1 May 2024

Researchers warn: Denmark will drain the Philippines and India of the health care workers they themselves need

Care Drain

Denmark has far better coverage of healthcare professionals than India and the Philippines, which report a shortage of nurses. "Ethically worrying" that Denmark wants to recruit from there, say three researchers. The Minister for Higher Education and Science says Denmark will follow WHO ethical guidelines.

Nurse at health care center in India
India is one of the world’s largest exporters of healthcare personnel. Here, a nurse at a health center in the Indian region of Bihar assists a mother in breastfeeding a newborn child. Photo: ANUSHREE FADNAVIS

This article is written by Emil Høj. It was published in Information on 9 April 2024. See the Danish article here. Translated to English by School of Global Health.

In the future, Denmark will be short of many welfare workers, including nurses and workers. In January, the government announced that it is prepared to explore the possibility of recruiting these two groups from so-called third countries.

"India and the Philippines have indicated that they are ready to discuss a collaboration on the education and recruitment of healthcare professionals," said Minister for Higher Education and Science Christina Egelund (M) in a press release.

But now three researchers from the Section of Global Health at the University of Copenhagen are warning against the plans: Both India and the Philippines are relatively poor countries that lack healthcare professionals themselves. Much more so than Denmark.

"It may well be that we have a recruitment problem in Denmark. But we're actually on the green side compared to so many low- and middle-income countries, including India and the Philippines," says Nanna Maaløe, a doctor and researcher in global reproductive health.

Along with Ib Christian Bygbjerg, Professor Emeritus of International Health, and Dan Meyrowitsch, Epidemiologist and Head of Research at the Section, Maaløe fears that Denmark could help drain the countries of important personnel. This could result in increased illness and death in already vulnerable healthcare systems, they estimate.

An agreement between the government and the political parties De Radikale, SF, De Konservative og Liberal Alliance states that they want to recruit up to 1,000 healthcare assistants from third countries, including India and the Philippines. Presumably, according to the three researchers, they will recruit people with a nursing education or similar.

But while Denmark has a coverage of just over four doctors and ten nurses and midwives per 1,000 inhabitants, the picture is significantly different in India and the Philippines, according to figures from the World Bank.

Both countries have just about one doctor per 1,000 inhabitants. India has just under two nurses and midwives per 1,000 inhabitants, while the figures for the Philippines are just under five nurses and midwives per 1,000 inhabitants.

Minister for Higher Education and Science, Christina Egelund, explains that the government is aware of the potential problem, which is why they are trying to first identify what this will mean for the two countries. India and the Philippines are already two of the world's largest exporters of healthcare professionals.

Both Egelund and Foreign Minister Lars Løkke Rasmussen (M) have visited India.

"Overall, when I talk to authorities, educational institutions and the government in India, this is considered a win-win for both Denmark and India," says Egelund.

Is it "compassionate"?

In addition to the situation with both the current and future increasing shortage of welfare staff, the government's initiatives should also be seen in light of the recommendations of the Resilience Commission, which looked at how to ensure more staff in the healthcare system.

The Commission found that Denmark is "below the OECD average for the share of doctors and nurses trained abroad, and there are signs that the attachment of foreign employees is not strong enough". Approximately 20 percent of them left the country again after five years in the period 2016-2021.

Therefore, the recruitment base in the health and elderly care sector should be "widened by removing barriers" to foreign staff, particularly from EU and EEA countries, the commission recommended. But there was no mention of seeking staff from outside the EU, EEA and the relatively affluent OECD countries, Nanna Maaløe notes.

She and her two colleagues believe that the debate on foreign recruitment has paid too little attention to the global shortage in the healthcare sector.

As the figures from the World Bank show, India and the Philippines, for example, have poorer doctor and nurse coverage than Denmark, and this must be set against the fact that the two Asian countries have significantly higher disease burdens and thus a greater need for healthcare.

"It takes three seconds to find the World Bank's figures," says Nanna Maaløe: "And with them in mind, the government should justify how it is humanely okay to bring in staff from India and the Philippines."

Considered in isolation, it's unlikely that the up to 1,000 healthcare workers, for example, will be the ones to tip the scales of the third countries from which Denmark might recruit them, researchers Nanna Maaløe, Ib Christian Bygbjerg and Dan Meyrowitsch acknowledge.

But the Danish initiatives should also be seen in light of the global trend of high-income countries recruiting healthcare professionals in low- and middle-income countries. Researchers fear that this is exacerbating the shortage of healthcare workers in countries where the disease burden is greatest.

"When high-income countries have some of the best functioning healthcare systems in the world, it is an ethically worrying way to use the world's resources," says Nanna Maaløe.

"Headhunting" or win-win?

Since 2013, Germany has been running a model where nurses from several countries are taught German and then offered the opportunity to join the German healthcare system. In particular, nurses from the Philippines have been successfully recruited to the country.

When the criticism has been voiced that there is a risk of creating a shortage in the countries from which labour is sourced, the response from the German authorities, according to the media Zetland, has been that they only have cooperation agreements with countries that, according to the WHO, have unemployment among local nurses. This is very much the case in the Philippines, while some reports suggest that this may also be the case in India. However, both countries are also reporting a shortage of nurses and doctors.

So, when low- and middle-income countries experience unemployment among, for example, nurses, it should not necessarily be seen as an indication that they have an abundance of them, says Nanna Maaløe.

"Often a symptom of a sick or vulnerable healthcare system is that there are challenges in hiring and retaining stable staff. Therefore, several unemployed are healthcare professionals," she says, "and this should rather be seen as a call to action that the structure of the healthcare system is in alarming need of support to be able to fulfil its tasks."

In Denmark, the government's plans have been criticized by the chairwoman of the Danish Nurses' Association, Dorthe Boe Danbjørg. She told DR in January that the government shouldn't "go headhunting in other countries where they also lack healthcare staff".

The statement has been met with an opinion piece in Altinget from Ulrik Beck, chief economist at the think tank Kraka, who argues that the outlook is brighter than it is now:

The chief economist points out that foreign labour often sends significant amounts of money back to their home country, which can be used to support families or to invest and boost the country's growth. In addition, many foreigners return to their home countries with new skills and increased wealth.

Finally, says Ulrik Beck, it is not certain that 1,000 more health care workers in Denmark equals 1,000 fewer in India and the Philippines, because the opportunity to come to the West may attract more people to train in the profession.

A research paper evaluating a change in US entry rules for nurses from the Philippines even found that for every nurse who travelled to the US, nine additional nurses were trained in the Philippines.

The three researchers from the University of Copenhagen recognise that this is the conclusion of the research article, but doubt that one nurse migrating to the US from the Philippines directly leads to nine more nurses being trained in their home country. Firstly, it is difficult to draw a direct causal relationship, and secondly, there may also be other reasons why more nurses are trained in the Philippines.

"For example, an increased need in the Philippines - we know this when we look at their large shortage," says Ib Christian Bygbjerg. However, both he and his two research colleagues emphasize that no one knows the full consequences of this recruitment, either good or bad.

SF shares the concern

The so-called brain drain - or care drain, as it is called when it comes to healthcare professionals - from low- and middle-income countries to high-income countries has previously been a contentious issue for parts of the left wing. SF is the only red party in the government's agreement about making it easier for up to 1,000 healthcare assistants from third countries to get jobs in Denmark.

Just over a year ago, SF's political leader, Pia Olsen Dyhr, noted in a post in the online media POV International that China and Russia have a "massive presence" in Africa and that it is "more than doubtful how big the gain is for the African states".

"China does indeed bring many Africans to China, where they receive education and PhD programmes. But is this not more of a brain drain, while the continent - as so often before - is being drained of its resources?" she wrote.

Health spokesperson, Kirsten Normann Andersen negotiated the recruitment agreement on behalf of SF. She shares the three researchers' concern about draining other countries of important healthcare professionals "100 per cent".

"It is crucial that we as a high-income country avoid this," she says, referring to the fact that SF, among others, got it written into the agreement that a recruitment model must comply with the WHO's ethical guidelines in this area.

Mostly, Kirsten Normann Andersen relies on other solutions in the agreement to address the recruitment crisis and finds it “difficult to envision a model” for recruiting from countries like the Philippines and India that can function without harming those nations. However, according to her, the agreement should also be understood as requiring different models to be investigated and presented to the parties involved before a final model is implemented.

- What if there is a model that does not meet your standards?

"Then we are not obliged to support it, but we are still involved in the other parts of the agreement," says the health spokesperson.

"I don't have the imagination to come up with a good enough model myself. But that shouldn't stop others from trying to find it."

Beware of generalisations

According to the Minister for Higher Education and Science Christina Egelund, the government recognizes that there can be pitfalls in recruiting from low- and middle-income countries.

But she points out, among other things, that India has launched a major strategy to increase the education of the population, both in the health sector and in general, and that this kind of collaboration with high-income countries is part of the strategy.

"There is something subtle about sitting in Denmark and interpreting India's view of its own needs differently than various actors in India do," says Egelund.

During her visit, Christina Egelund also stopped by the WHO's department in India, which, according to her, denied that there was a problem with recruiting nurses, for example. Among other things, because several states in India have an abundance of them.

To the objection that the surplus may also be an expression of a dysfunctional healthcare system, the minister warns against "assessing the entire Indian healthcare system as a whole".

"If you want to paint a picture of the entire Indian healthcare system as one that is not good, I think you are going the wrong way round," she says.

When the WHO's ethical guidelines are mentioned in the recruitment agreement from the Danish Parliament, reference is made to both a code from 2010 and a strategy from 2020. Among other things, the code advises against "active recruitment of healthcare professionals from developing countries facing critical shortages" of exactly that.

Christina Egelund agrees with SF that collaborations with other countries must live up to the guidelines.

"This is extremely important," says the minister.

- So if, when they are finished, you send your models with India and the Philippines to WHO headquarters, they will say that it is perfectly fine?

"We are fortunate that the WHO has written the ethical guidelines, and we will honour them and stay within the framework. I don't see that as a challenge, but as a strength."


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