German health workforce strategy depends on nursing drain from India

Germany’s bid to address its nursing shortage through international recruitment spans Latin America, eastern Europe, and Asia. India, especially the State of Kerala, finds itself among the top cadre providers

September 15, 2023 by Peoples Health Dispatch
Germany Kerala nurses
Nurses working in private hospitals in Kerala protest in April 2023 seeking higher wages. Photo: NewsClick

Germany’s efforts to address its nursing shortage largely consist of recruitment campaigns spanning Latin America, Eastern Europe, and Asia. India, which is among the top sources of migrant nurses to OECD countries, and particularly the State of Kerala, has become a focal point for these campaigns. Although not considered a standard destination for Indian nurses, Germany’s popularity has grown among those planning to leave India. Santosh Mahindrakar, an activist and researcher in the People’s Health Movement (PHM) Germany, says that nurses are drawn to Germany due to the promise of a stable social support network and better pay and working conditions.

In 2016, six years after the introduction of the World Health Organization’s (WHO) Global Code of Practice on the International Recruitment of Health Personnel—a voluntary instrument supposed to partially rein in recruitment practices harmful to health systems in the Global South—3.2% of Kerala nurses working abroad had already chosen Germany as their destination. While this percentage was significantly lower than those working in the United States and the Gulf states, it did indicate a steady interest in pursuing nursing careers in Germany.

Mahindrakar, himself a nurse, explains that the benefits of moving to Germany now mostly outweigh the barriers that Kerala nurses usually encounter on their path to becoming fully licensed nurses in the country. This could change as other countries, like Ireland, work towards removing administrative barriers for migrant health workers to attract more workforce, but the perspective of obtaining jobs in German hospitals remains a good option for many Kerala nurses.

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

Yet, like nurses from other Global South countries, those from Kerala and other parts of India face an extended period of accreditation certification upon arriving in Germany. During this period, they can only work as nursing aides, in less stable conditions and for substantially lower salaries than what they would earn as full-fledged nurses. Learning the language is also complicated and after completing their adaptation courses, further learning of German is not supported in a systematic way.

Even after achieving language and certification accreditation, Indian nurses essentially start from scratch. Although they might have pursued nursing specialties before coming to Germany, they begin their careers with a basic salary, as Mahindrakar explains. In addition, while trying to establish themselves within the German healthcare system, these nurses often delay joining trade unions or engaging in other forms of organizing. 

“Foreign nurses will not become a member of a union because there’s no direct nurses’ union like for example in Ireland and the UK. There are general unions here, and they ask for 1% of your gross salary, which is a significant amount for nurses coming from abroad,” says Mahindrakar.

The influx of nurses from Kerala to Germany is rationalized by the seemingly high number of nursing graduates the State produces annually. Kerala has 135 nursing schools, including 20 government institutions, which provide general nursing and midwifery courses. The State is among the leading sources of nurses working both in India and abroad. The proliferation of nursing colleges, primarily private ones, has been a nationwide trend for a while now, according to Mahindrakar.

This surge in nursing graduates across India doesn’t automatically translate into local employment, especially in public institutions. Jobs in private hospitals are more accessible but come with lower salaries and reduced job security. Traditionally, these positions were considered stepping stones toward emigration to Gulf countries and English-speaking countries. For many, they still serve this purpose. Yet, as job security in the public sector has somewhat been reduced due to healthcare privatization and neoliberal policies, concerns are mounting that the trend of emigration may grow in the public sector as well.

In fact, recent inquiries have shown that as many as half of nursing school students intend to migrate during the early stages of their education. By their third year, the majority share this intent, reflecting the influence of peers, the aspiration for recognized and well-compensated positions, and the determination of recruitment agencies to meet the growing demand for healthcare workers in the Global North. This trend allows Germany, much like other high income countries, to rely on a well-trained workforce at a fraction of the cost it would take to train professionals domestically. 

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.