The Global Cost Of Quick-Fix International Nurse Recruitment

When nursing graduates in low- and middle-income countries (LMICs) receive their hard-earned diplomas, they’re no longer cheered on only by proud family members and university faculty.

“The recruiters pitch up on the nurses’ graduation day in our country,” one delegate told me at the recent World Health Assembly (WHA).

It’s a striking image: nurses, newly educated by their home countries, swarmed by recruitment agencies hoping to attract them to wealthier nations experiencing staff shortages. Experienced and specialist nurses, including critical care nurses, are also being aggressively recruited, depriving their native countries of vital expertise.

Across a week of conversations with the world’s nurses, nurse leaders, and policymakers at this year’s WHA, a clear picture emerged of a worsening nursing migration crisis driven overwhelmingly by a small number of high-income nations, including the UK, USA, Canada, Australia, and certain Gulf states, poaching nurses from vulnerable countries in what some African healthcare leaders have called a “new form of colonialism”.

This is not only a workforce and staffing issue: it’s a public health and global equity issue that threatens the achievement of our shared UN sustainable development goals, including universal health coverage.

Tackling this requires immediate action on multiple fronts. We propose three key measures: a temporary ban on actively recruiting nurses from fragile health systems; a stronger WHO Global Code of Practice with robust monitoring and accountability mechanisms; and meaningful compensation for underresourced countries losing nurses to wealthier nations.

Our world’s most vulnerable health systems need us to develop, not deplete, their nursing workforce—and with crucial worldwide elections and the next G20 meeting fast approaching, now is the time to prioritise this issue on the global agenda.

To chart a path forward, we must first understand the current situation and how we got here. 

Deepening global inequalities

It’s important to protect individual nurses’ rights to migrate in search of better opportunities but the playing field is grossly unequal.

The distribution of the world’s nurses is strikingly uneven across regions — the State of the World’s Nursing report shows that just 3% (less than 1 million) of the world’s nurses are in Africa with over 80% in Europe, the Americas,  and the Western Pacific region. With up to a tenfold difference in nurses per capita between high- and low-income nations, this means affluent countries are recruiting from the most fragile health systems who can least afford to lose their workers.

At WHA, we heard repeated frustrations around high-income countries draining nurses from this scarce pool, offloading the costs of nursing workforce education and planning onto vulnerable nations. In Africa alone, one in ten nurses (and one in five doctors) now work outside the continent, stripping away desperately needed expertise.

We heard that small island states like Tonga and Fiji have suffered even more acute losses. At the Fiji National Economic Summit 2023, health leaders discussed losing 26.7% of their nurses the year previously — and at WHA, we heard that this trend has continued, with 20%–30% of Fiji’s nurses leaving year on year, mostly headed to countries like New Zealand and Australia. 

Stepping-stone migration 

We are seeing new patterns of “carousel migration”, where countries like New Zealand and the UK act as stepping stones for nurses who then go to other nations like Australia, evident in the number of overseas-trained nurses seeking Certificates of Current Professional Status (CCPS) which indicates they’re gearing up to work abroad. We also heard that Canada and Australia are actively recruiting from the UK, with advertisements plastered across public transport hubs urging UK-based nurses to make the move.

We know from historical data that migration left over 40% of nursing jobs in the English-speaking Caribbean unfilled, and the issue hasn’t improved — we heard from Jamaica that ~20% of Jamaica’s nurses were applying for credentials to leave.

Historically the Philippines has been a supplier of nurses for the world but we heard concerns from their representatives at losing a third of Filipino nurses overseas each year and the impact that has on meeting their own country health needs. This sounds a cautionary note on the  “educate-to-export” model that purposefully trains nurses as labour exports, which has been advocated for as a solution to the current global shortage. This is a risky policy that could widen health inequalities as the gap in numbers of nurses grows between source and destination countries — and it locks the sending countries into dependence on nursing exports rather than setting them on a path to sustainably grow their own healthcare workforce.

Crisis made worse by stopgap measures

Poor working conditions, limited opportunities, and economic strains in developing countries drive nurses to seek better salaries abroad. Even as vulnerable nations face nurse shortages, we are hearing that some lack employment for their nursing graduates due to underdeveloped health systems. They need high-income countries to support them in building robust health systems — rather than raiding their workforce. 

Over a year ago, ICN declared a global health emergency based on the global shortage of 6 million nurses and deep-seated health inequalities, exacerbated by the brain drain of skilled nurses from vulnerable nations. We are already off track on our global ambitions to achieve universal health coverage by 2030 — and rising levels of often aggressive and ethically questionable nurse recruitment is a major contributor, widening healthcare gaps and jeopardising our progress.

Nurses in high-income countries are ageing and burning out — and we are consistently seeing governments make the unethical and unsustainable choice to plug their staffing gaps by looking abroad, rather than addressing the root causes and investing in both educating and retaining their nurses. 

This is a short-sighted, leaky-bucket approach. It’s also self-defeating to simply try to turn the tap of nursing education to fully open, without fixing the holes of poor employment and working conditions that cause so may to leave. The failure to create decent working conditions and retain the valuable nurses we already have has led to an alarming rise in strike action by healthcare workers worldwide. Increased pressures on the nurses left behind in countries like Fiji and Tonga has sparked labour unrest.

In high-income destination countries like Sweden, where nurses are currently on strike, health leaders at WHA side events said “migration is being used to short-cut the issues of decent work and investment in the education, recruitment and retention of our health and care workers.” An unsustainable dependence on nurse immigration also undermines healthcare resilience and pandemic preparedness in wealthier nations — we saw how temporary blocks on health worker mobility during Covid left wealthier countries massively short staffed.

Reshaping global policy and practice 

The WHO’s Global Code of Practice on the International Recruitment of Health Personnel calls for countries to prioritise self-sufficiency by training and retaining domestic health staff and identifies vulnerable states off-limits for hiring unless bilateral agreements are in place where hiring countries invest in the source nation’s health workforce or education.

So far, though, we have seen little evidence for meaningful, well-defined bilateral agreements with clear financial commitments. Often, these agreements give more of a whiff of creating an ethical veneer than ensuring truly proportional and mutual benefits.

To actually stem the tide of nurse migration from developing countries, the Code must be drastically strengthened and universally and consistently enforced.

We need at least a temporary freeze on active recruitment of nurses from the world’s most fragile health systems.

We need a better system for monitoring and reporting on international nurse mobility, national self-sufficiency, and compliance with the Code, and we need measures to ensure accountability. Only seventy-seven countries, representing 55% of the world’s population, are currently reporting their health worker migration information to WHO. At a time when we need nations to take this worsening issue more seriously than ever, European countries are actually reporting less than in previous years — fewer than half submitted data to WHO in the latest reporting round.

We need wealthier countries to compensate vulnerable countries when recruiting from them, by directly investing longer-term in their health infrastructure and education, perhaps through an “offsetting” program akin to carbon credits.

Above all, we need to act now — we cannot afford to wait until next year’s WHA to address this burning problem.

That is why the International Council of Nurses is calling on the G20 heads of state to make effective implementation of ethical health worker migration policies a central agenda item when they convene in November.

Building self-sufficient nursing workforces is the only way to achieve our global goals of health for all.

Howard Catton is the Chief Executive Officer at the International Council of Nurses.

Image Credits: © Dominic Chavez/The Global Financing Facility, State of the World’s Nursing Report, UK Health Foundation, WHO, Studioregard.ch.