Steffen Angenendt, Anne Koch, and Melanie Müller

Foresight*: Global Competition for Health Care Workers from Africa

2020/C 64, December 2020

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ISSN 1861-1761

doi: 10.18449/2020C64

(English version of SWP‑Aktuell 87/2020)

Pretoria, 12 February 2024: During a ceremony, the German Minister of Health and his South African counterpart sign the “Together We Care” agreement on the training and assignment to Germany of 20,000 South African nurses. “Together We Care” is part of a comprehensive cooperation agreement. Training centres for medical personnel are to be set up in several South African cities. The agreement also contains commitments to support a vocational training system and the facilitation of visas. The event has received extensive media coverage and a predominantly positive reception. The German weekly newspaper FAZ publishes a front page article with the headline “Germany can hold its own in global competition”, and the weekly taz welcomes the agreement with an article entitled “Germany remains a country of immigration”.

Foresight*: Global Competition for Health Care Workers from Africa

Steffen Angenendt, Anne Koch, and Melanie Müller

The agreement is the result of intense negotiations between Germany and South Africa. The long-standing shortage of skilled nursing staff in Germany has worsened dramatically since the outbreak of the Covid-19 pandemic in 2020. Meanwhile, many Eastern European governments are making efforts to keep their health care workers in their own countries or to encourage them to return by offering financial incentives. As a result, the shortage of medical personnel and trainees has become so severe that it puts the functioning of the entire German health care system in jeopardy. The situation is similar in neighbouring European countries. In 2016, WHO predicted that by 2030, an additional 18.2 million health care workers would be needed across Europe. This forecast seems increasingly realistic.

How It All Began

For these reasons, since the beginning of 2021, the Federal Government has been prioritising the improvement of staffing levels in the nursing sector. In doing so, it is following the recommendations of the German Hospital Institute (DKI) of 2019, which aim to expand training capacities, reduce the proportion of part-time workers, activate the “hidden reserve” of former health care personnel, and ensure that workers stay in nursing care longer. Due to widespread public concerns about non-European immigration, the DKI’s recommendation that additional nursing staff be acquired from abroad is initially ignored. Soon, however, the German Economic Institute (IW) has to significantly revise its 2018 forecast – which predicted a need for an additional 130,000 to 150,000 new full-time care workers by 2035 in the elderly care sector alone – upwards. As a result, there are growing calls from policy makers and civil society alike for increased recruitment efforts abroad.

The German government must react. In an interdepartmental meeting convened by the Chancellery in October 2021, departmental representatives discuss which non-European countries would be suitable for the recruitment of nursing staff. The Federal Ministry of Health (BMG), the Federal Foreign Office (AA), the Federal Ministry of Labour and Social Affairs (BMAS), the Federal Ministry for Economic Cooperation and Development (BMZ), and the Federal Ministry of the Interior (BMI) participate. Early on, the group decides to focus on the African continent in order to create synergies with the Federal Government’s ongoing efforts to establish a new partnership between the European Union (EU) and Africa.

Together, the ministries agree on several criteria: The BMG attaches great importance to the fact that the respective countries have been successful in dealing with the lingering Covid-19 pandemic, and that the average level of education among the general population is high enough to pursue a nursing qualification that meets German standards. The AA emphasises the added value of existing German language skills among the population and demands that language institutions such as the Goethe Institute already exist in the respective countries. The BMZ urges that the focus of attention should be the surplus of youth as well as the levels of youth unemployment, as these factors can increase the development-policy benefits of possible recruitment programmes and dispel concerns about brain-drain. The BMI, which is still highly critical of the acquisition of skilled workers from abroad, intervenes repeatedly to raise security concerns. The weekly magazine Der Spiegel quotes the Federal Minister of the Interior as saying: “First we worked for years to keep Africans out of Germany, and now we are inviting them.” This kind of mindset hinders negotiations for extended periods and delays the project.

Nevertheless, in view of the urgent need for action, the ministries finally agree to exploratory talks with a number of the African countries that – in the ministries’ view – meet at least some of these criteria, and with which Germany can build upon existing cooperation agreements. These include the Ivory Coast, Ghana, Kenya, Morocco, Senegal, Tunisia, and South Africa. Since many young Africans would like to work in Europe, the ministries are optimistic that they will be able to conclude initial recruitment agreements with some countries of origin within a year.

“Germany Is Late to the Party”

Just before summer break, June 2022: Disillusionment is spreading in the Federal Government. In the first round of negotiations, none of the states approached show any interest in the German government’s offer to upgrade the skills of foreign nursing staff in a crash course format, and to employ them in German facilities for an initial period of two years. The reasons are similar everywhere: “We have already received more attractive offers from other countries”, “Why should we send sought-after nurses to Germany without any compensation?”, and “Germany is late to the party”.

How could this have happened? Apparently, the global competition for health care workers intensified within a short period of time, when not only European countries started recruiting nurses from Africa, but also China, Australia, and Canada. Reports in the media further accelerated the process. The responsible German decision-makers underestimated this development. One reason for this was their inward-looking focus and their preoccupation with the concerns of the electorate. Other European countries – above all the former colonial powers France and the United Kingdom – used confidential bilateral channels to negotiate beyond public view due to the general level of reservation about the issue.

France has reached agreements with Algeria, Morocco, and Tunisia, and the United Kingdom with Kenya. The Chinese government, for its part, has been able to build on existing exchange programmes for African students and promoted them effectively at the last Forum on China-Africa Cooperation. Because there was already an immense and rapidly growing demand at home before the pandemic began, Beijing promised Senegal, Côte d’Ivoire, and Ghana considerable direct investment if the three countries granted China comprehensive access to trained nurses. As a result, these countries rejected similar offers from other countries. South Africa managed to avoid being pressured into any such nearly exclusive recruitment agreements. However, emboldened by the negotiation successes of other African countries, it made significant demands.

Against this backdrop, the German offer to poach temporary care workers without substantial compensation is not competitive. The media are increasingly concerned about the growing difficulties in attracting urgently needed skilled workers to Germany. Disturbing reports about neglected elderly people in understaffed nursing homes are further fuelling the debate. The press accuses the government of having failed at negotiating and defending German interests with sufficient determination.

Breakthrough in the Negotiations

Now the German government is under pressure to act and decides to focus its efforts on a specific country of origin. The choice is South Africa, Germany’s most important economic partner in sub-Saharan Africa. President Cyril Ramaphosa and his government, which is led by the African National Congress (ANC), is interested in cooperating with Germany. But the ANC is divided. Following the approach of former President Jacob Zuma, one faction would prefer cooperation with other BRICS countries, especially China and Russia. This hinders the start of concrete negotiations.

The German ministries need to discuss how the concerns of South Africans can be addressed. In view of China’s aggressive offers, it is no easy task putting together a tailor-made package that not only takes South Africa’s specific needs into account, but that is also more attractive than competing offers. In addition, smaller European countries, such as the Scandinavian countries and the Netherlands, have now entered the global competition for health care workers. They are offering the South African government the prospect of extensive trade and investment partnerships.

To speed up the development of a competitive offer, the German government quickly sets up consultations with country experts from research and development cooperation, the health care sector, chambers of commerce, the labour ministry, and the South African diaspora. These consultations show that the vocational training sector is a top priority for the South African government for reducing the high levels of youth unemployment among secondary school graduates. With this in mind, the BMZ proposes an idea that has been discussed in expert circles for years: transnational training partnerships. Such partnerships would provide for the establishment of two-tier nursing schools in South Africa that are co-financed by Germany, providing training for South Africa’s and Germany’s health sector in parallel. With these partnerships – and the idea of a fair balance of interests that underlies this concept – Germany’s offer to South Africa could stand out from competing offers. The other ministries agree with this strategy. At a special meeting of the German–South African Binational Commission in March 2023, the German government presents its partners with a new offer for the training and assignment of nurses. On this basis, the South African government agrees to start concrete negotiations.

Internal EU Competition and South African Controversies

Although the South African government shows a general interest in the German offer of training partnerships, the cabinet in Pretoria agrees that the global competition for health care workers should be used as an opportunity to make further demands, especially with regard to visa policy. A tough series of negotiations between the two governments begins. The German delegation argues that visa issues must be coordinated at the European level and are therefore not up for discussion in the bilateral negotiations. The South African side does not accept this position. Instead, it refers to parallel negotiations with Finland and the Netherlands, in which concrete measures for the facilitation of visas have already been offered. Caught off guard by this intra-European competition, the German delegation asks for a two-week break in September 2023 in order to agree internally on a new package of offers.

Before this is finalised, another obstacle arises: An internal power struggle within the ANC almost leads to the failure of the negotiations. Opponents of President Ramaphosa are leaking sensitive information to the press to weaken him and his faction in the ANC ahead of the 2024 elections, thus strengthening their negotiating power within the party. These leaks include information on possible training partnerships with Germany. Ace Magashule, the president’s fiercest opponent, is implying in the South African press that Ramaphosa is a traitor who is selling young black South Africans to the West in pursuit of a neo-liberal economic policy. Serious South African media are leading the discussion in a different manner, but with a similar tone: Why Germany, of all countries? Why is the Federal Republic poaching the good people? And what do we get out of it?

This sparks a debate on partnerships, above all, at South African universities, where there has been a critical discussion on the decolonisation of the education system and international relations since 2014. Germany is seen as a problematic partner in this context. Firstly, the German government has still not sufficiently expressed guilt and responsibility for its role in the Herero and Nama genocide in Namibia and is therefore not considered an acceptable partner. Secondly, the shift to the right in Europe and the racist attacks on migrants, which have also occurred in Germany, are worrying. Thirdly, the question arises as to whether South Africa needs the care workers more than Germany.

This discussion puts Ramaphosa under massive domestic political pressure just under a year before the parliamentary and presidential elections. At the same time, however, it gives him the necessary support in the negotiations to demand not only training partnerships and the facilitation of visas but also far-reaching support for South Africa in developing a vocational training system. With this comprehensive package of demands, Ramaphosa eventually succeeds in both appeasing critics from his own ranks and selling the results as a success in the fight against youth unemployment before the upcoming elections. In December 2023, after strong intervention by the other ministries, the BMI finally gives in to the demands of the South African government, clearing the way to work out concrete details.

The Agreement

At the heart of the “Together We Care” agreement is the establishment of 10 two-tier nursing schools in South Africa that are co-financed by Germany in order to provide training for both the domestic and German markets. This includes placing graduates in suitable jobs in Germany – at least 17,500 in the first five years. In order to meet the acute German need for nursing staff, 2,500 South Africans who have already completed the basic training in nursing care are sent to Germany and then receive further training on a part-time basis.

Beyond the health care sector, the agreement contains extensive commitments by the German government to promote vocational training programmes, thereby supporting the development of South African capacities in manufacturing and agriculture. In addition, the German government has promised to facilitate visas for business trips and university exchange programmes.

A final point of contention is whether the assignments of care workers should from the outset be temporary working stays with an obligation to return, or whether any return would be voluntary. Finally, there is agreement on a mobility-oriented approach, according to which the decision is left to the migrants themselves. This could encourage circular migration, if this is in the migrants’ interest. In order to safeguard this mobility approach and freedom of choice, the South African government demands a “mobility promotion package” from the German government. It should include financial and practical support for returnees to South Africa, but at the same time offer them the opportunity of re-migrating to Germany with a work permit. When the German government accepts, the South African Mail and Guardian carries the headline: “Germany and South Africa finally seeing eye to eye.” Finally everything is set for the agreement to be signed.

A Look into the Future: African Context

Once the negotiations are concluded, the German side urges its new partner country South Africa to rapidly implement the agreements on the assignment of nurses. Despite warnings from the BMZ, there is no pilot phase. All 10 nursing schools are to be set up at the same time, and the first 2,500 “direct assignments” to Germany will take place as early as March 2024.

This ambitious schedule creates concerns. Instead of being purely beneficial, the new cooperation also poses problems for South Africa’s health care system, which is characterised by a sharp imbalance between the public and private provision of health care. Although South Africa has made considerable efforts to strengthen the public health care system and reduce corruption since the beginning of the Corona pandemic, there is still a long way to go: The incentives to work in public health care remain weak. In line with this, the bulk of applications for direct assignments to Germany come from the poorly paid public sector, threatening to further reduce the country’s already limited human resources. In rural areas in particular – in the Eastern Cape, Mpumalanga, and Limpopo provinces – there is a severe shortage of nursing staff. The development community soon voices criticism of the process. In reaction to this, the BMZ feels compelled to launch new programmes to strengthen the South African health care system in parallel with the “Together We Care” agreement. These programmes are aimed primarily at strengthening rural health care systems, and also promote medical technology cooperation between German and South African companies.

At the same time, the training partnership has direct consequences for neighbouring Zimbabwe, which is still governed by Emmerson Mnangagwa and the Zimbabwe African National Union – Patriotic Front. After the country slid into a serious economic and food crisis in 2020 and the government’s repression of the population intensified, more Zimbabweans emigrated to South Africa. The distressing conditions of the Zimbabwean health system only became visible in 2021 and 2022 as the pandemic spread in rural areas – a fact the government tried to conceal. Hardly anyone from Zimbabwe wants to return to the crisis-torn country.

A large proportion of Zimbabwe’s health care workers have been in exile in South Africa since the end of 2020. This is mainly because the government reacted to the strikes and protests by doctors and nurses in Zimbabwe in June and July 2020 with increasingly harsh responses and arrested journalists who exposed corruption in the health sector. Those who could, left the country. As a result, the health system has become so decrepit that access to health care has deteriorated even further.

Figure 1

The “Together We Care” agreement has additional implications for Zimbabwe. Until Germany and South Africa reached an agreement, it had been difficult for South Africa to employ qualified Zimbabwean health care workers. But the new partnership creates additional jobs in South Africa. As a result, even more health care workers in Zimbabwe are trying to come to South Africa. This has advantages for South Africa because it replenishes some of the expertise that is migrating to Germany. At the same time, the BMZ is being criticised for not having considered the potential negative consequences for the region. Now the ministry is faced with demands to strengthen Zimbabwe’s health care system and resume bilateral development cooperation with the country.

A Look into the Future: European Cooperation

For the German government, the agreement with South Africa represents a hard-earned negotiation success, and it knows how to present this achievement to the public for its own benefit. However, the representatives of the various ministries concerned with the issue know that the German–South African agreement can only be a first step on the long road to eliminating the shortage of skilled workers in the health care sector. In the meantime, many wealthy states have intensified their recruitment efforts on the African continent and in South East Asia. China is gaining ground in several potential partner countries that Germany is also competing for with its European neighbours. In view of the obvious disadvantages of this internal EU competition, the European Commission presents a proposal for a European recruitment strategy in autumn 2025. It is based on the assumption that pooling the negotiating powers of all EU member states makes as much sense in the recruitment of skilled workers as in other policy areas. This brings new momentum to the discussion on a common European labour migration policy, which the European Commission believes should in the future focus more on economic sectors and their needs than on the individual qualifications of workers.

Dr Steffen Angenendt is Head of the Global Issues Research Division.
Dr Anne Koch is Associate in the Global Issues Research Division.
Dr Melanie Müller is Senior Associate in the Middle East and Africa Research Division.

* Foresight deals with conceivable events in the future. It offers insights on a fictitious event (not an analysis of real-life developments) with the aim of working through non-linear or unexpected developments.