We are at the midpoint of 2024, a remarkable year in terms of the number of democratic elections taking place around the world. What is also striking is that in many countries such as the UK, USA, France, Germany and others of the EU we are seeing growing disquiet around immigration and a trend towards support for right-wing parties. With India now a top exporter of health workers, what do such trends mean for the tens of thousands of Indians training as health workers in the hope of finding a job in those countries?
India has long been the top source country for the supply of doctors to OECD countries, and trails only behind the Philippines as a source country for nurses. Current OECD figures estimate an increase in the annual inflow of India-trained nurses to the UK, for instance, from 261 in 2013 to 6,304 in 2021, an increase in Germany from 9 in 2013 to 483 in 2021, and an increase in Australia from 6,237 in 2013 to 14,015 in 2021.
Bilateral policy agreements such as the 2022 framework agreement between the Indian and the UK government for collaboration on healthcare workforce or the 2013 “Triple Win” agreement between the German government and the state government of Kerala set the stage for further cooperation in the field. Not least, the Indian government’s Heal by India initiative is reported to be designed to increase health workforce mobility out of India to different parts of the world.
Commercial industry, individual cost
A key motor of health worker out-migration is a complex training and migration industry in India itself which aims to educate and recruit nursing candidates in ever more encompassing ways. As we have recently argued, this industry is heavily commercialised and works on a networked basis, with ever-evolving networks of contractors and subcontractors processing parts of the supply chain of training and exporting nursing candidates.
Given the commercial nature of these services, they are often offered at a significant cost to individuals. Much of the education and language training takes place at private institutions in India. Key destination countries typically cover the cost of recruitment, training and travel (in keeping with the WHO Global Code of Practice for International Recruitment), but fees for additional and customised training (prior to travelling) as well as any in-country re-sits for mandatory licensing exams are often born by the nurses themselves. Nurses and their families thus often invest life savings or take out huge loans to access such training, incurring large debts.
One of the most troubling issues is that of employer repayment clauses covering travel costs. Reports on these clauses have emerged where nurses have sought to change employer prior to completion of a mandatory minimum period, typically three years. The logic is that it prevents employers from losing money they invest in supporting travel costs, however it also risks locking unsuspecting nurses into abusive and exploitative relations with little prospect of escape.
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The complexity of the training and migration system, and the extensive involvement of agencies, means that regulation is partial and lacking in many respects. Training centres and agencies often fall within regulatory grey areas and subcontracting practices make it challenging to hold unscrupulous actors to account. In the absence of tighter regulation, profit-driven services may not only fail to provide high-quality skills training but also put nurses at risk of being trapped abroad, amassing huge debts and unable to return to India or move elsewhere.
The advertising that targets nurses for migration often mobilises the dream of a ‘global’ career, however state and non-state actors gatekeep access to employment for nurses in individual countries, often requiring a more tailored approach to migration. This has meant that Indian migration agents and training specialists increasingly offer highly-specialised modules and training targeting one specific labour market in the West. Services offered in the field span training for specific licensing exams, simulation-based training for a particular piece of equipment or technology, and soft skills training. Thus, while these actors claim to train and prepare nurses for a global career, in practice, education and training is often geared towards specific countries – rather than producing ‘global nurses’, they produce more customised or bespoke workers ready to meet specific national shortages or working environments.
A large number of nurses who fail to reach the mandatory English test scores to land a job in the UK public sector opt for the private sector instead, often ending up in positions way below their qualifications. They work either in privately operated care homes or for private companies that send domiciliary care workers to patients’ homes, jobs for which no nursing qualification is required. The reason behind this trend is simple: according to respondents of our study, recruitment agencies can charge up to 15,000 GBP to help a care assistant migrate abroad, while they only receive about 1-2,000 GBP for a public sector nurse. While the UK NHS, for instance, maintains a list of ‘ethical recruiters’ with whom it operates, the private sector lacks similar constraints. The unregulated and exploitative nature of this market even led one Kerala-based respondent to compare it to chains of human trafficking. Indeed, repayment clauses have been reported to be even higher for private sector nursing aide positions, and may be considered forms of modern slavery.
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For many nurse trainees, agents and policy-makers, the prospect of more and more nurse migration is a chance to remedy India’s youth underemployment problem with the growing care needs of ageing populations in high-income countries. But there is good reason to question this. The COVID-19 pandemic rang alarm-bells in those high-income countries regarding their growing reliance on migrant health workers and what happens when travel is disrupted. This came amidst growing disquiet about migration numbers that has cast doubt on the political appetite to continue mass recruitment of international nurses.
For example, the UK government’s NHS Long Term Workforce Plan is highly critical of reliance in the NHS on foreign-trained health workers and sets out policies to reduce international recruitment over the coming years. It emphasises the COVID-19 pandemic and the need to drastically expand domestic training to ensure workforce sustainability. In Germany, the right-wing party Alternative für Deutschland is projected to make huge gains in certain parts of the country in the upcoming elections, promises to curb overall migration and to use other means, for example artificial intelligence, to address the shortage of nurses. What will the pressure to reduce international recruitment mean for the nurses who receive training in India that is highly specialised towards working in these countries?
There is a seductive logic to the idea of boosting health worker exports, but so far little attention has been paid to the individualised costs and risks involved, and the impact of anti-migration rhetoric and policy spreading in high-income countries. We have seen so many instances of Indian migrant workers being trapped, abused and killed in the hope of finding a good job. We must not walk blindly into a new calamity for workers.
Sibille Merz, Benjamin Hunter and Ramila Bisht are scholars at Kings College, London.
The article is based on research conducted with support from the UK Economic and Social Research Council.
This piece was first published on The India Cable – a premium newsletter from The Wire & Galileo Ideas – and has been updated and republished here. To subscribe to The India Cable, click here.
