For decades, nurses from Asia have looked to hospitals in the US for a chance at upward mobility. Hundreds of thousands of people from countries like the Philippines, India, and China, aided by a nursing shortage in the US and special visas for migrant nurses, have sought to create new lives for themselves abroad, in the process dramatically transforming health systems in the US and their home countries.
But in recent years, hospital doors in America have started to close to foreign-trained nurses, opening instead in other parts of the world like the United Arab Emirates and Singapore. Meanwhile, countries that have provided generations of health workers for wealthier states continue to struggle with their own bare-bones health care systems.
The direction of global migration of health workers has historically been from low- and middle-income countries in Asia to high-income countries in North America and Europe. According to the the Organisation for Economic Co-operation and Development, the US has been the primary destination for migrant doctors and nurses, followed by the UK and Germany.
America has faced nursing shortages since the 1930s, when hospital usage increased and health care became more complex. Then in the 1980s and 90s, reduced Medicare reimbursements and the rise of managed care to control healthcare costs led hospitals to shrink budgets and lay off nurses. Nurses kept on staff faced longer hours and increased responsibilities, and the profession became less popular for young women.
This coincided with a growing demand for care for chronic illnesses as life expectancy rose. But since young Americans were uninterested in what had become seen as a bad career choice, hospitals began to rely on immigrants to fill the gap. In 1999, the US began to offer a special temporary work visa to nurses coming from abroad. Subsequently, the number of foreign-educated nurses passing the National Council Licensure Examination, a requirement to work in the US, more than quadrupled from 2000 to 2007.
The influx of foreign-born nurses not only helped the US healthcare sector to develop, it also changed the country’s demography; in 2009, Asian Americans surpassed Hispanics as the fastest growing racial group in the country. The Philippines has sent nurses to America since it was a US colony in the early 1900s; today, nearly one out of every five Filipino women in the US works as a nurse.
But now, those trends are shifting. While healthcare is expected to be the fastest growing employment sector in the US through 2024, according to the US Department of Labor, hospitals have increasingly looked inward for people to fill openings.
Nurses only need an associate’s degree or a certificate from a hospital program in order to practice in the US. However, many hospitals are now seeking registered nurses (RNs) with bachelor’s degrees. And while historically migrant nurses were more likely to have a bachelor’s degree than their domestic colleagues, that’s changing. In 2010, 69 percent of nurses born abroad had a college degree, compared to 53 percent of nurses born in the US. But the number of degree programs for nurses in the US has grown and enrolment has surged. In 2003, there were 529 programs in the US offering students a bachelor of science in nursing. Today, there are 883.
In December 2009, the temporary work visa program for foreign nurses expired. American nursing associations and labor unions pressed lawmakers not to renew the H-1C visa program for nurses, urging healthcare systems to develop a domestic workforce instead. Since then, the number of internationally educated nurses taking and passing the licensure exam in the US has declined sharply, dropping from nearly 23,000 in 2007 to just under 5,500 in 2015.
The changes in nurse demography in the US will have immediate and long-term consequences. President Obama’s Affordable Care Act gave millions of previously uninsured Americans greater access to health care, and many of the newly-insured come from immigrant communities who speak many different languages. Migrant nurses can offer cultural-competency that domestically educated nurses may lack. “Speaking another language and having this cultural sensitivity is extremely important,” says Jeanne Batalova, Senior Policy Analyst for the Migration Policy Institute based in Washington DC.
And in the long run, the US simply needs more nurses—from anywhere. Retiring baby boomers already drive a huge demand for healthcare, and many aging nurses are retiring (or will retire) with them. The World Health Organization (WHO) estimates that up to 40% of nurses in developed countries will leave employment by 2023, either due to retirement or for higher-paying jobs.
The nursing shortage is likely going to get worse across the world. With more people moving into cities, eating processed foods, and getting less exercise, incidences of chronic noncommunicable disease are on the rise. People are living longer, but they now need more medical treatment. The WHO estimates the world will be short 12.9 million healthcare workers by 2035. The need is greatest in sub-Saharan African countries, where just 3% of the world’s health workers bear 25% of the world’s disease burden.
WHO and other international advocacy groups also worry that the health workforce in countries like the Philippines that send nurses elsewhere are being bled dry.
The US may no longer want nurse migrants from the Phillipines. But plenty of nurses from the Philippines are still leaving home—they’re just not going as far. Between 1993 and 2010, the major destinations for Filipino nurses were the US, UK, and Saudi Arabia, according to the WHO. Since 2010, Singapore and the United Arab Emirates have emerged as the new primary destinations for migrant nurses.
In 2006, Singapore began formally recognizing licenses from other ASEAN member states like the Philippines. From 2010 to 2014, the number of overseas Filipino workers in Singapore doubled to 140,205. But although Filipino nurses may be closer to home in Singapore, they earn significantly less than they would if they had gone to the US; the median yearly income of an RN in Singapore is $27,100, compared to $58,371 in the US.
“Nobody can stand in the way of nurses moving around the world. It’s been a great way for people to share and to learn,” says Howard Catton, nursing and health policy consultant for the International Council of Nurses. “But in terms of how you plan and build your own workforce, self-sufficiency is the principal that we would encourage countries to aspire to.”
In 2010, WHO adopted a “Global Code of Practice on the International Recruitment of Health Personnel” to slow down the emigration of nurses from developing countries with fragile health systems. Though not legally binding, the Code suggests international standards for behavior and member states are obligated to consider its recommendations.
Those recommendations are a tough pill to swallow for nurses seeking foreign wages to send home. The Philippines’ biggest export, arguably, is its own people: remittances accounted for more than 10% of GDP in 2015. There have been local efforts to incentivize the country’s nurses to stay home: a law was proposed this past year to raise the base salary of nurses in the Philippines. But former president Benigno Aquino III stuck down the proposed legislation. And so the country’s healthcare system continues to hemorrhage talent.
“Who is left behind to provide the care? The best nurses—they’re leaving,” says Batalova. “That’s a problem for a country that has a large number of children and young adults. They need the next generation of nurses.”