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Implications of Labor Migration from the Philippines

JORGE V. TIGNO

Abstract

Globalization and the consequent increase in international migration impact on the health and weD-being of migrants and the populations of both the sending and receiving countries. Health care delivery systems may also be affected either positively or negatively. International labor migration is·a highly complex process with different dimensions that affect health in different ways. Migration health is the nexus between disease and other threats to physical well-bein& on one hand_

and human mobility on the other. Migration health can also refer to the well-being of communities that either send or receive migrants. The Philippine government must play a key role in upholding the right to health of Fi1ipino migrants even as it must work for counterpart programs on the part of the receiving country. The role of · civil society cannot be over emphasized

Keywords: globalization, migration health labor migration, Filipino migrants

Introduction

Globalization is broadly understood as the intensification and/or proliferation of cross-border flows and transnational networks. Altogether it is made up of a multiplicity of interactions, factors, and mechanisms "that lead to the establishment

VOLUME X NUMBER 1 (January- June 2006) 45

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

of transnational structures and the global integration of cultural, econom1c, environmental, political and social processes on global, supranational, national, regional and local levels" (Rennen and Martens 2003 as cited by Huynen, et al.

2005, 2). Table llists the hallmark features of globalization as identified by Huynen, et al. (2005). The emergence of global markets; increased cross-cultural interactions;

Table 1. Features of Globalization

New global governance structure

Global markets

Global communication and diffusion of information

Global mobility

Cross-cultural interaction

Global environment changes

Globalization influences the interdependence among nations as well as the nation-state's sovereignty leading to (a need for) new global governance structures.

Globalization is characterized by worldwide changes in economic infrastructures and the emergence of global markets and a global trading system.

Globalization makes the sharing of information and the exchange of experiences around common problems possible.

Global mobility is characterized by a major increase rn the extensity, intensity and velocity of movement and by a wide variety in types of mobility.

Globalizing cultural flows result in interactions between global and local cultural elements.

Global environment threats to ecosystems include global climate changes, loss of bio- diversity, global ozone depletion and the global decline in natural areas

Source: Table 2, Huynen, Maud, Pim Martens, and Henk BM Hilderink (2005), ·The Health Impacts of Globalization: A Conceptual Framework." in Globalization and Health, accessed at http://www.qlovlbalizationandhealth.com/contenU111114 in October 2005, p.5.

as well as the advent of advanced information, communication, and transportation infrastructures are promotive of migratory flows and resettlements. These factors and linkages have become the driving forces for transnational migration.

International migration is a phenomenon that affects a growing number of countries. It has reached proportions that inevitably generated serious implications for polities, societies, and economies. There are approximately 175 million people

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living outside their country of birth - almost 3 percent of the world population, roughly equivalent to 40 percent of the entire European Union (around 454 million) and almost double the total population of the Philippines. It is even larger than the population of]apan (almost 128 million). It is said that around 700 million people (including visitors on business or personal/family trips) cross nation-state boundaries (See Saker, et al. 2004 and Lee and Dodgson 2003) and one million per week move from less developed countries to the highly developed areas (See Garrett 2001). Many of these migrants come from or can be found in Asia (around 50 million) and almost half (48 percent) are said to be women. (Bach 2003, 2)

Global developments particularly in the fields of information/ communication and transportation technologies have allowed migration flows to flourish both at the domestic and international levels. Rapid improvements in transportation technologies have given more people (especially in developing countries like the Philippines) the opportunity to avail of cheaper transport and freight fares. Relatively faster and safer ways to travel by land, sea, and air have allowed more people to travel over greater distances in shorter periods of time. Moving one's place of residence and employment across borders is easily done now and can be compared roughly with simply moving from one city to another. Moreover, technology now allows for migrants to maintain their ties with families and friends at the country of origin thus minimizing the anxiety and pain associated with classical separation.

Rapid and extensive access to information via the Internet and the transnational media, among others, provide a growing number of people with an idea (at times untrue and exaggerated) of conditions in other societies and areas halfway around the world. People have become more aware of what they can expect in different economic, social, and political environments.

With rapid and extensive integration across economies and societies particularly between developed, highly industrialized and developing countries, migration can be expected to increase and intensify further. Linkages across borders will compel multinational corporations to hire workers in areas where they have investments as well as train them in the home office. At the same time, barriers to less skilled workers will be raised and border patrols intensified as a consequence of globalization.

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

The 1997-1998 Asian regional financial crisis illustrates the degree to which countries respond to perceived and real immigration and emigration flows. Newly industrialized countries in Southeast Asia such as Singapore and Malaysia have established more stringent barriers to immigration in their respective areas. Most affected are migrants coming from political strife-ridden Indonesia and crisis-plagued Philippines as well as the less developed countries of South Asia (e.g., India, Pakistan, and Bangladesh).

From the increased border crossings of knowledge, capital, goods, and most of all persons, a number of issues have emerged that radically affect both the sending and receiving areas.

Population pressures, social and political uncertainties, as well as growing relative poverty have become the primary motivation for hundreds of thousands of Filipinos to leave the country in search of better opportunities elsewhere. As more and more people move (aided in no small way by global forces and structures), a number of migration-related issues have now become more magnified and to some extent become acute. The health situation of migrants or migration health is one such issue that deserves serious consideration not only by the governments of destination areas but also by the countries of origin.

This paper will focus specifically on the impact and implications of global mobility, a distinctive feature of globalization, on health concerns obtaining in the Philippines. This paper is about the implications derived from the large-scale out- migration oflabor from the Philippines on health and well-being of migrants, their families, as well as that of the populations in both the sending and receiving countries.

This paper underscores the health risks faced by migrants leaving the Philippines for overseas employment. It also provides a backdrop for understanding the health concerns facing authority-holders in both sending and receiving countries.

More specifically, this paper will (a) provide a brief review of the relevant literature on migration health so as to provide clarity of analysis in the context of Philippine experience; (b) trace or outline the key issues and concerns pertinent to the subject of migration health currently obtaining in the Philippines; and (c) recommend the most likely alternatives and policy options to address these issues and concerns. The presentation begins with the dynamics of international labor

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migration and the extent to which such movement has been made even more complex and transnationalized by global forces.1 This is followed by a discussion of the implications of labor migration on health, as well as the health care issues and concerns of Filipino migrant workers. And, finally, a number of policy options are suggested for consideration both by authority-holders and by civil society groups.

International Labor Migration

For purposes of this paper, a migrant worker is one who seeks, is employed or has been actually employed overseas on a contractual or temporary basis, which can be conceptually differentiated from a permanent migrant (immigrant) or refugee or tourist although the distinctions are not mutually exclusive. A tourist or refugee can first become a migrant worker and ultimately become a permanent immigrant or settler. The term migrant worker will be used throughout the paper although the popular literature in the Philippines (particularly in the mass media) would often refer to them as overseas contract workers (OCWs) which is often used interchangeably with Filipino migrant workers (FMWs) or Filipino overseas workers (FOWs).

Human migration is a complex process. In order to develop a simple and coherent framework, a distinction must be made between regular or documented migration and irregular or undocumented migration.2 The World Health Organization (WHO) identifies regular migrants, on the one hand, to be those

"people whose entry, residence and, where relevant, employment in a host or transit country has been recognized and authorized by official State authorities" (WHO 2003, 9). On the other hand, irregular or undocumented migrants are those "people who have entered a host country without legal authorization and/or overstay authorized entry as, for example, visitors, tourists, foreign students or temporary contract workers" (WHO 2003, 9). Human smuggling falls under irregular , migration. It is contended that labor migration can involve both regular and irregular procedures.

In addition to the distinction between regular and irregular migration, there is also the distinction between forced and voluntary migration. Voluntary migration

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A Policy Paper on the Health Implications of labor Migration from the Philippines

Migration health has many dimensions. In immediate terms, migration health can refer to the state of

"physical, mental, and social well being and not merely the absence of disease or infirmity" of migrants.

4

Migration health can also

refer to the well-being of communities that both send

and receive migrants (including the families of migrants).

involves the movement of "people who have decided to migrate of their own accord (although there may also be strong economic and other pressures on them to move)" (WHO 2003, 9).

Involuntary or forced migration refers to the movement or displacement of persons due to war, environmental disaster, famine or state development projects (See WHO 2003). Also included under forced migration are situations that allow for deception or coercion of the person to move such as the trafficking in human beings.3 Voluntary migration generally involves labor migration although it is possible for a migrant to move voluntarily initially and later on to be forced by circumstances beyond the person's control to continue to stay and work (albeit under inhuman working conditions).

In any case, it is argued that the extent of the impact on and implications to the health of migrants is affected by the type of migration that takes place (i.e., whether it is forced or voluntary, or whether it is documented or undocumented).

The nature of the health problem to be experienced by the migrant will depend principally on the person's status (e.g., documented or undocumented) and also on the motivation to move (e.g., willful or deceived or forced).

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What is migration health?

Health refers to a state of physical as well as mental well-being of a person. It also involves security from epidemiological threats such as diseases that constitute the primary threats to one's well-being and wellness.

Wheras most studies on migration emphasize the goal and process of maintaining the integrity and security of borders from unauthorized crossings and intrusions, migration health is where epidemiology meets demography. It is the nexus between disease and other threats to physical well-being, on the one hand, and human mobility, on the other. It is one that takes into account the state of well- being of people who have moved as well as those people indirectly affected by the movement. Migration health has many dimensions. In immediate terms, migration health can refer to the state of "physical, mental, and social well being and not merely the absence of disease or infirmity" of migrants.4 Migration health can also refer to the well-being of communities that both send and receive migrants (including the families of migrants).

The Migration Health Department of the International Organization for Migration (IOM) is tasked to respond "to the needs of individual migrants as well as the public health needs of host communities through policies and practices appropriate to address the challenges facing mobile populations today" (See IOM website at http://www.iom.int). Moreover, the concerns of this IOM Department

"covers infectious disease control, emergency interventions, chronic diseases, mental health, particular cultural and health concerns, human rights issues,.migration health management and many other issues that affect the health of migrants and the communities they live in or transit."

For all the quantitative and qualitative significance of transnational migration as a whole, not much emphasis is given neither to acknowledging nor to acting upon migration health issues and concerns. There are several reasons . Carballo and Mboupa (2005) suggests these reasons to be the following: '

The first and most important may be the fact that the pace of contemporary migration has outstripped the capacity of countries not only to respond but indeed to even keep pace with and acknowledge the growing scope and

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

nature of cross-border migration. The second is that to acknowledge the health needs and problems of migrants is to some extent to recognize li- ability and responsibility. This, in an international context where the cost of health care is becoming a universal problem, may well be an important reason why countries have been reluctant to confront the issue of migration and the health care of migrants. A third reason is that surrounding the phenomenon of migration is the myth that all migration is ultimately suc- cessful and that in the final analysis everyone stands to benefit. While this may be true from a structural-functionalist perspective, the reality is that migration is (and probably always has been), characterized by relatively massive human wastage in terms of avoidable illness, injury, neglect and mortality. (Carballo and Mboup 2005, 13)

Health Implications of Human Mobility

Globalization has made it possible for "people and microorganisms" to mix at

"an unprecedented scale" (Glasgow and Pirages 2001, 196 as cited by Koehn 2006).

The increased and large-scale mobility of people across borders has either reintroduced old infections or introduced new strains of old diseases in destination areas. Some of the more recent examples are the rapid transcontinental transmission of Severe Acute Respiratory Syndrome (SARS) and the Acquired Immune Deficiency Syndrome (AIDS) caused by HIV as well as the impending pandemic threat of the avian influenza (H5N1 virus). Such public health issues can have serious consequences both for the migrant as well as the non-migrant populations.

In this regard, Director Antonio Amparo of the Bureau of Quarantine states that-

Infectious microbes can travel quickly from one country to another - in people and in commercial products - within hours, and new diseases like SARS, Marburg and Ebola, West Nile and new forms of old diseases, like drug-resistant malaria and Tuberculosis and influenza [including the present avian influenza], can emerge in one region and spread throughout the world ... As travel and trade (including tourism) become increasingly global, new infectious diseases are also increasingly able to spread and make a

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worldwide impact [and the] ... migration of humans has been the pathway for disseminating infectious diseases.5

Certainly, globalization is seen to be an important context and driving force behind the persistent and prevailing health issues and concerns confronting many countries today (see Huynen, et al. 2005). The impacts of globalization on transnational labor migration are essential to understanding the persistent as well as emerging trends and concerns in regard to the health and well-being of migrants.

The literature is consistent in identifying the different health dimensions of mobility, i.e., the existing medical condition during pre-departure; the health problems during migration; the health issues arising after arrival; and the health consequences of return travel (Gushulak and MacPherson 2006 and 2000, 68; and see alPHa 2003, 9; McKay, et al. 2003; and Bhugra and Jones 2001, 216). Thus, the migrants' health conditions are affected by their (a) preexisting health situation or their health status at the point of origin; and (b) acquired health problems that result from the actual journey and arrival and adjustment in their new environment (See Carballo and Mboupa 2005).

Favorable outcomes can materialize when a migrant moves to an area where preventive health services are more accessible or widespread than in their country of origin. At the same time, such positive effects can also be felt by the receiving country especially when the migrant is a skilled (or more so if he/she is a health care) professional.

Adverse health outcomes among migrants arise out of situations in which persons are made vulnerable to contracting diseases in the course of the journey or upon their arrival such as exposure to unsafe working conditions, harmful occupational practices (such as unprotected sex or under-aged sex). (See Simonet 2004; Loutan 2002; Gushulak and MacPherson 2000; Carballo, et al. 1998; Diallo 2004; and

Bach 2003)

.,

In addition, other factors that can affect the state of migration health are: (a) legal status~ (b) the job category of the migrant; and (c) the package of policies being implemented by the government in the receiving country. 6 The extent and nature of the health problems and risks can vary depending on whether the migrant

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

is undocumented or legal and whether the work involved is labor-intensive or sexual, in nature. The impact and implications of migration health can also be both negative and positive depending on the policies in both the sending and receiving areas. By and large, the policies that have been observed and applied (especially in receiving countries) is one that can be considered restrictive, complicated, difficult, and unattractive which may eventually produce unintended consequences that are detrimental to the health and well-being of the overall population (See Carballo and Mboupa 2005). Furthermore, Carballo and Mboupa (2005) state that-

The type of work people are expected to perform once they arrive, the physical and housing conditions available to them, the access (perceived or real) they have to health and social services . . . and the extent to which they are able to remain in contact with family are important determinants of health and well being. Language skills and familiarity with the culture of the host community also play an important role in determining health outcomes (Carballo and Mboupa 2005, 4).

The Extent of Labor out-migration from the Philippines

The level oflabor out-migration from the Philippines is as extensive as a large- scale sending country. Indeed, it is not impossible to imagine the Philippines ranking third after China and India, with the largest migrant population worldwide. Stock estimates (i.e., the estimated number of actual Filipinos abroad) compiled by the Commission on Filipinos Overseas (CPO) as of December 2003 indicate that there can be as much as 7.9 million Filipinos living abroad with roughly 3.38 million being migrant workers as indicated in Table 2 . What is significant to note in the estimates is that the number of irregular or undocumented migrants is said to be around half the size of the regular or temporary migrants. The largest number of temporary migrants is currently located in West Asia or the Middle East (e.g., Saudi Arabia, Kuwait, etc.) followed by East Asia (e.g., Hong Kong, Singapore, Japan, South Korea, and Taiwan).

If the above estimates were accurate, the total stock population of migrant workers would be roughly equivalent to four percent of the country's total population.

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However, based on the 2000 Census of Population and Housing by the National Statistics Office (NSO), the number of overseas workers is at 992,397 or roughly equivalent to 1.3 percent of the national population (Ericta, et al. 2003, 2).

The discrepancy may be due to the inability or unwillingness of those asked in the census to expose their relatives working abroad for various reasons. Still the census figures are substantial.

Table 2: Stock Estimates of 0 verse as Filipinos By World Region As of December 2003

REGION I COUNTRY PERMANENT TEMPORARY IRREGULAR TOTAL

WORLD TOTAL 3,074,429 3,385,717 1,515,688 7,975,834

AFRICA 318 53,706 16,955 70,979

ASIA, East & South 85,570 944,129 503,173 1,532,872

ASIA, West 2,290 1,361,409 108,150 1,471,849

EUROPE 165,030 459,042 143,810 767,882

AMERICAS/ 2,386,036 286,103 709,676 3,381,815

OCEANIA 226,168 55,814 31,001 312,983

AUSTRALIA 209,017 716 2,923 212,656

Regions Unspecified 8,767 8,767

SEABASED WORKERS 216,031 216,031

Prepared by the Commission on Filipinos Overseas from CFO, DFA, POEA and other sources covering 1 92 countries I territories.

Legend:

Permanent- Immigrants or legal permanent residents abroad whose stay do not depend on work contracts.

Temporary - Persons whose stay overseas is employment related, and who are expected to return at the end oft heir work contracts.

Irregular - Those not properly documented or without valid residence or work permits, or who are overstaying in a foreign country.

As with global trends, more recent figures indicate that a significant number of Filipino migrant workers are women. Table 3 shows the male-female ratio for newly

#"

hired migrant workers to be 1 to 2. Meanwhile, the NSO data on overseas employment by sex reveals that the ratio is almost even with the males (50.27 percent for males and 49.73 percent for females) (Ericta, et al. 2003, 2). There is

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

an indication that the number of women migrants is increasing at a faster rate than that of the men.

Table 3. 0 eployment of Newly Hired Migrant Workers by Gender (2002)

Gender TOTAL Percentage

Female 199,423 69%

Male 88,732 31%

F/MRatio 2

Total 288,155

Source: Philippine Overseas Employment Administration Statistics accessed at: http://www.poea.gov.ph docs/Deployed% 20New%20Hires%20by%20Skill%20and%20Sex.xls in July 2005.

Migration involves a highly selective process. Filipinos who work abroad tend to comprise the highly productive and highly educated portion of the local workforce and overall population. About four in five Filipino migrant workers have completed high school education while 50 percent have had some years of college education prior to going abroad. In contrast, only 20 percent of locally employed Filipinos have actually completed high school (See Carino 1992). Around 50 percent of these Filipino migrants are in their early 20s and 30s while this age-group comprises only 25 percent of the total local population (See Stahl1986).

Moreover, quite a number of these Filipino migrant workers have had at least two years of local work experience prior to overseas employment. Many are married while most (if not all) have sought overseas employment in order to support a family or some family members back in the Philippines. Many are employed doing construction-related and production (i.e., manufacturing) work while a substantially growing number are involved in services (e.g., domestic work, entertainment, health, etc.).

The significance of labor migration from the Philippines is underscored by the fact that billions of dollars from the incomes of migrant workers overseas are sent back to the country from all over the globe. In 1982, remittances from migrants overseas totaled more than US$ 810 million. Ten years later, these remittances

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reached more than US$ 2 billion. By 2000, remittance inflows to the Philippines reached more than US$ 5 billion annually as seen in Table 4.

Table 4: OVERSEAS FILIPINO WORKERS FOREIGN EXCHANGE REMITIANCES (1984- 2000 In US$Millions)

YEAR LAND BASED GROWTH RATE

1982 642.34 67.43

1983 660.08 2.76

1984 472.58 -28.41

1985 597.89 26.52

1986 571.75 -4.37

1987 671.43 17.43

1988 683.31 1.77

1989 755.19 10.52

1990 893.4 18.3

1991 1,125.06 25.93

1992 1,757.36 56.2

1993 1,840.30 4.72

1994 2,560.92 39.16

1995 4,667.00 82.24

1996 4,055.40 -13.1

1997 5,484.22 35.23

1998 4,651.44 -15.19

1999 5,948.34 27.88

2000 5,123.77 -13.86

Q1 2001 1,081.66 -21.82

• Source : Bangko Sentral ng Pilipinas (BSP). May not add up to totals due to rounding off.

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

current Data on the Health Problems of Filipino Migrant workers

The body of literature on Philippine migration is certainly quite extensive in the areas of examining the socio-economic impacts of transnational population movements; the family; women migration; and migration policy discourses. (See Asis 1995; Battistella and Paganoni 1992; CIIR 1987; and Gonzalez 1998).

However, there appears to be limited attention given to migrant health concerns.

Despite several glaring realities (e.g., the feminization of Philippine migration;

the high degree of population mobility brought about by developments in information, communication, and transportation technologies), there continue to be gaps between what is known and unknown in current Philippine migration health studies. This may be due in part to the estimated large number of undocumented migrants which can adversely affect any estimate of the actual population.

At the same time, actual interventions at the official I governmental level are not yet extensively tuned to the impacts and implications of migration health. In a forum on global health issues and international labor migration held in September 2001, the Overseas Workers Welfare Administration (OWWA) data on migration health was limited to health or medical problems experienced by migrant workers and their dependents who filed claims or requests for financial assistance. There has not been any systematic attempt to generate large-scale data on migration health in the Philippines much less their implications on the rest of society. At best, there are anecdotal evidences but not really enough to identify the state of migration health in the country.

Health concerns associated witll labor migration from the Philippines

This paper takes off from the framework used by Gushulak and MacPherson to describe the impact of different environments and the phases of human mobility on health.

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Filipino migrant workers are vulnerable to health risks. The extent and nature of the health problems and risks that migrant workers are exposed to are quite extensive. In general, the two major dimensions of physical health are those that are communicable and non-communicable. Communicable diseases include tuberculosis (TB); hepatitis B and C; schistosomiasis; malaria; sexually transmitted diseases (STDs) such as syphilis and HN/AIDS. Of particular concern to countries that both send and receive migrants is the alarming spread of AIDS/HN as well as the avian influenza and SARS.

Non-communicable diseases can be classified into organic disorders (e.g., asthma, cardiovascular problems, pulmonary dysfunction, hypertension, stroke, diabetes, oral or dental health, reproductive health problems; cancers; etc.);

substance abuse (migrants may be coerced by the trafficker to assist in the illicit drug trade; isolation and family separation may lead to increased risk of substance abuse); occupational illnesses (due to unsafe and dangerous working conditions including risk of exposure to occupational injuries or toxic materials); sexual abuse (especially among commercial sex workers which can lead to sexually transmitted diseases); and psychosocial or mental illnesses that can lead to schizophrenia, depression, or even suicide) (See Gushulak and MacPherson 2000; Simonet 2004;

and Carballo, et al. 1998).

Another dimension of migration health involves the (inward or outward) migration of health professionals. Losing a part of the health workforce can "result in either an absence of some services or in professionals' having to adapt their roles to deliver services commonly outside their scope of practice" (Stilwell, et al., 2003 ).

A related dimension to this would be migrants' access to health care services. The extent of access to health care services can have an effect on the early detection of certain illnesses whether they are communicable or not.

The implications of migration health cannot be underestimated. For instance, the migration of female migrants can cause the emergence of repr.oductive health issues including sexually transmitted diseases (STDs). The clandestine migration of workers can lead to problems with regard to occupational health and access to health care services in the country of destination. Another critical health concern is the mental stability of migrants as well as the children left behind. Migrants can be

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

exposed to numerous health risks that can lead to serious implications later on for the Philippines in general as well as for their relatives left behind in particular. By and large, the movement has made migrants more susceptible or vulnerable to health risks that could very well be prevented given alternative circumstances and responses from the authorities concerned.

At the same time, income remittances from professional migrants (especially those belonging to the health care sector) may compensate for the sending country's economic imbalance temporarily. However, the long-term effect is that (unless they are properly reinvested in health care human capital formation) countries that continue to send their health professionals abroad more than what they are able to receive or train locally "will end up with a net loss of human capital in the health system ... and [which] could have serious implications for coverage of and access to services in developing countries." (Stilwell, et al. 2003)

For purposes of descriptive simplification, health concerns may be classified into four types. Communicable diseases are classified as Type I health concerns while the non-communicable diseases are Type II concerns. Type II concerns largely refer to mental health problems. However, this does not disregard the importance of other related migration health areas of concern including occupational health problems and substance abuse problems which are considered as life-style and work- related concerns. The paper presumes that the issues of occupation health and substance abuse can be the causes and effects of mental health disorders among migrants. Type III concerns are those involving reproductive health issues which can be communicable (e.g., STDs) and non-communicable problems (e.g., sexual abuse). Type IV concerns would be those that have to do with the health care delivery system including (a) the migration of health care professionals and (b) migrants' access to health care services particularly in the country of destination.

This typology (Figure 1) is certainly not exhaustive but only serves to highlight some of the key concerns pertaining to migration health from the Philippines.

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Figure 1: Typologies of Migration Health Concerns

Mental Health

1 schizophrenia

1 substance abuse problems

1 eating disorders

.. . . . ..

···~~~

Type II

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Communicable Diseases

tuoercu1os1s hepatitis B and C schistosomiasis malaria

avian influenza SARS.

etc .

.. . . . .. . . . ..

: Type I :

···~~~

. .

: Type Ill :

.

:

...

Reproductive Health

STDs

sexual abuse

(] anuary- June 2006)

Health Situation

access to health services migration of health professionals

...••••....•

. .

: TypeiV

61

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

Type 1 Migration Health concerns- communicable Diseases

Infectious diseases constitute a serious area of concern not only in terms of maintaining migratior1 health but also in bringing about the well-being of the overall population. According to Director Antonio Amparo of the Bureau of Quarantine

"every hour, infectious diseases take more than 2000 lives."7 As discussed above, the advent of contagious diseases is affected by (a) the conditions within which the migrant lived prior to the journey and (b) the conditions in the country of destination.

In general, migrants move from poor health (as well as socio-economic) conditions to better health situations. Such a movement can have an effect upon the country of destination especially so if the migrant has been exposed to communicable or contagious diseases in the country of origin.

However, the situation may not be simple as it appears. Conditions within the receiving country (including the government's policies) may aggravate the weak health conditions of migrants and the surrounding population. Where overcrowding is common and the living as well as working conditions are poor or inadequate, infectious diseases such as TB may arise and spread. Nevertheless, microbes and other biological organisms do not stop at the border. These organisms accompany the billions of people that cross borders each year. Director Amparo asserts that

"organisms that survive primarily or entirely in the human host that are spread either through sexual contact, droplet nuclei and close physical contact can be readily carried to any part of the world in hours." Tubercolosis, for instance, is one contagious disease that has the potential to affect many travelers. Director Amparo states that -

International travelers today need to be aware ofTB because travel may increase the risk of contracting TB for two reasons:

they are more likely to visit countries where TB is prevalent; their mode of transportation is frequently a confined area (such as an airplane), where they potentially share air space with someone

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who has TB. Although health officials stress that TB is more commonly transmitted from repeated daily exposure, documented cases of transmission while in the aircraft has been reported. 8

Two emerging and also serious contagious diseases are the severe acute respiratory syndrome ( SARS) and the avian or bird influenza virus that has appeared in China, Vietnam, and Thailand. Countries like the Philippines continue to seriously look out for the entry or emergence of these two diseases and to prevent them from

The prevalence of young migrant women from the Philippines strongly underscores the importance of reproductive health concerns. In this paper, these types of concerns have to do with pregnancy-

related issues as well as problems associated with STDs especially among women. It also relates to satisfying and safe sex and the capability to reproduce as well as the freedom to decide on when and which contraceptive method to use.

entering the country. However, given the number of migrant workers (including tourists and other travelers) that enter and leave the country each day, it is a difficult task to continue monitoring migrants and travelers for symptoms of SARS and avian influenza.

Irregular migrants arrive via irregular or illegal channels. As such, they have not gone through the typically highly selective process of immigration screening and "more likely to have those characteristics associated with the risk factors for greater disease potential" including the risk of acquiring and spreading contagious diseases ( Gushulak and MacPherson 2000, 69).

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

Type 11 Migration Health concerns- Non-communicable Diseases

The World Health Organization (WHO) has argued that the mental health of immigrants and refugees are serious areas of concern. Although not much is known about the exact mental health conditions of migrant populations, there is some evidence to suggest that severe psychological stress may be due to uprooting, disruption of family life and a hostile social environment typical in the life of the migrant. Moreover, a significant proportion of migrants have little or no access to mental health care, either because they are excluded from existing service arrangements or because such services do not exist in many countries. (See UNDESA 2005 and Loutan 2002)

The labor migration process is one that is highly selective in the sense that it greatly favors either men or women but not both and certainly not with their families.

It has been increasingly observed in the Philippines that children are typically left behind with either friends or relatives or grandparents. This development can have serious implications for all concerned - the migrants, the surrogate parents, and especially the children- as far as mental health is concerned. Carballo and Mboupa (2005) have observed that even when family reunification occurs it is rarely easy for the partners or the children to be reconciled (Carballo and Mboupa 2005, 5).

Due to the complicated and selective nature of the migration process, certain psychiatric or mental conditions can be highlighted in dealing with the issue of migration health. These include schizophrenia and other common mental disorders such as the likelihood to entertain suicidal thoughts and initiate self-harm;

alcoholism; insomnia; eating disorders; and post-traumatic stress disorder. (See Bhugra and Jones 2001; McKay, et al. 2003; and Carballo, et al., 1998)

The factors that might mitigate such mental conditions in migrants include the absence or presence of social support networks; proximity with other members of the same ethnic group; and early detection and diagnosis. (See Bhugra and Jones 2001 and Carballo, et al., 1998). The mental stress and psycho-social problems are magnified as a result of the other compounding elements in the migration process itself. The decision to move is usually accompanied by a certain fear of what is still largely unknown in the area of destination (despite the attractiveness as well as the

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economic and material opportunities it may eventually bring about). This fear is made even worse by the status of the migrant upon arrival. The clandestinity associated with the attempt to circumvent established legal procedures and mechanisms including payment for the complicity of corrupt government officials and organized crime groups adds to the overall feeling of uncertainty that can have serious effects on the mental well-being of the person concerned.

Ms. AndreaAnolin of the Batis Center for Women acknowledges that "there is a gap in research concerning the prevalence of mental health problems among women migrant workers" and because of these gaps, existing policy responses may be insufficient or inappropriate.9 The case of Filipino women migrant workers is a serious area of consideration as far as Type II migration health is concerned. In particular, these are the women migrants who work as (a) domestic helpers in Hong Kong, Singapore, Malaysia, Saudi Arabia, Kuwait, among other countries of destination and (b) entertainment workers primarily in Japan. Ms. An olin states that 90 percent of the Filipino women migrants to Japan are entertainment workers while a few are married to Japanese men and where the marriage is seen largely as an economic transaction.

Ms. Anolin also observed that women migrants are exposed to a number of abusive living and working conditions that eventually lead to some degree of psychological instabilities. During the process of resettlement, migrant women experience difficulty in adjusting to the culture and language of the country of destination. Loneliness and homesickness are common.

These social difficulties are aggravated by work-related problems. Ms. Anolin asserts that "in Japan employment contracts are honored more in the breach than in compliance"; the women are not properly informed about the nature of the work they will perform as well as their compensation and benefits (all too frequently a certain portion is deducted from the salaries of the women); employers are abusive and cruel; and there is competition from other entertainment worker~ 10 In addition, women who are trafficked are likely to be prostituted against their will. The migrant women are also sexually harassed and abused (at times raped). For those married to Japanese men, reports of domestic violence are not uncommon.

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

As a result, it is not surprising to find migrant women who are depressed, have an acute sense of persecution, incoherent, and sometimes they hallucinate. These problems manifest themselves in a number of ways including suicidal tendencies, eating disorders, substance abuse, and extremes of emotions. 11 Not only are the

migrants themselves at risk with respect to mental health disorders but so are the families left behind, including the children of the migrants.

Type 111 Migration Health concerns- Reproductive Health

The prevalence of young migrant women from the Philippines strongly underscores the importance of reproductive health concerns. In this paper, these types of concerns have to do with pregnancy-related issues as well as problems associated with STDs especially among women. It also relates to satisfying and safe sex and the capability to reproduce as well as the freedom to decide on when and which contraceptive method to apply.

The increasing demand for women to migrate forms much of the context for the reproductive health dimension of migration health. The types of jobs taken by migrant women from the Philippines also impact on reproductive health. Many are employed in the entertainment sector which is prone to prostitution. In a survey by Unlad Kabayan, about one-third of the migrant women respondents said that they had experienced reproductive health problems abroad.12 The common problems experienced are: dysmenorrhea, irregular menstrual period, abnormal vaginal discharge, painful urination, painful intercourse, dizziness, vomiting, and! or weight gain after missed menstruation, high blood pressure during pregnancy, ectopic

d b . 13

pregnancy, an spontaneous a ortton.

Several reasons were cited by the respondents in the Unlad Kabayan survey for why they do not seek reproductive health care services. These include problems with language communication; the desire to engage in self medication with medicines sent from the Philippines; the fear of being caught and deported for undocumented migrants; the objection of employers; and the desire to continue sending money back to the Philippines. Almost all are aware of the dangers of STDs including HNI AIDS. However, not that many take the necessary precautions to prevent the

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contraction and spread of SIDs. Only one in five migrant women are said to use contraceptives. The stigma attached to SIDs and HIV/AIDS can also be a problem in so far as dealing with such diseases upon return are concerned. Families may wish to hide their migrant members or choose not to report such cases to the authorities. As a result, many such cases tend to go unreported and can even aggravate the health situation of the country upon the return of the migrants.

Type IV Migration Health concerns- Health care services and Professionals

Access to Health Care. Health care services refers to the set of services and methods that contribute to the overall well-being and health maintenance of the overall population in general and the migrants in particular. This includes preventive care and health services related to the detection and treatment of illnesses. The absence or lack of viable health care services in the Philippines can be an inducement for Filipinos to migrate. It is not uncommon for Filipinos to migrate in order to generate enough income to pay for the health care needs of a loved one.

There is evidence to suggest that "migrants may sometimes be reluctant to assert their rights and stop short of availing themselves of the health services they are entitled to for reasons that are not totally clear but may range from language problems and lack of information to cultural gaps and various forms of discrimination." (UNDESA 2005)

Migrants (whether legal or irregular) continue to have "limited access to health services due to a number of cultural, linguistic, and structural reasons [which] ...

may affect the recognition and treatment of illness." (Gushulak and MacPherson 2000, 69; and see Simonet 2004) In not a few cases, undocumented migrants are also prevented from availing themselves of government services by their own employers. Access to adequate health care on the part of migrants is "compounded by more limited access to health information, health promotion,"health services and health insurance." (UNDESA 2005)

The policies and practices of governments particularly in receiving areas effectively make the migrants' lives "more insecure and risky from a health

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

perspective" (Carballo and Mboup 2005, 13). The denial or limited access (whether intentionally or unintentionally) on the part of government health care services to migrants "have also contributed to a worsening of the health of migrants and the larger public health of the countries concerned" (Carballo and Mboup 2005, 1.3).

Availing of health care abroad is also seen as too expensive particularly among those undocumented or irregular migrants who are not likely to carry health insurance.

Trafficked persons are often afraid of interacting with official systems that provide basic social services even if such

services are made available without cost for fear that they will be reported to immigration authorities. (Gushulak and MacPherson 2000, 72) In all of this, state policy is significant. Toyota (2003) argues that-

... the state can be an obstacle to rather than the provider of public health services in the case of the 'floating population,' or 'un-authorized' migrants. It is entitlement and/

or empowerment which determine access (or non- access) to economic, social, and political resources that avert vulnerability. (2)

The irregular status of the migrants may not allow them to readily seek and obtain medical care. Their precarious financial and legal situation can preempt their ability to pay for health care. This in

There is a need to address the looming crisis in human health resource because of migration. Human health resource development must be rationalized in the light of demand for health services in other countries and our national needs.

One option to limit the outflow of health care professionals is by way of a quota system. Training programs must be

designed so that the role of other health

professionals can be

expanded to substitute for

doctors in underserved

areas.

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a sense will force them to seek medical care by other means which may not be as reliable and are in fact dangerous (Gushulak and MacPherson 2000, 72).

Migration of Health Professionals. Migration health is also affected by the nature of the migration process that takes place such as the outflow or inflow of health professionals. The categories of health care workers affected by migration are diverse and can include "physicians, specialists, nurses, paramedics, midwives, technicians [e.g., X-ray technicians, laboratory technicians], consultants, trainers, health management personnel, [dental hygienists, physiotherapists, medical rehabilitation workers], and other professionals." (Chanda 2002, 159) Accompanying the significant rise in transnational migration is "the increase in skilled labour migration" many of whom are "health -care professionals in search of better pay and enhanced career opportunities to work in other countries." (Bach 2003, 2 and see Chanda 2002)

The migration of health care professionals from the Philippines is not a new phenomenon. During the mid -197 Os, a total of 13,480 physicians were working in the Philippines compared to 10,410 Philippines-trained physicians who were employed in the United States. (Goldfard, et al. 1984, 1-2 as cited by Bach 2003, 4) The out-migration of health professionals from the Philippines is due mainly to the low wages for such professionals combined with the growing demand abroad.

According to Dr. Rodel Nodora of the Planning and Standards Division of the Health Human Resource Development Bureau (HHRDB), the Department of Health (DOH), roughly eight percent of the country's labor force is comprised of health human resources. According to the National Statistical Coordination Board (NSCB) and the Commission on Higher Education ( CHED), the country currently has some 350 nursing colleges, around 30 medical schools, 129 midwifery schools, 31 dental schools, 35 pharmacy colleges, 95 colleges for physical and occupational therapists (0T/PTs).14 These training and education institutions tum out tens of thousands of medical and health professionals each year, ~

The Philippines has certainly become a major source of health-care professionals worldwide. More than 70 percent of the 7,000 nursing graduates each year leave the country despite the existence of an estimated 30,000 unfilled nursing positions in the Philippines (Corcega, et al. 2002, 3; Adversario 2003; and OECD 2002,75

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

in the Philippines (Corcega, et al. 2002, 3; Adversario 2003; and OECD 2002, 75 as cited by Bach 2003, 4). Table 6 provides a list of the number of health care professionals trained in the Philippines and how they are currently deployed as of 1998. A significant portion of nurses (more than 39,000) are actually practicing abroad. The country is presently one of the largest source markets for nurses, occupation and physical therapists (OT/PTs), and medical technicians.

Table 7 illustrates the extent to which the number of health care professionals working abroad has been growing rapidly over the last 10 years. As of 2003, there were almost 9,000 nurses and almost 5,000 OT/PTs working abroad. The leading countries of destination for Filipino nurses are Saudi Arabia, the US, and the United Kingdom together making up almost 85 percent of the total deployments for theperiod as seen in Table 8. This outflow of health human resources from the country seriously hampers the capacity to provide for adequate local health care.

This health outflow is aggravated by the inequitable distribution of health care professionals who are concentrated in the urban areas.

Table 6. Stock Distribution of Health Workers Produced in the Philippines as of 1998

Government Abroad Private Others Total

Nurses 9778 39174 nd 214959 263911

Dentists 1963 242 10513 18320 31038

Doctors 7671 495 18425 38546 65137

Pharmacists 229 302 nd 28324 28855

Midwives 15893 1196 nd 103412 120501

MedTech 1560 2090 nd 27396 31046

OT/PT 76 3300 nd 2602 5978

Source: Table 1 of the Presentation of Dr. Rodel Nodora of the Planning and Standards Division of the Health Human Resource Development Bureau (HHRDB) under the Department of Health (DOH) during the "Second Global Health Forum on International Labor Migration From the Philippines," 18 October 2005, Foundation for Integrative and Development Studies (FIDS}, World Health Organization (WHO), and the Department of Health (DOH), ISSI Bldg., UP Diliman

Ultimately, the migration of health workers contributes to the problems faced by health care systems in sending countries including the Philippines. Although it

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1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Total

Doctors 86 91 57 69 47 82 63 59 27 61 129 112 883

Dentists 27 22 38 48 36 52 19 56 33 57 62 40 490

Nurses 5788 6739 6853 7597 4698 4282 3217 5413 7683 13536 11867 8968 86641

Pharmacists 52 32 32 54 57 42 33 55 30 64 57 74 582

Medtechs 312 329 302 270 247 343 287 nd nd nd nd nd 2090

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Midwives 246 295 126 161 142 113 113 66 55 190 312 276 2095 uo·

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Ot!Pt 542 608 645 581 426 289 209 147 235 330 517 371 4900

Year ToTal 7053 8116 8053 8780 5653 5203 3941 5796 8063 14238 12944 9841 97681

Source: Table 2 of the Presentation of Dr. Radel Nodora of the Planning and Standards Division of the Health Human Resource Development Bureau (HHRDB) under the Department of Health (DOH) during the "Second Global Health Forum on International Labor Migration From the Philippines," 18 October 2005, Foundation for Integrative and Development Studies (FIDS), World Health Organization (WHO), and the Department of Health (DOH), ISS I Bldg., UP Diliman.

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A Policy Paper on the Health Implications of Labor Migration from the Philippines

does contribute positively in terms of addressing shortfalls or shortages in health personnel in receiving countries (and hence contribute to the further improvement of their respective health care systems), the brain drain that underpins this kind of migration has had an adverse impact on many sending countries. Although the number of migrating health professionals is a small proportion of the total of highly skilled migrants nationwide, the loss of such "health human resources" for less developed countries can significantly and adversely affect the capacities of their respective systems to deliver adequate and equitable health care for all. (See Bach 2003; Stilwell, et al., 2003; Diallo 2004; and Scott, et al. 2004)

Table 8. Leading Countries of Destinations for Filipino Nurses (Percentage Distribution from 1992-2003)

Country of Destination Percentage (%)

Saudi Arabia 57.58

United States 13.87

United Kingdom 12.42

Libya 3.58

United Arab Emirates 3.34

Ireland 3.33

Singapore 2.70

Kuwait 2.30

Qatar 0.80

Brunei 0.08

TOTAL 100.00

Source: Table 9 of the Presentation of Dr. Rode/ Nodora of the Planning and Standards Division of the Health I

Development Bureau (HHRDB) under the Department of Health (DOH) during the "Second Global Health Forum on International Labor Migration From the Philippines, "18 October 2005, Foundation for Integrative and Development Studies (FIDS), World Health Organization (WHO}, and the Department of Health (DOH), /SS/ Bldg., UP Diliman

Policy Recommendations

Migrants are highly vulnerable to health problems for a variety of reasons.

Gushulak and MacPherson (2006) have put forward several proposals for consideration by national authorities in order to preempt the serious consequences

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consequences of these health problems. Among their proposals is a mechanism for immigration medical screening and the inclusion of mobility as a determining factor for health outcomes.

In turn, the following actions are recommended in the light of insights gained from data gathered in preparing this paper and are directed to Philippine government authorities and civil societies. Some advocacy issues are also included for consideration of the governments of destination countries. The findings and observations made in the paper using the typologies of migration health concerns are summarized in the matrices of Table 10.

Migrant Status Documented

Undocumented

Table 10. Migrant Status

Job Type

All categories

Usually menial labor and sex work

Health Risks

Undergo screening procedures - Perceived health risks likely to be low

Do not undergo screening procedures - Perceived health risks iikely to be high

Policy Dimension

Less restrictive, complicated, and unattractive

More restrictive, complicated, and unattractive;

criminalizes the migrants

A primary recommendation is for the Philippine government to see to it that the process of migrant worker recruitment is competently regulated without criminalizing the migrants.

The Philippine government must integrate health concerns in its program for migrant workers, e.g., a mandatory health insurance for all migran~ regardless of status. It needs to craft and implement proper.intervention mechanisms that can promote awareness of the health risks faced by migrants including provision of relevant information on health and reproductive rights during the pre-departure stage as well as upon return and to initiate programs for health evaluation of returning

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Mga Sanggunian

NAUUGNAY NA DOKUMENTO

Commission on Human Rights (CHR), Council for the Welfare of Children (CWC), Department of Interior and Local Government (DILG), Department of Health (DOH), Department of Social

National Statistics Office, POPCEN 2007 B-3 the provisions of Act Number Thirty-seven Hundred Fifty-three, and those of the Statistics Division of the Bureau of Customs,

The laudable objective of the government in assisting the poor indigent patients of government hospital is the driving force in the implementation of DOH-MAP. It aims to make

This pattern is: taking all level 2 respondent hospitals together, the wide variability of the respondents compliance to the required number of health human resource and

b. rational capacity of their dine-in services. Mandatory Minimum Requirements for Operation of Dine-In Services. In addition to the minimum health standards under DOH AO

The data sources include the Department of Environment and Natural Resources, the Mines and Geo-Sciences Bureau, and the National Mapping and Resource Information Authority.

BUREAU OF AGRICULTURAL STATISTICS 1184 Ben-lor Bldg., Quezon Avenue, Quezon City LIVESTOCK &amp; POULTRY STATISTICS DIVISION.. 332-1543 info@bas.gov.ph

The PNHRS is actually part of a global movement adopted by the Council on Health Research for Development (COHRED) to establish national health research