# The care drain: recruiting the world's health workers Poorer countries train the doctors and nurses that richer ones then hire, so origin countries subsidize rich-world health systems. The WHO's voluntary Code is the debated response. *This story parallel: Why Kenya is poor: commodities, deindustrialization, and debt* *This story part of: Weaponized incompetence: was the weak state built to be weak?* *This story part of: Health and medicine* *The World Health Organization: power, failure, and the funding leash parallel this story* *Health and medicine parallel this story* ## c. 1948 — The United States draws in Filipino and other foreign nurses The US Exchange Visitor Program, opened in 1948, brought Filipino nurses to American hospitals for training, and many stayed. Later immigration laws widened the door, and foreign-trained nurses and doctors became a fixture of the US health system. Filipino nurses in the US have long earned many times what they could at home. ## c. 1974 — The Philippines builds a state system to train nurses for export Under President Ferdinand Marcos the Philippines set up state machinery, later the Philippine Overseas Employment Administration, to send workers abroad and earn foreign currency. Nursing schools geared toward overseas jobs, and the country became the largest single source of migrant nurses, supplying roughly a quarter of the world's overseas nurses. Remittances now fund a large share of the national economy. ## 2000 — The NHS Plan turns to overseas recruitment England's NHS Plan set targets for thousands of new doctors and nurses and backed active recruitment from abroad to meet them. It opened a sustained drive to hire staff trained in other countries. Britain has relied on internationally trained health workers ever since. ## c. 2000 — Gulf states recruit health workers at scale Wealthy Gulf states built much of their hospital workforce by hiring abroad, drawing nurses and doctors from the Philippines, India and across Africa and the Middle East. The United Arab Emirates alone employs tens of thousands of Filipino nurses. Private recruitment agencies handle much of the hiring. ## c. 2003 — South Africa both loses and recruits health workers South Africa lost doctors and nurses to Britain, Canada and the Gulf while itself hiring staff from Zimbabwe, Nigeria and other African states to fill the gap. Britain and South Africa signed a memorandum in 2003 meant to limit direct NHS recruitment of South African staff. The pattern shows migration flowing up a chain of income, with each country drawing from poorer ones. ## c. 2004 — The care drain strains health systems in poorer countries Malawi lost so many nurses to Britain and elsewhere that in 2004 it launched an emergency programme to train and keep staff. When a country trains a health worker who then emigrates, it pays for the schooling but loses the service, a transfer of value from poor to rich. Thin staffing weakens maternal care and treatment for common illness in the countries that can least afford the loss. ## 7 April 2006 — The World Health Report names a global health-worker shortage WHO's 2006 report, Working Together for Health, estimated that the world was short about 4.3 million doctors, nurses, midwives and support workers. It named 57 countries with critical shortages, 36 of them in Africa. The report tied the gap to failures in childhood immunization, safe childbirth and treatment for HIV, malaria and tuberculosis. ## 21 May 2010 — The World Health Assembly adopts the Global Code of Practice The World Health Assembly adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel as resolution WHA63.16. It urges richer countries not to actively recruit from places with critical shortages and asks members to report on their practices every three years. The Code is voluntary and not legally binding. ## c. 2010 — Others defend migration as a right and a benefit Economists and some source-country governments argue that health workers have a right to move and that blocking them is unfair. They point to remittances, which fund families and economies, and to the skills and money that return migrants bring home. In this view the answer is better training, pay and conditions, not limits on the freedom to leave. ## 24 November 2011 — A study puts a price on doctors leaving sub-Saharan Africa A BMJ human-capital analysis estimated that nine sub-Saharan African countries lost about $2.17 billion in training investment as their doctors moved to Australia, Canada, the UK and the US. The same doctors saved destination countries far more, with Britain gaining an estimated $2.7 billion. Zimbabwe and South Africa carried the heaviest losses relative to the size of their economies. ## c. 2014 — Critics call the Code toothless Researchers and health advocates argue the Code changed little because it is voluntary and carries no penalties. Evaluations published around 2014, four years after adoption, found weak awareness and limited effect in destination countries, and later reporting showed recruitment from safeguarded countries continued. In this view the Code sets norms but cannot stop wealthy systems from drawing staff away. ## 2016 — A UN commission projects a shortfall of millions of health workers by 2030 The UN High-Level Commission on Health Employment and Economic Growth projected a worldwide shortfall of about 18 million health workers by 2030, concentrated in low- and lower-middle-income countries. WHO later revised the projected 2030 gap to roughly 10 million. Both figures point to demand growing fastest where staff are already scarce. ## 2020 — COVID-19 speeds up international recruitment The pandemic pushed rich countries to hire foreign health workers faster to cover exhausted staff and rising demand. UK recruitment of overseas nurses climbed sharply in the years after 2020, much of it from countries on the safeguards list. The surge sharpened the argument over whether voluntary ethical rules can hold when systems are under strain. ## 2020 — WHO publishes a safeguards list of countries not to recruit from WHO issued the Health Workforce Support and Safeguards List, naming countries facing the most severe shortages where active international recruitment should not happen. The 2020 list held 47 countries, most of them in sub-Saharan Africa. Employers and governments treat it as the red list for ethical recruitment. ## 2021 — Britain signs government deals to recruit from red-list countries The UK and Kenya signed a bilateral agreement in 2021 to bring Kenyan nurses into the NHS, and the UK signed a similar memorandum with Nepal in 2022. Both countries were on WHO's safeguards list, and government-to-government deals are the route the UK's own code allows for recruiting from such places. The deals bar recruitment fees and are framed as targeting surplus, unemployed staff. ## 2023 — WHO expands the safeguards list The 2023 update of the safeguards list grew to 55 countries, adding Comoros, Laos, Rwanda, Samoa, Timor-Leste, Tuvalu, Zambia and Zimbabwe. Of the 55, 37 are in the WHO African region. WHO plans to refresh the list every three years. ## c. 2023 — Foreign-trained staff become central to the NHS By the 2020s a large share of NHS staff had trained or been born abroad. Non-UK nationals made up roughly a third of hospital doctors and close to a third of nurses, and about a quarter of nurses on the UK register had trained overseas. The health service depends on this inflow to keep running.