The German health care system is under strain due to a shortage of skilled workers. Estimates project a lack of 1.8 million health workers by 2035. Facilities for the elderly are especially facing difficulties to provide quality care due to human resource constraints.  Advocacy groups describe this as a “self-made crisis” that has arisen due to too few investments in human resources, unattractive working conditions for nurses and other medical staff, too little participation by representatives of workers, and an ageing population.

Policy makers have responded to the shortage of skilled workers in the last years with legislation that facilitates the immigration of international (health) workers into Germany, most recently the Fachkräfteeinwanderungsgesetz, the skilled worker immigration law, which was approved by the government in July this year, and allows international workers who fit certain criteria to travel to Germany in search of employment. In addition, measures have been taken to facilitate the homologation of degrees, including bilateral agreements such as Triple Win (started in 2013 and run by the German Agency for International Cooperation (GIZ)) which aim to establish a precedent for the recognition of foreign nursing degrees. More specifically, Triple Win aims to recruit qualified foreign nurses from partner countries such as Indonesia, Jordan, Colombia and Brazil among others, where there is presumably “a surplus of qualified experts that cannot be absorbed by the local labor markets” with the objective of supporting “remittances and the transfer of know-how” to the countries of origin.

While supporting the ethical recruitment of international health workers is an important element of transforming health care systems in Germany, I argue in this piece that it is as important to ensure that Germany’s health care system is attractive to, and supportive of nationally trained health workers. This requires, among others, improving employment opportunities for women*, introducing anti-racism and diversity trainings for health care providers and the reintroduction of health care as a common good.

Recognition and employment of foreign trained workers in Germany

But first some more background. From 2015 till 2019 the number of applications for health workers in Germany went from 6000 to almost 15 000 a year. The majority of these applicants receive a so-called “notification of deficit”, which describes the gaps in their degree that must be overcome before they can achieve employment of equal level in Germany. After receiving this notification, applicants are typically granted a visa to remain in Germany and “update” their degree. This process can take anywhere between 18 months and 5+ years, depending on the origin of the degree, the state in which the applicant has applied for employment, the applicants’ language competencies and other conditions.

In a review of all degree recognitions, the federal institute for vocational training concluded that in 2020 less than 3% of all foreign trained health worker applications were rejected at the time of application, so an outright rejection is fairly uncommon. This same year, the potential number of foreign trained health professionals who applied and could potentially work in Germany during their recognition process was, according to this report, approximately 23 000 (see also the Expert Council on Integration and Migration Annual Report 2022).

Germany has been criticized for its rather “active” recruitment policies for the healthcare sector. Especially efforts to recruit nurses from Kosova and Bosnia have recently been stopped due to the exodus of health professionals from these countries. Efforts to improve recruiting policies led to the development of a “Gütesiegel” (approval certificate) which, although voluntary, has led to the development and implementation of shared guidelines for the process of international recruitment among certified agencies. Germany also voluntarily follows the WHO Global Code of Practice on the International Recruitment of Health Personnel which is the core component of bilateral, national, regional and global responses to the challenges of health personnel migration and health systems strengthening, by not recruiting health workers from the 57 “red-listed” countries in the Code. The recent visit of German government officials to Ghana, listed as “barred” on the WHO code countries, was met with criticism.  

Critical self-reflection needed

Reference to the WHO Code as a guiding document in the developing market for health workers is justified. The Code outlines central objectives and principles for health personnel migration and recruitment policies, such as: discouraging active recruitment from countries with critical health workforce shortages; focusing on policies and incentives which support the retention of health workers in underserved areas; emphasizing the importance of a multi-sectoral approach in addressing the issues and encouraging countries to develop sustainable health systems that would allow, as far as possible, for domestic health services demand  to be met by domestic human resources.

While the emphasis of the Code is on the need to create opportunities for health systems strengthening in developing countries, these same principles should also apply to the responsibility of developed countries to organize their own health systems in such a way that they are attractive to, and supportive of health workers already employed in national health systems. The Code’s Guiding Principle 3.6  actually states “Member States should strive, to the extent possible, to create a sustainable health workforce and work towards establishing effective health workforce planning, education and training, and retention strategies that will reduce their need to recruit migrant health personnel. Policies and measures to strengthen the health workforce should be appropriate for the specific conditions of each country and should be integrated within national development programmes.”

Multiple groups have pointed to the issues in the German system that led to large numbers of qualified workers leaving the system and have also flagged that insufficient efforts are being taken to sustainably integrate foreign trained workers whose training has already been recognized in Germany  into health professions.

In addition to recruiting foreign-trained workers (from not red-listed countries, clearly), three main areas need special attention in order to improve the situation of health workers in Germany:

1. Moving away from profit-oriented health care services and the (re)introduction of health services oriented towards the common good;

2. Public policy aimed at improving the integration and retention of women in the workforce, especially in health care, through improved recognition of care professions such as nursing, caregiving and professional childcare and;

3. Anti-racism and anti-discrimination strategies in health care institutions and wide-reaching diversity strategies that focus on an improved work-environment for health workers and health service providers.

A few final remarks

While examining the emerging interconnectedness of international care networks and the recruitment of skilled health workers a key question arises: what is Germany’s (shared) responsibility in strengthening health systems in the countries of origin (i.e. apart from not poaching health workers from red-listed countries) and how could the country assist in this joint endeavour? Perhaps part of the answer could be: Germany should not only (re)introduce health services as a common good nationally but also monitor with attention (and tackle) the growing neoliberal forces that drive a privatization of health and health education in many partner countries. It is hard to say if the Triple Win programs alone can effectively play this role as they are only a small fragment of the international recruitment landscape. However, during the negotiations for a Memorandum of Understanding between Germany and a partner country, the Triple Win program may have a positive influence on shaping recruitment policy through roundtable discussions in which workers rights, government interests and recruitment needs can perhaps be negotiated equally.