ICN calls for a strengthened code on international recruitment and a fair deal for countries that are losing their experienced nurses

The International Council of Nurses (ICN) is calling for the World Health Organization’s (WHO) code of practice on the international recruitment of nurses to be significantly strengthened to ensure a fair deal that includes proper compensation for source  countries with far fewer nurses and weaker healthcare systems, and whose nursing workforces are increasingly being targeted by wealthier nations.

Speaking after a visit to Ghana earlier this month, ICN CEO Howard Catton said the current Global Code of Practice on the International Recruitment of Health Personnel has not protected countries on WHO’s so-called ‘Red List’ — those countries identified as being so vulnerable that there should be no international recruitment from them — from the aggressive and rampant recruitment of their nurses, including senior nurses with specialist experience and irreplaceable expertise.

“After the pandemic, we saw a surge in international recruitment, mainly by higher income countries who were using it as a quick fix to make up for the nursing shortages that have resulted from not training and retaining enough nurses to meet their countries’ health care needs.

‘Despite our warnings about the negative impact of this issue over the past two years, and the associated media coverage, very little appears to have changed. While I was in Ghana, which is a Red List country, I was told that between 400 and 500 nurses are continuing to leave the country to work overseas every month, many of whom are very experienced and in specialist roles. This places huge additional pressure on the health system and the remaining nurses within it who struggle daily to provide the fundamental care that the people of Ghana need.

WHO’s Code requires any active recruitment from Red List countries to be protected by government-to-government bilateral agreements, but in practice, few bilaterals are being used, and WHO’s own analysis has highlighted that many are too weak to be effective.

‘The WHO Code describes ethical recruitment as that where there is mutual benefit — which should mean that source countries are receiving millions of dollars to compensate them for the valuable nursing resources they are losing but we are just not seeing evidence that is taking place. We are simply not aware of the details of the few agreements that are in place and what level of compensation, if any, Ghana is receiving. High-income recruiting countries are saving thousands of dollars for each nurse they recruit overseas rather than educate internally.

‘I was explicitly told that current recruitment activity is having a hugely detrimental impact on the ability of Ghana’s health system to provide care, which is why it is so important to ensure that there is a fair deal for all source countries including compensation that goes directly into strengthening nursing in the countries targeted and their health systems.

‘Without these assurances, we are on a fast road to widening inequalities which will prevent the achievement of universal health coverage and the Sustainable Development Goals and lead to increasing resentment. Unethical recruitment practices which leave low-resource countries picking up the tab for educating nurses who are then drawn to wealthier nations has been described to me as feeling like a form of neo-colonialism.”

Mr Catton said another issue of growing concern was that some private employment agencies are avoiding compliance with the Code by providing ‘back-channel’ processes that enable nurses to be recruited to wealthier countries ‘under the radar’.

“Given the number of nurses leaving Ghana and the few government agreements in place, it is clear there is considerable recruitment agency activity, and nurses have indicated to us that these agencies tell them that they are working on behalf of major hospitals and healthcare providers in destination countries. We must address these back-channel processes and should consider financial levies as part of ensuring a fair deal to the source countries. The health harms that are being caused as a result of current aggressive recruitment activities can no longer stay under the radar. That requires both global and national approaches and a shift from a voluntary to a mandatory code of practice which includes financial compensation, much greater transparency and coordinated action by the small number of high-income countries responsible for the vast majority of current recruitment activity. Imagine if the high-income countries leading current recruitment and the G20 came together to say we will establish a global nursing education fund to build nursing schools and support nursing jobs in the places we are recruiting from. That is what real mutual benefit could look like.”

Mr Catton also highlighted that nurse unemployment in Ghana could run into the tens of thousands, but that this reflected a ‘lose-lose’ situation in the country, which has inadequate resources to employ sufficient nurses, and was not a sign of oversupply.

While in Ghana, Mr Catton received a commemorative plate from the Ghana Registered Nurses and Midwives Association (GRNMA) in recognition of ICN’s achievements in protecting nurses and nursing during its 125 years of existence. He also received an award for his personal contribution to nursing globally.

Mr Catton was the special guest of honour at GRNMA’s 5th Annual Dinner and Awards Night 2024.

Receiving the award on behalf of ICN, Mr Catton said: “This event is evidence of the incredible dedication and professionalism of Ghana Nurses and Midwives and it's a wonderful opportunity to honour those who have shown exemplary professionalism and innovation in their field. I am both proud and humbled to share this occasion with you.”

GRNMA President Mrs Perpetual Ofori-Ampofo, who presented Mr Catton with his personal award, stated: “Mr Catton’s presence is a testament to the growing recognition of nurses and midwives in Ghana. His visit is a pivotal moment for global and local health partnerships.”

The citation on the award given to ICN by the Ghana Registered Nurses and Midwives Association (GRNMA) reads:

For 125 years you have carried out your mandate as the global voice of nursing with integrity, transparency, inclusivity and honesty. The GRNMA in its nearly 65 years of existence has enjoyed recognition, guidance and protection from the ICN. We honour you today as a PARTNER and wish to assure you that the GRNMA will forever remain a proud member of the ICN. Congratulations! 13th December 2024.

While in Ghana, Mr Catton had a meeting with the GRNMA and the Ghana Nursing and Midwifery Council, with discussions centring on the need for greater investment in nursing, limited job opportunities for nurses and midwives in the country, and the challenge of the ‘brain drain’ caused by recruitment from wealthy countries. During the meeting, Mr Catton praised the nurses and midwives of Ghana for their dedicated service despite the challenges they face and assured them of ICN’s continuing support.

Mr Catton also met recently with scholars on this year’s ICN Global Nursing Leadership Institute (GNLI) programme from the Africa region, who are working on a project to strengthen retention strategies to enable African countries to encourage their nurses to stay rather than seek work overseas. He said their project would support ICN in its advocacy work around this issue.

Mr Catton took the opportunity to raise awareness about the challenges facing Ghana’s nurses by speaking to local broadcast and print journalists.

The GRNMA award ceremony saw nurses from around Ghana receive recognition for their work in a wide range of work settings and specialties in front of an audience of dignitaries, including Ghana’s Ministers of Health and Labour Relations.

Guest of Honour Nii Ahene Nunoo III, Paramount Chief of Abola Traditional Area, pictured with Mrs Ofori-Ampofo, conveyed his appreciation for the audience of nurses and midwives. He said: “It is truly an honour to be in the presence of dedicated professionals who have excelled in their fields. Nurses and midwives are the backbone of the healthcare system. They provide essential care, advocate for patients, and serve as a crucial link between patients and the healthcare system.”