The Philippines has provided the world with skilled medical professionals for decades. But as more and more workers abandon the Philippines for higher salaries abroad, public health experts say the country's health care system is on the brink of collapse.
It is Monday morning at the Rizal Memorial District Hospital on the island of Mindanao in the southern Philippines. Roughly 30 or 40 patients are lined up at the outpatient center to see a doctor.
The single story hospital is one of nine public facilities in impoverished Zamboanga del Norte. It has the barest facilities: a basic laboratory, a faulty X-ray machine and no ability to perform major surgery.
But the biggest shortage in many Philippines' hospitals is not equipment, it is people.
Public health experts say a mass exodus of nurses and doctors overseas is killing the country's health system.
Dr. Jaime Galvez Tan is a former Philippine health secretary.
"Hospitals are closed. I've seen hospitals abandoned over the last few years," he said. "We're back to the 1950s when there were no rural doctors available, no rural nurses. This is the impending collapse, the looming crisis."
The Philippines, one of the poorest countries in Asia, has been exporting nurses since the 1960s, primarily to wealthy places such as the United States, Europe and the Middle East.
Experts estimate more than 100,000 nurses have left since 1994. But what is alarming, the experts say, is that over the past six years, thousands of doctors have left, lured by high salaries overseas and pushed by political and economic instability at home.
There are estimates that about 1,000 hospitals have closed in the past five years because of a shortage of doctors.
Most of the doctors, trained at Philippine universities, wind up working overseas as nurses, because it is faster to get a nursing license than a medical license in most countries.
Doctors in Philippine public hospitals earn up to $800 a month. Nurses are lucky to get $250. In many wealthy countries, nurses earn more than $4000 a month.
Dr. Alma Naraga is a former municipal health officer who worked in far-flung villages in the province. She recently graduated from nursing school.
"My husband encouraged me to take up nursing," she said. "He has a sister working in Ireland as a nurse. His sister is doing well, doing better than me financially."
With fewer doctors and nurses, people complain of long waits to get treatment. More women must give birth without the help of a doctor, nurse or midwife.
In the provinces, treatable emergencies such as meningitis or strokes are often fatal, because there are no specialists to treat them. Here in Zamboanga del Norte, the wealthy travel hundreds of kilometers to bigger cities to seek treatment for life-threatening illnesses. Because of the distance, however, some do not survive the trip.
Public health experts say the exodus of nurses is not expected to let up because demand from developed nations is increasing, as their populations grow older.
The government encourages Filipinos, including medical professionals, to work abroad, because they send back billions of dollars to the country annually.
But Dr. Jean-Marc Olive, the World Health Organization (WHO) representative in Manila, says the government should change the policy if it is to keep the shortage of health care workers from worsening.
"The government needs to invest more into health," she said, "In the Philippines, it's barely three percent of GDP. That's not enough to be able to sustain a good health work force."
Dr. Galvez Tan, the former health secretary, says the government must form a plan that considers the social costs of exporting labor.
He says the goal is not to ban medical workers from migrating but to tame the outflow and minimize disruptions.
Among his proposals: compulsory government service for graduates of public medical and nursing schools and creating career-advancing programs to retain personnel.
A recent World Health Organization report says countries recruiting health workers from developing countries have a responsibility to recognize that the workers' absence may have immediate and adverse effects. The WHO calls for more ethical recruitment policies and for aid donor nations to focus on helping expand the health work force in poor countries.
Some industry organizations have urged the government to curb the migration of essential workers - not only doctors, but also pilots and information technology professionals.
The migrant labor laws allow the government to suspend or ban deployment of certain critical skills in pursuit of national interest or public welfare. But the labor secretary has said to do so may be a violation of people's freedoms.
Dr. Naraga says she has not made up her mind about leaving. She worries about the patients left behind.
"If the need to really stay here is such that my service is needed, I would be willing to say, spend five years here provided that we will also be compensated for our work," she explained. "And also I hope the local politicians will realize that what we are doing is not as easy as they think and that we will be appreciated."
Despite the debate, for many the dollars beckon. New nursing schools have opened and mid-career professionals, including lawyers and teachers, are signing up.
Despite that, in Zamboanga del Norte, a new hospital is being built, although officials are not certain the government will find the doctors and nurses to staff it.