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An unsettling business:
how agents are commoditizing foreign nurses for German healthcare
Germany's response to the Covid-19 pandemic won international recognition. But its nursing profession is in crisis. During the current second Covid-19 spike, hospital Intensive Care Units are stretched to breaking point due to a lack of staff. Hospitals are desperately scrambling for nurses from South America, the Balkan countries and Asia. It's a lucrative business for recruitment agents – but all too often at the cost of the nurses themselves.
A cross-border investigation
Johanna Salinas had planned to build a new life for herself and her family as a nurse abroad. She quit her job in a hospital in the south of Columbia and threw herself into learning German. She took out a loan to pay for exam fees and prepared her children for their new life in Europe. In early 2020 she travelled to Germany to work in a hospital in Hamburg, Germany's second largest city. But after 18 months of preparation and anticipation, the dream would end in Germany after barely a month.
"In Columbia, I already sensed how inexperienced the agent was but I decided to give him the benefit of the doubt", says Johanna Salinas (name changed). But I had to suffer his inexperience firsthand. They didn't have a clue what they were doing."
In Hamburg, Salinas became desperate within days. Her German wasn't good enough for her work, which often made her new colleagues angry. She entered on a short-term visa but her employer and the agent left her on her own. "The hospital gave me no support at all," says Salinas. Banks refused to open a bank account. "They said I might be a drug dealer or member of a Columbian guerilla organization."
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The hospital couldn't pay her wages without bank account. During her last week in Germany, she was down to ten euros. In desperation, Salinas asked her former boss in Columbia whether she could return to her old job and bought a flight back home.
The global Covid-19 pandemic spotlighted a burning issue: Germany, and other nations in Europe, lacks nurses. This threatens not only patient safety but is also prompting many overworked nurses to leave the profession. Studies have shown that in hospital departments with lower staffing levels, higher patient mortalities occur. Early this year, local media reported that Berlin's Charité hospital – where Christian Drosten, the first to develop a Covid-19 test at the outset of the pandemic works – turned away a child diagnosed with leukemia apparently due to lack of staffing and the child died soon after.
In 2018, there were 1.7 million nurses working in Germany. The industry itself says this is barely enough and one estimate projects that the shortfall will reach 270,000 nurses by 2035. In some German regions, the health system is already dependent on foreign nurses.
Hospitals pay up to 15,000 euros in fees to agents who search the world for qualified nurses. But the promise of a new life abroad comes with conditions attached. The financial risk often is entirely placed on their shoulders, not on the hospitals or the agents. When nurses want to change their employer, they first have to reimburse the cost of their recruitment. And so their life in Germany begins in debt.
"The official requirements are so complicated that nurses are unable to move about Germany and get a foot in professionally without the help of recruitment agencies and employers", says expert Lukas Slotala.
For the agents, that makes it almost the perfect business model. This investigation shows that there are hospitals and agents operating with probably illegal contracts. Politics is doing little to end these dubious practices.
And it's hard enough to find nurses. There are few left in the Balkan countries and southern Europe. Hospitals are forced to look further afield, to South America and Asia. CORRECTIV has teamed up with newsrooms in South America, Serbia and Spain as well as with local newspapers in Germany to investigate the unsettling business of procuring nurses.
"Some of this borders on human trafficking, with people's hardships and worries being manipulated to generate a profit," says Isabell Halletz of an industry working group on foreign nurses which brings together employers and agents from the German health sector.
Not invited to the party
The agent who brought Johanna Salinas to Germany for her all too brief stay is part of Germany's unregulated nursing recruitment market. The Hamburg-based company was founded in 2018 by a Serbian national who himself had come to Germany as a nurse a few years previously.
While working in a Hamburg hospital he no doubt saw firsthand the shortage of nurses in Germany and how much hospitals were willing to pay for foreign nurses. He set up a recruitment agency with its own language school in Columbia.
On social media, the 28-year-old presents himself as a successful entrepreneur. In video clips, Columbian nurses sit in a cocktail bar overlooking the port of Hamburg and saying how well everything has worked out. There are flashy video clips of his travels and meetings between German hospital representatives and nurses in Columbia – as though global migration was a party with the Serbian businessman as its generous host.
Johanna Salinas did not feel part of that. 'It is you who have failed, not the project,' the agent told her when she said she wanted to return to Columbia, Salinas claims.
"We're with them at all times"
The agent says that only two nurses, one of them Salinas, have not been satisfied. He says the two simply lacked the patience required for the first steps in Germany, for example for the accreditation of the foreign nursing certificate or the opening of a bank account. He says he took a financial hit from the nurses' return to Columbia.
The agent recounts how he himself felt abandoned when he arrived in Germany, hence the idea to establish his own agency. He says he looks after the nurses he recruits. "We're with them at all times. I have clients I've been taking care of for four years now."
In the language school in Columbia, set up just before she began her German classes there, Johanna Salinas was left with a different impression. The teachers were not qualified. Both patients and medical staff in Germany are often unhappy when foreign medical staff are unable to express themselves fluently in German – this case shows it is not necessarily they who are to blame.
A former worker of the school confirms that. "The teachers had no academic training", he says to CORRECTIV, "Everything had to be solved quickly".
The nurses attending the school committed themselves to reach a CEFR (Common European Framework for Reference of Languages) B2 proficiency in German – with A1 being a beginner and C2 indicating fluency — within six months. A totally unrealistic goal.
Alone at the hospital
The agent admits that when he set up the language school some of the teachers had no certification. But he says that this is no longer the case. He says he qualified as a certified examiner to assess the language skills of the nurses recruited by his company. He says he has recruited more than 200 nurses for German health employers from about half a dozen countries including Columbia and Serbia. "They are doing very well here."
Johanna Salinas adds that the Hamburg hospital provided little support. She had only partially reached the far lower B1 level of German proficiency – after a course the agent says should have taken her to B2. Salinas says that on her first day at work she had to sign contracts she hardly understood.
Salinas was handed a folder with hospital documents and work rosters and was given a brief tour of the hospital. "They expected me to arrive in the hospital and start work after two hours."
Foreign nurses often feel left alone at their workplace. To some, the experience is so troubling that they return to their home countries.
Things did not improve. Salinas says she felt helpless as she was unable to communicate effectively with either colleagues or patients. She had worked as a nurse for almost two decades back in Columbia. In the Hamburg hospital, in order to do the right thing, she desperately tried to identify the work flows she knew from home to make up for the lack of language skills.
Salinas left Columbia to make a new life for her family in Germany, but in Europe she just felt let down. "I want to tell my story so others won't have to go through the same thing," she says.
The language hurdle
Foreign nurses need to prove B2 language level to have their foreign nursing qualification recognized in Germany. But experts say even that is not sufficient for the job.
"B2 really is quite meagre", says Andrea Schmidt-Rumposch, head of nursing at the Essen University Hospital in Germany's most populous state of North Rhine-Westphalia. "They're arriving with B2 but the minimum really is C1". C1 is the requirement for international students who wish to study at a German university, for instance.
The Essen hospital has been recruiting nurses from outside Germany/EU since 2019, from Serbia and the Philippines. It provides them with German classes on the job that reflect the working environment of nurses and has hired two full-time staff to deal with international recruitment.
The number of non-EU nurses applying to have their nursing degrees accepted in Germany has increased exponentially in recent years. In 2012, the number was below 500. By 2019 it had shot up more than 20-fold to around 12,000 – and the actual demand for qualified staff is much larger still.
That is fueling a boom in the recruitment market. With the cost of recruiting a nurse internationally standing at around 10,000 euros, the current market is worth an annual 120 million euros. The recruitment hasn't stopped during the Covid pandemic. The businessman of Serbian origin, for instance, used a humanitarian flight to bring in a nurse from Columbia when travel options were limited.
Dubious players
There are many respectable recruitment agents in the market who help international nurses in the process of having their degrees certified by Germany authorities which can take anything up to two years. "The official requirements are so complicated that nurses are unable to move about Germany and get a foot in professionally without the help of recruitment agencies and employers", says Lukas Slotala of the University of Applied Sciences Würzburg-Schweinfurt, an expert on nursing since his time working for the city of Darmstadt near Frankfurt.
But the business also attracts operators offering misleading promises – in particular concerning the all-important issue of language skills.
"One agent once told me right here in my office that he could take somebody without any knowledge of German to B2 within one week," says Slotala. "Unfortunately, some inexperienced hospitals and nurses fall for that."
"This is modern debt bondage. How is an employee earning close to the minimum wage supposed to repay these amounts?" says law professor Christiane Brors.
The sticking point
Overpromising on language skills is only one of the pitfalls of a business that remains largely unregulated. The key issue in the international recruitment of nurses is the cost. Language classes, travel, accreditation procedures and recruitment fees for each nurse recruited are now 10,000 euros or more.
The concern of hospitals is that internationally hired nurses may only remain with them for a few months before deciding to return home or switch employers. Some hospitals as well as agents are transferring this financial risk entirely onto the nurses by requiring them to sign one-sided contracts which force the nurses themselves to shoulder the upfront costs.
Documents seen by CORRECTIV show several cases of this, each involving costs of about 15,000 euros. In one case, a hospital asked an Asian nurse who wanted to quit her job to reimburse not only language classes and travel costs but also the some of the wages the hospital paid to her colleagues during her initial training on the job. In extreme cases, hospitals have required nurses to sign contracts committing them to work for them for five years, as documents seen by CORRECTIV show.
A non-transparent business
It is not known how many recruitment agencies are operating in the market. "There are also individuals who immigrated themselves or who know somebody in third countries and who then act as recruiter", says Isabell Halletz. "That is what makes it so opaque."
A second case unearthed by this investigation shows how a recruitment agent tried to make money while offloading the entire risk onto the nurses.
Nordoberpfalz Clinics, a public hospital group in the German state of Bavaria, employs 3,000 staff and runs its own nursing school. As with many hospitals across Germany, its training facility is unable to maintain staffing levels and the group has recruited international nurses – working with an agent at times using legally questionable contracts.
Destination Banja Luka
At the start of 2020, a number of Mexican nurses began working for Nordoberpfalz Clinics. But en route to their new life in Germany, the new recruits first made a rather curious detour to Banja Luka, Bosnia and Herzegovina's second city. This was where the agent – a company called QI Consult based in the German city of Dortmund – arranged for a six-month German course.
Employment lawyers consulted by CORRECTIV consider certain clauses in the recruitment agent's contract to be in clear violation of German labour law. Nurses committed themselves to pay back costs of about 15,000 euros if they quit their jobs before a period of five years – the actual amount depending on how soon before the end of that period they sought to leave.
Christiane Brors, a law professor at Oldenburg University, thinks the clause is invalid. "This is modern debt bondage. How is an employee earning close to the minimum wage supposed to repay these amounts?"
Another isolated case?
Nordoberpfalz Clinics says that there were no reimbursement clauses from its side and that it too considered a five-year clause to be in violation of German labour laws.
A representative of the recruitment agency QI Consult told CORRECTIV that the company only included this clause in its early days and only in some cases, adding it no longer makes use of it. Nurses should bear no costs associated with the recruitment and migration to Germany, he said. "We take care of our clients after they begin work and we help with family visa or other issues that assist with integration in Germany," the company said in a statement to CORRECTIV. It said it arranged German classes in Banja Luka for a pilot group of nurses due to the high costs of language classes in Germany and that in the future it would seek to implement more classes in the nurses' home countries.
A state solution?
Public recruitment of international nurses does without recruitment agencies and oppressive contracts. Germany's Federal Employment Agency and GIZ, Germany's international aid agency, have recruited nurses since 2013 in a joint project called 'Triple Win'. The project covers Vietnam, the Philippines, Tunisia as well as Bosnia and Herzegovina and initially Serbia. It is called Triple Win as three parties are intended to benefit from it: the German healthcare system, the international nurses seeking higher wages, and the partner countries whose labour markets are relieved through migration. Countries such as the Philippines also seek to export nurses as their economies depend on their remittances.
But the public recruitment program falls far short in coping with the demands of German healthcare providers. Only around 2,600 nurses have entered Germany through the program in the seven years since it began.
And while legitimate recruitment agencies, depending on what is agreed with the healthcare provider, usually take care of international nurses while they settle into German, critics say the state-run program does not do enough in this regards, limiting acceptance of the program by German employers.
In October 2019, Federal Health Minister Jens Spahn travelled to Mexico, meeting nurses and Mexican officials.
Language barriers aside, the lengthy process of certifying the nurses' home country degrees poses the biggest hurdle to the international recruitment of nurses by German healthcare providers. A confusing number of government offices is involved in an application process which can take up to two years. The industry has long called for easier-to-understand standards to be introduced. Experts say that to date, most of Germany's states have not yet managed to create a central office which employers can turn to, leaving the latter with an odyssey through local government departments for each nurse they seek to recruit from abroad.
In October 2019, amid much fanfare, the German state of Saarland and the federal Health Minister Jens Spahn announced the creation of DeFa (In English: The German Agency for International Healthcare Professionals), an agency designed to solve just that. The new organization promised to speed up the accreditation process to just six months. Spahn also travelled to Mexico that month, meeting nurses and Mexican officials. But one year on, DeFa has processed a disappointing 28 applications.
4,500 euros
Anabel Flórez arrived in Germany in 2018. Only one of the six other nurses on her German language course in the Columbian capital Bogota, organized by another small German recruitment agency, made it with her. The agency that organized the classes had promised her a job as a nurse in a hospital, the kind of work she did in Columbia. Instead, she found herself working as a care assistant in a nursing home for the elderly near Frankfurt. She says the recruiter had not been transparent with her.
"The owners of the nursing home were really sweet but such under-use of my professional skills was very frustrating. After three months, I left."
But that was not so easy for Flórez. While the nursing home's owners could understand her situation, they expected here to pay back 4,500 euros, part of the cost of her recruitment.
Flórez only managed to switch employers because she found another recruitment agency that agreed to pay the compensation. In the end, this was not necessary. She has now a new position in a Frankfurt hospital where she is happy with the work.
Rogue Operators
TalentOrange, a Frankfurt-based agency says it has recruited almost 1,000 nurses from South America, Asia and southern Africa since 2013.
"There are many black sheep," TalentOrange's Tilman Frank says of some of the agencies operating in the market. "I find it hard to understand there is no way to handle this or for people somewhere else to assess how reliable the company they're dealing with is."
Frank proposed a quality seal for recruitment agencies to Germany's federal health ministry to address the issue. "That would make it easier for people outside Germany to feel more secure."
Healthcare providers are also pushing for better regulation. "Every week, around ten recruitment agencies approach me, mostly just one or two-person outfits," says Andrea Schmidt-Rumposch of the Essen University Hospital. "It would helpful if at some point we had certain quality standards. We really do need another level of standards here."
An industry working group set up by the federal health ministry also recommends the introduction of a quality seal, Meanwhile a state-funded institute for the recruitment of international nurses is developing a certification for what it calls ethical recruitment. Even so, any quality seal is likely to be only voluntary.
In Germany, healthcare isn't the only industry affected by an ageing population and the resulting lack of young, qualified staff. Car manufacturers, for example, have resorted to training locals in their overseas subsidiaries, in Asia and elsewhere, to later transfer them to their German plants. But in healthcare, companies typically do not have foreign subsidiaries and only larger employers can afford to afford to set up training schemes abroad. Berlin's public healthcare provider Vivantes is one. It has been training nurses in Vietnam since 2015. Smaller providers, particularly in rural areas that are less attractive to international nurses, will need to team up for their international recruitment efforts.
In Germany, the cost of training nurses is financed by the national health system as well as individual German states. Experts such as Lukas Slotala suggest the same approach should be adopted for the cost for international recruitment of nurses – which is lower than training nurses in Germany. That would protect nurses such as Johanna Salinas or Annabel Flórez since the health system would underwrite all costs. But that still would not solve another issue associated with the international recruitment of nurses: Germany is luring them away from countries that also need them.
A global race
In 2010, Germany signed a code of conduct drafted by the World Health Organization (WHO) that commits its signatories to act against unscrupulous middle-men and to grant nurses recruited abroad the same rights as local hires. It is also meant to ensure that recruiting nations don't hire nurses from countries with healthcare personnel shortages. The WHO country list was last updated back in 2006 although the organization discussed changes to it during its general assembly earlier this month. The 57 countries mentioned are mostly among the world's poorest. But some of the more developed countries where Germany is recruiting, such as Serbia, are themselves confronted with an ageing population – and their demographic situation, unlike in Germany, is made worse by an exodus of young people.
In 2016, Mexico could count only 2.89 nurses per 1,000 inhabitants – compared to almost 13 per 1,000 in Germany. The WHO assumes that a country needs a ratio of 4.45, including midwifes and doctors, to have a functioning healthcare system.
The global Covid-19 pandemic has made the situation worse. The Philippines, long a major provider of nurses to other countries, suspended all international recruitment in April 2020. Serbia ended its participation in the German Triple Win project in June.
A homemade solution?
Many in the industry say the solution should be found at home.
"Recruitment can only be one part of a whole package of measures", says Dietmar Erdmeier responsible for health policy at the executive board of Ver.di, Germany's second largest trade union with around two million members. He says that many nurses are leaving the profession long before retirement age due to the high work load. "I see quite often how rundown people are when they're in their mid or late 50s, the muscles, bones, mental illnesses, busted knees, back problems. So there must be physical and mental alleviation."
High work load aside, nursing wages need to be increased. Andrea Schmidt-Rumposch of the Essen University Hospital estimates that base earnings will have to be 20 percent higher to make jobs in the industry more attractive and to accurately reflect responsibilities for patients and difficult working hours. International recruitment is just one piece in the puzzle to solve Germany's nursing crisis – and a temporary one at that, she says. The minimum wage for nurses who have received three years of training is 15 euros per hour.
"We need to create working conditions that ensure that it's attractive for our young adults to go into nursing, because it's a great job."
During the Covid-19 pandemic, healthcare employees have felt much appreciation from the general public, But that has not translated into higher wages, something the German leftist party Die Linke (The Left) has called for.
"All those who want to come to work here in nursing are welcome but target recruitment is wrong", says Pia Zimmermann, Die Linke member of Germany's parliament, the Bundestag who also serves on the health committee. "In principle, Germany needs to be able to attract the staff it needs from its own population, train them and retain them in the profession. The reason that hasn't worked to date are of our own doing and have been well-known for over ten years."
Johanna Salinas was able to return to her old job in Columbia. In the summer, she finally received the paltry wage from her time in Germany. "You should be grateful," her former agent told her.
Update 2 December 2020. An earlier version incorrectly stated that the involvement of the Triple Win program ends when international nurses enter Germany. We have changed that phrase.
Update 4 December 2020. The article was updated to reflect a change in the version given by the recruiting agency that helped Anabel Flórez change jobs.
Investigation: Olaya Argüeso, Miriam Lenz, Lisa Pausch, Frederik Richter, Juan Diego Restrepo Text: Olaya Argüeso, Frederik Richter Editorial: Olaya Argüeso, Frederik Richter, Justus von Daniels, Gabriela Keller Design: Benjamin Schubert Illustrations: Janosch Kunze Collaboration: Michel Penke Communication: Belén Ríos Falcón, Katharina Späth, Luise Lange, Valentin Zick
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