The Covid Delta variant has swept across south-east Asia over recent months, prompting lockdowns and overwhelming hospitals – from Malaysia to Thailand and Indonesia. Now the impact is being felt in the Philippines, just as the country’s chronic lack of health workers reaches a crisis point.

“The disease has become very aggressive,” said Michael Bilan, who works on a Covid ward in Manila. This time, patients tend to require a higher amount of oxygen, for longer, he said. The number of Covid patients is also at a record high: last week, 277 were receiving treatment. New wards have been opened to meet demand.

The Philippines is one of the world’s biggest suppliers of nurses, with 17,000 leaving to work overseas, including in the UK and the US, in 2019. But it is increasingly struggling to staff its own wards, where pay is low and conditions poor. Last week, the Private Hospitals Association of the Philippines estimated 40% of private hospital nurses quit last year, and more have left followingafter new waves of infections this year.

Maristela Abenojar, president of Filipino Nurses United, warned more will go unless the government begins large-scale recruitment to ease the pressure on wards, and pays overdue benefits to staff. “If they don’t act immediately in the next few days there might be a huge mass mobilisation among the health workers,” she said.

The warning comes as cases in the country, one of the worst hit in south-east Asia, continue to rise. On Saturday, 16,694 infections were reported, as well as and 398 deaths – the second-highest daily death toll since the pandemic began. So far, 31,596 people have died.

Last year, the government sought to ease the health worker crisis by setting up an emergency recruitment scheme with benefits such as a 20% salary boost for a minimum three-month contract. It has done little to improve conditions, says the FNU.

Controversially, tThe government banned healthcare workers from moving to work overseas, halting travel plans of nurses who had spent vast sums of money training, taking tests and obtaining the papers required for working in other countries. The measure was later replaced with a cap on the number allowed to leave, following fierce protests from nursing groups.

The attempt to stop nurses from going abroad marks an abrupt change of policy in the Philippines, said Yasmin Ortiga, assistant professor of sociology at Singapore Management University, who has studied migration trends among Filipino nurses. “They’ve always encouraged [nurses to go abroad], because nurses do very well overseas,” she said. Nurses are less likely than other groups, such as domestic workers, to need state protection, and remit significant funds back to the Philippines. “I think for a long time the country just saw them as the ideal migrant workers,” said Ortiga.

Even the medical syllabus taught to students is shaped by the trend for health workers to go abroad. “There are diseases that are not present in our country that we still study – they are found in western countries,” said Joyce Brillantes, national vice-chair for the Philippine Medical Students Association. In the second year of her medical degree she learned about rocky mountain spotted fever, which is common in the US, and not in the Philippines. “We study this, we memorise this, it comes up in our exams,” she said. “There is so much more that we could learn about medicines in the Philippines context that we are not learning.”

When the pandemic hit, some on social media criticised nurses for wanting to leave the country, questioning their patriotism.

The Philippines is not simply suffering from a brain drain due to migration, said Ortiga, who added that this oversimplifies the problems. There are already many trained nurses in the country but they are working in other fields – in call centres, as teachers, or police officers.

“In the Philippines, because we try to produce nurses for export, we have an oversupply of skilled people in the country,” she said. During the 2000s, the higher education sector, which is dominated by private institutions, rapidly expanded nursing courses in response to growing demand for Filipino nurses in the US.

This created an abundance of newly trained nurses, and many were unable to find work in local hospitals – a requirement for applications to work overseas. Demand for nurses abroad then fell after the 2009 financial crisis, exacerbating the situation. Many nurses had little choice but to leave the profession, while some worked for free for years to try to secure enough experience for foreign jobs, said Ortiga. “It made hospitals very complacent.”

Pay and working conditions for nurses in the Philippines have remained unattractive. Of Filipino Nurses United members who are employed in private hospitals, where salaries are least generous, most earn between 8,000 and 10,000 pesos (£120 and £145) a month.

Nursing groups had hoped the pandemic would force the Philippine government to invest in the health service and improve the conditions on hospital wards. Instead, Covid has aggravated longstanding problems. “Our nurses are more overworked – instead of just eight hour [shifts] they are extending work for 12 hours,” said Abenojar.

When nurses become infected and need to be isolated, their colleagues’ workload increases dramatically. On Covid wards, one nurse can be responsible for 15 or more patients, according to Abenojar. Relatives, who in the past could help look after patients, are no longer allowed to visit, due to the pandemic restrictions. The full burden of care instead falls to nurses.

“You can imagine they are in full gear, PPE, from head to toe, catering to more than 15 patients in 12 hours,” said Abenojar. Some cannot find time to eat, or avoid going to the toilet because they don’t want to remove their protective clothing because they fear supplies are low.

Anger among health workers, who say their pleas for greater investment have been ignored, grew further last week, when the state auditor highlighted “deficiencies” worth 67.3bn pesos (almost £1bn) in the country’s pandemic response fund. Some nurses have still not received their full benefits, such as hazard duty pay.

In Bilan’s hospital, nursing staff have been redeployed from outpatient services, which were shut due to the lockdown. This has provided some relief, yet colleagues have continued to leave. “I can’t blame them actually,” he said. “It’s frustration, the stress.”

Health figures have criticised the government for not investing enough in mass testing, and for failing to give clear messaging, including around vaccinations. So far, 11.5% of the population is fully vaccinated against Covid.

“Instead of learning from our past mistakes, every time a new aggressive variant arrives, it’s like we’re going back to square one, and we have to adjust again and the numbers just keep on rising,” said Bilan.

“It’s very hard,” he added. “We see patients dying on a daily basis with Covid. It feels like we cannot do anything more. We have given our best.”

Rebecca Ratcliffe

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