HRH retention for destination countries Incentives for reintegration for Recruiting countries Policy Recommendations Domestic Policies Creation of incentives for return migration: Positions for return migrants Development of Framework for maximizing the utilization of those with skills, experience Incentives for investments/ temporaryreintegration Policy Recommendations Within organizations Creation of Position that provide incentives for longevity Career Path Development Ensure continuing development Improve work conditions Policy Options Five Core Elements for National and Bilateral Policy on Labor Migration and Related Support Measures: An informed and transparent labor migration admissions system designed to respond to measured, legitimate labor needs, taking into account domestic concerns as well. A standards-based approach to “migration management” protecting basic rights of all migrants and combating exploitation and trafficking. Enforcement of minimum national employment conditions standards in all sectors of activity. A plan of action against discrimination and xenophobia to sustain social cohesion. Institutional mechanisms for consultation and coordination with social partners in policy elaboration and practical implementation. Future Outlook Achieve mutually beneficial migration arrangements if reintegration programs are effective But we should not loose sight of more empowering and actions towards social transformation…. The State of the Nation’s Health: A Summary People’s health and welfare overall as the result of economic and political conditions Poor health outcomes, especially for the poorest Dysfunctional and fragmented health care delivery system Privatization as the state’s key health policy Systemic and worsening poverty and inequities urgently need to be address Migration… Everyday, more than 3,000 Filipinos are forced to work overseas - P480,000 (approx. US$ 8,900.) in government revenue daily. Labor export program commodifies and exports Filipino workers abroad As the national economic and political crisis intensifies – so too will the export of workers because of the increased dependence on dollar remittances and inability to create jobs in the Philippines Abuses against migrants range from contract violations, physical and mental abuses and death Assert People's Control Collective action to uphold and defend people's rights Health Land Living wages Social Equity Assert People's Control Rescind detrimental government policies What Needs to Be Done? Short Term/Immediate Intervention Increase wages Increase budget for health Hold national consultations with all stakeholders Improve regulation of medical and nursing schools Rescind commitments to General Agreement in Trade in Services (GATS) What Needs to Be Done? Long Term/Strategic Intervention Review the overall health care system Formulate a pro-people health policy and program Discontinue labor export policy Review and rescind WTO commitments Discontinue globalization policies (deregulation, liberalization, and privatization) Draw up independent political and economic policies Challenges ahead • Alma Ata vs. “Alana Ata?” • Social determinants of health • “Ethical” recruitment of nurses vs. labor export policy • Universal health care? Socialized health care? • Medical tourism and sale of organs • WTO and health as a matter of trade and investment • Globalization and health privatization Continuing advocacies • Health as a matter of right and state responsibility • Health in the framework of equity, not equality • Access to medicine as part of access to health • Health not just “the absence of disease” or adequate services but as a people’s overall well- being: economic, political, social, cultural • Health as a public service, not a business or trade investment • Health in the context of a truly independent and democratic society “Medicine has imperceptibly led us into the social field and placed us in a position of confronting directly the great problems of our time.” “For if medicine is really to accomplish its great task, it must intervene in political and social life. It must point out the hindrances that impede the normal social functioning of vital processes, and effect their removal.” Dr. Rudolf Virchow (1821-1902) “I don’t deserve to be treated like this. I care about my job, SIR. I care about you!!!" Sharon Cuneta Artist, “Caregiver” WHAT WE WANT Defend and Uphold People’s Right to Health Resist the Commodification of Health WTO OUT of Health WHAT WE WANT Health for ALL, Health in the Hands of the People Genuine Freedom and Democracy Migration… Does it bridge the north and south problem? Is it ethical? Should it be supported? Constrained? Regulated? HEAL. STRUGGLE. LIBERATE. Health Alliance for Democracy (HEAD) Council for Health and Development Maraming Salamat po….Thank you.
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