Healthcare workers around the world continue to experience the overwhelming impact of COVID-19. The pandemic has exacerbated the failings our healthcare systems, including the ongoing global healthcare workforce shortage.

To address the dire need for nurses, hospitals and healthcare agencies in the United States and other wealthy countries are pushing to increase the recruitment and hiring of foreign-trained nurses. While migrant nurses would help fill these gaps, there are ethical issues to consider if migrant healthcare workers leave their countries of origin.

Nursing Shortage Crisis in the US

In September, the American Nurses Association urged the US Department of Health and Human Services to declare the shortage of nurses a national crisis.

Around the world, nurses have risked their lives on the front lines of the pandemic. In May 2021, the WHO estimated that approximately 115,500 healthcare workers have died from COVID-19. The toll of the pandemic has increased anxiety, trauma, and burnout among nurses, causing many to leave or consider leaving their professions. It is projected that the US will need 1.1 million new nurses by 2022.

The American Hospital Association urged the Senate Health, Education, Labor & Pensions Committee to enact several policies to address this workforce crisis. Among the priorities were recommendations to expedite visas for highly trained foreign healthcare workers and to pursue visa relief for foreign-trained nurses. The American Association of International Healthcare Recruitment also pushed the US State Department to prioritize visas for foreign-trained nurses as they are “critical to providing high-quality care to patients across America.”

Immigrants’ Contribution to the US Healthcare System

Immigrants make up a significant share of the US healthcare workforce. According to the Migration Policy Institute, in 2018, over 2.6 million immigrants were employed as healthcare workers in the US, making up about 18% of the workforce. Most of the country’s immigrant nurses are from the Philippines, followed by India, Nigeria, Mexico, and Jamaica.

TIMES documented the integral role of Filipino nurses in staffing the US healthcare system during times of crisis, as well as their experiences with exploitation, wage discrimination, and disproportionate negative health impacts while working in the US. As of March 2021, 26% of the nurses who died from COVID-19 in the US were Filipino, yet only 4% of the workforce is Filipino.

Uneven Distribution of Healthcare Workers Worldwide

In 2018, the global shortage of nurses was estimated to be to 5.9 million, with most of the shortage concentrated in low- and lower middle-income countries, according to the WHO’s first State of the World’s Nursing. In contrast, 81% of the world’s nurses are in American, European, and Western Pacific regions.

Prior to the pandemic, the WHO projected a global shortage of 18 million healthcare workers by 2030. Further illustrating the uneven distribution of healthcare workers worldwide, the African Region has access to just 3% of the world’s healthcare workers, spends less than 1% of the world’s financial resources, and suffers more than 24% of the global burden of disease, while the Americas, including North American, Central America, and South America, has almost 37% of the world’s healthcare workers, spends more than 50% of the world’s financial resources for health, but only accounts for just 10% of the global burden of disease.

Impact on Source Countries’ Healthcare Systems

There are devastating effects to areas of the world that lack sufficient healthcare workers and yet need them the most. A study of Ghana’s healthcare facilities found that 72% of all clinics and hospitals were unable to provide a full range of services due to lack of personnel. Similarly, from 2002 to 2007, Malawi had lost 53% of its health administrators, 64% of its nurses, and 85% of its physicians, mostly to NGOs funded by the US, Britain, or private sources such as the Gates Foundation.

Some migrant workers send remittances which can improve the health and wellbeing of their families in their origin countries. However, studies have found that emigration of women who have received post-secondary education can negatively impact infant and child mortality rates in origin countries, suggesting that the benefits of remittances do not outweigh the negative health effects of losing educated women in these countries.

Policy Response to Recruitment Practices of Foreign-Trained Nurses

The policy response to the global nursing shortage requires a global commitment to building sustainable workforces and following ethical outsourcing of foreign-trained nurses. While individuals should have the freedom to seek job opportunities outside of their countries, governments recruiting them must employ ethical practices that balance their needs with transparency, fairness, and promotion of sustainability of healthcare systems.

Countries that rely on migrant nurses can promote equitable practices by encompassing the following guidelines from the WHO’s Global Code of Practice on the International Recruitment of Health Personnel:

  • Prioritize strengthening a sustainable nursing workforce within their countries to reduce the need to recruit foreign-trained nurses. Countries should invest in the education, jobs, well-being, and retainment of nurses within their countries.
  • Consider benefits for both their country and the source countries when establishing bilateral or multi-lateral agreements. Possible arrangements that benefit source countries include technical or financial support with worker retention, training, and return migration to strengthen health systems capacity.
  • Support safeguards that protect vulnerable countries facing critical shortages of healthcare workers.
  • Ensure fair recruitment, contractual, and labor practices for all healthcare workers. Migrant healthcare workers must enjoy the same legal rights and responsibilities as the domestically trained workforce.
  • Promote data gathering, research, and information exchange on international healthcare migration and health systems for ongoing monitoring, analysis, and policy formulation.

The COVID-19 pandemic has shown evidence of the urgent need for greater investments in the global healthcare workforce. Governments must recognize the value of nurses by prioritizing their wellbeing and developing strategies to build and retain resilient workforces. Additionally, ethical recruitment practices must be considered as a global priority to ensure that countries with fragile healthcare systems are not stripped of their essential healthcare workers during times of crisis.