Will Germany’s bid to address shortage of nurses put more pressure on Brazil’s health system?

As Germany seeks to recruit overseas nurses to bridge its healthcare staff deficit, questions are arising about the strategy’s impact on the health systems of source countries

August 17, 2023 by Peoples Health Dispatch
Foreign recruitment of nurses Germany, Brazil
(Photo: via Twitter)

In the next 10 years, Germany is expected to face a shortage of 200,000-300,000 nurses. In recent years, German health officials have focused on addressing this deficit by recruiting thousands of nurses from abroad, including through bilateral agreements. Their efforts have painted the German health system as an attractive destination for nursing professionals, particularly from Eastern Europe and the Western Balkans, from very early in their training.

A report from the coalition Pillars of Health in 2022 showed that Germany has the second-highest number of foreign-born nurses in Europe, surpassed only by Ireland. Most migrant nurses come from Bosnia and Herzegovina, Croatia, Poland, Romania, and Turkey. However, more recently, there has been an increased interest to recruit nurses from the Global South, including countries like the Philippines, India, and some countries in Latin America.

Given Germany’s reliance on international recruitment to address its healthcare workforce crisis, it was unsurprising that a thematic meeting between Hubertus Heil, the German Minister of Labour and Social Affairs, and his Brazilian counterpart Luiz Marinho, took place in June of this year. However, this meeting raised concerns among health rights groups, who cautioned that Germany’s strategy is not considering the impact on healthcare systems in source countries.

Contrary to the view shared by a section of German officials that there is a nurse surplus in Brazil, the country actually has a lower nurse-to-patient ratio than Germany. Brazil’s ratio stands at 10.6 nurses per 1000 patients, compared to Germany’s 12.5. The ratio in some parts of Brazil is even lower than that, standing at seven nurses per 1000 patients. Instead of being an indicator of saturation, the high unemployment numbers used to back the claims about a surplus of nurses in Brazil actually point to the need to invest more in the public health system in Brazil, including by creating more jobs.

Full picture needs to be considered to understand impact of German strategy

Shortly after the Heil-Marinho meeting, the Association of Democratic Doctors (Verein demokratischer Ärzt*innen, vdää*) and the Brazilian Center for Health Studies (Centro Brasileiro de Estudos de Saúde, CEBES) published a position paper outlining the main problems in the narrative surrounding active nurses’ recruitment. Karen Spannenkrebs, a medical doctor and activist in vdää*, explains that they first contacted CEBES to develop the joint position when they saw that the media coverage of the meeting lacked critical perspective.

CEBES and vdää* identified several areas in the discussion of recruitment processes that lack detail or are painted in an overly positive way. One such area is the difference between nursing education in Brazil and Germany, which leads to challenges for newly-arrived nurses. As Spannenkrebs explains, nurses in Germany undergo practical and theoretical training, while nurses in other countries often pursue a university degree. Their roles can also differ from those of nurses in other countries. For example, they don’t typically collect blood samples but are responsible for patient’s body care. On the other hand, Brazilian nurses must complete a university degree before practicing, which isn’t automatically recognized in Germany. Until qualification harmonization is achieved — a process that can last from months to years — Brazilian nurses work as nursing assistants with lower income and mismatched tasks.

This situation can catch migrant nurses off-guard, as their expectations are often shaped by international recruitment agencies. “Since their [the recruitment agencies] primary purpose is to profit from the recruitment, they often give big promises which do not reflect reality,” says Spannenkrebs.

Migrant nurses lack support at arrival

While some agencies genuinely support migrant health workers, not all of them are well-meaning. They tend to downplay the effort required to learn German or transfer language course costs to the nurses. Some go as far as to shift most financial risks to the nurses, by making them sign contracts which force them to pay thousands of euros if they quit their jobs before the end of an agreed period of time.

Nursing is stressful enough for local health workers, given the excessive workload and commercialization of the health system. Spannenkrebs points out that because of the issues described in the CEBES-vdää* paper, migrant nurses find themselves in an even worse position.

Most employers don’t support them enough in the integration process, which can lead to frustration and problems within the teams, and reinforce discrimination and stereotypes. The German language is quite difficult to learn, so it can be a big problem, since most hospitals don’t offer language courses during work hours. And then there is also racism in German society which they may have to face,” says Spannenkrebs.

The narrative around the recruitment of nurses from Brazil also lacks the contextual information that could help understand the workers’ decision to migrate in the first place, Spannenkrebs points out next. The Unified Health System (Sistema Único de Saúde, SUS) in Brazil has suffered from underinvestment and budget cuts, resulting in stagnant or worsening working conditions and income. Therefore, when Germany recruits from Brazil, it takes advantage of SUS’s underfunding, as highlighted in CEBES and vdää*’s position paper.

“We have to see the health workforce crisis in the context of the current state of the health systems,” says Spannenkrebs. “The global health workforce crisis can’t be solved with international recruitment of health workers. This will only relocate the crisis from one country to another, following global financial and power imbalances. We have to fight for strong health systems that enable good working conditions for healthcare workers everywhere,” she concludes.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.