Global Competition for Health Care Workers from Africa Steffen Angenendt, Anne Koch, and Melanie Müller

NO. 64 DECEMBER 2020 Introduction

Foresight*: Global Competition for Health Care Workers from Africa Steffen Angenendt, Anne Koch, and Melanie Müller

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 recep- tion. 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”.

The agreement is the result of intense nego- How It All Began tiations between Germany and South Africa. The long-standing shortage of skilled nurs- For these reasons, since the beginning of ing staff in Germany has worsened dramati- 2021, the Federal Government has been cally since the outbreak of the Covid-19 pan- prioritising the improvement of staffing demic in 2020. Meanwhile, many Eastern levels in the nursing sector. In doing so, European governments are making efforts it is following the recommendations of to keep their health care workers in their the German Hospital Institute (DKI) of own countries or to encourage them to 2019, which aim to expand training capac- return by offering financial incentives. As ities, reduce the proportion of part-time a result, the shortage of medical personnel workers, activate the “hidden reserve” of and trainees has become so severe that it former health care personnel, and ensure puts the functioning of the entire German that workers stay in nursing care longer. health care system in jeopardy. The situa- Due to widespread public concerns about tion is similar in neighbouring European non-European immigration, the DKI’s countries. In 2016, WHO predicted that by recommendation that additional nursing 2030, an additional 18.2 million health care staff be acquired from abroad is initially workers would be needed across Europe. ignored. Soon, however, the German Eco- This forecast seems increasingly realistic. nomic Institute (IW) has to significantly

* 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.

revise its 2018 forecast – which predicted hinders negotiations for extended periods a need for an additional 130,000 to 150,000 and delays the project. new full-time care workers by 2035 in the Nevertheless, in view of the urgent need elderly care sector alone – upwards. As a for action, the ministries finally agree to result, there are growing calls from policy exploratory talks with a number of the Afri- makers and civil society alike for increased can countries that – in the ministries’ recruitment efforts abroad. view – meet at least some of these criteria, The German government must react. In and with which Germany can build upon an interdepartmental meeting convened existing cooperation agreements. These by the Chancellery in October 2021, depart- include the Ivory Coast, Ghana, Kenya, mental representatives discuss which non- Morocco, Senegal, Tunisia, and South Africa. European countries would be suitable for Since many young Africans would like to the recruitment of nursing staff. The Fed- work in Europe, the ministries are optimis- eral Ministry of Health (BMG), the Federal tic that they will be able to conclude initial Foreign Office (AA), the Federal Ministry recruitment agreements with some coun- of Labour and Social Affairs (BMAS), the tries of origin within a year. Federal Ministry for Economic Cooperation and Development (BMZ), and the Federal Ministry of the Interior (BMI) participate. “Germany Is Late to the Party” Early on, the group decides to focus on the African continent in order to create syner- Just before summer break, June 2022: gies with the Federal Government’s ongoing Disillusionment is spreading in the Federal efforts to establish a new partnership be- Government. In the first round of negotia- tween the European Union (EU) and Africa. tions, none of the states approached show Together, the ministries agree on several any interest in the German government’s criteria: The BMG attaches great importance offer to upgrade the skills of foreign nurs- to the fact that the respective countries have ing staff in a crash course format, and to been successful in dealing with the linger- employ them in German facilities for an ing Covid-19 pandemic, and that the aver- initial period of two years. The reasons age level of education among the general are similar everywhere: “We have already population is high enough to pursue a received more attractive offers from other nursing qualification that meets German countries”, “Why should we send sought- standards. The AA emphasises the added after nurses to Germany without any com- value of existing German language skills pensation?”, and “Germany is late to the party”. among the population and demands that How could this have happened? Appar- language institutions such as the Goethe ently, the global competition for health care Institute already exist in the respective coun- workers intensified within a short period tries. The BMZ urges that the focus of atten- of time, when not only European countries tion should be the surplus of youth as well started recruiting nurses from Africa, but as the levels of youth unemployment, as also China, Australia, and Canada. Reports these factors can increase the development- in the media further accelerated the pro- policy benefits of possible recruitment process. The responsible German decision- grammes and dispel concerns about brain- makers underestimated this development. drain. The BMI, which is still highly critical One reason for this was their inward-look- of the acquisition of skilled workers from ing focus and their preoccupation with the abroad, intervenes repeatedly to raise secu- concerns of the electorate. Other European rity concerns. The weekly magazine Der Spie- countries – above all the former colonial gel quotes the Federal Minister of the In- powers France and the United Kingdom – terior as saying: “First we worked for years used confidential bilateral channels to nego- to keep Africans out of Germany, and now tiate beyond public view due to the general we are inviting them.” This kind of mindset level of reservation about the issue.

SWP Comment 64 December 2020

2 France has reached agreements with The German ministries need to discuss Algeria, Morocco, and Tunisia, and the how the concerns of South Africans can United Kingdom with Kenya. The Chinese be addressed. In view of China’s aggressive government, for its part, has been able to offers, it is no easy task putting together a build on existing exchange programmes tailor-made package that not only takes for African students and promoted them South Africa’s specific needs into account, effectively at the last Forum on China- but that is also more attractive than com- Africa Cooperation. Because there was peting offers. In addition, smaller European already an immense and rapidly growing countries, such as the Scandinavian coun- demand at home before the pandemic tries and the Netherlands, have now entered began, Beijing promised Senegal, Côte the global competition for health care d’Ivoire, and Ghana considerable direct workers. They are offering the South Afri- investment if the three countries granted can government the prospect of extensive China comprehensive access to trained trade and investment partnerships. nurses. As a result, these countries rejected To speed up the development of a com- similar offers from other countries. South petitive offer, the German government Africa managed to avoid being pressured quickly sets up consultations with country into any such nearly exclusive recruitment experts from research and development co- agreements. However, emboldened by the operation, the health care sector, chambers negotiation successes of other African coun- of commerce, the labour ministry, and the tries, it made significant demands. South African diaspora. These consultations Against this backdrop, the German offer show that the vocational training sector is to poach temporary care workers without a top priority for the South African govern- substantial compensation is not competi- ment for reducing the high levels of youth tive. The media are increasingly concerned unemployment among secondary school about the growing difficulties in attracting graduates. With this in mind, the BMZ urgently needed skilled workers to Ger- proposes an idea that has been discussed in many. Disturbing reports about neglected expert circles for years: transnational train- elderly people in understaffed nursing ing partnerships. Such partnerships would homes are further fuelling the debate. The provide for the establishment of two-tier press accuses the government of having nursing schools in South Africa that are co- failed at negotiating and defending German financed by Germany, providing training interests with sufficient determination. for South Africa’s and Germany’s health sector in parallel. With these partnerships – and the idea of a fair balance of interests Breakthrough in the Negotiations that underlies this concept – Germany’s offer to South Africa could stand out from Now the German government is under pres- competing offers. The other ministries sure to act and decides to focus its efforts agree with this strategy. At a special meet- on a specific country of origin. The choice is ing of the German–South African Bi- South Africa, Germany’s most important national Commission in March 2023, the economic partner in sub-Saharan Africa. German government presents its partners President Cyril Ramaphosa and his govern- with a new offer for the training and assignment, which is led by the African National ment of nurses. On this basis, the South Congress (ANC), is interested in cooperating African government agrees to start concrete with Germany. But the ANC is divided. Fol- negotiations. lowing 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.

SWP Comment 64 December 2020

3 Internal EU Competition and 2014. Germany is seen as a problematic South African Controversies partner in this context. Firstly, the German government has still not sufficiently ex- Although the South African government pressed guilt and responsibility for its role shows a general interest in the German in the Herero and Nama genocide in Na- offer of training partnerships, the cabinet mibia and is therefore not considered an in Pretoria agrees that the global compe- acceptable partner. Secondly, the shift to tition for health care workers should be the right in Europe and the racist attacks on used as an opportunity to make further de- migrants, which have also occurred in Ger- mands, especially with regard to visa policy. many, are worrying. Thirdly, the question A tough series of negotiations between arises as to whether South Africa needs the the two governments begins. The German care workers more than Germany. delegation argues that visa issues must be This discussion puts Ramaphosa under coordinated at the European level and are massive domestic political pressure just therefore not up for discussion in the bi- under a year before the parliamentary and lateral negotiations. The South African side presidential elections. At the same time, does not accept this position. Instead, it however, it gives him the necessary support refers to parallel negotiations with Finland in the negotiations to demand not only and the Netherlands, in which concrete training partnerships and the facilitation measures for the facilitation of visas have of visas but also far-reaching support for already been offered. Caught off guard by South Africa in developing a vocational this intra-European competition, the Ger- training system. With this comprehensive man delegation asks for a two-week break package of demands, Ramaphosa eventually in September 2023 in order to agree inter- succeeds in both appeasing critics from his nally on a new package of offers. own ranks and selling the results as a suc- Before this is finalised, another obstacle cess in the fight against youth unemploy- arises: An internal power struggle within ment before the upcoming elections. In the ANC almost leads to the failure of the December 2023, after strong intervention negotiations. Opponents of President by the other ministries, the BMI finally Ramaphosa are leaking sensitive infor- gives in to the demands of the South Afri- mation to the press to weaken him and his can government, clearing the way to work faction in the ANC ahead of the 2024 out concrete details. elections, thus strengthening their negotiating power within the party. These leaks include information on possible training The Agreement partnerships with Germany. Ace Maga- shule, the president’s fiercest opponent, is At the heart of the “Together We Care” implying in the South African press that agreement is the establishment of 10 two- Ramaphosa is a traitor who is selling young tier nursing schools in South Africa that are black South Africans to the West in pursuit co-financed by Germany in order to provide of a neo-liberal economic policy. Serious training for both the domestic and German South African media are leading the discus- markets. This includes placing graduates in sion in a different manner, but with a simi- suitable jobs in Germany – at least 17,500 lar tone: Why Germany, of all countries? in the first five years. In order to meet the Why is the Federal Republic poaching the acute German need for nursing staff, 2,500 good people? And what do we get out of it? South Africans who have already completed This sparks a debate on partnerships, the basic training in nursing care are sent above all, at South African universities, to Germany and then receive further train- where there has been a critical discussion ing on a part-time basis. on the decolonisation of the education Beyond the health care sector, the agree- system and international relations since ment contains extensive commitments by

SWP Comment 64 December 2020

4 the German government to promote voca- made considerable efforts to strengthen the tional training programmes, thereby sup- public health care system and reduce corrup- porting the development of South African tion since the beginning of the Corona pan- capacities in manufacturing and agricul- demic, there is still a long way to go: The ture. In addition, the German government incentives to work in public health care re- has promised to facilitate visas for business main weak. In line with this, the bulk of trips and university exchange programmes. applications for direct assignments to Ger- A final point of contention is whether many come from the poorly paid public sec- the assignments of care workers should tor, threatening to further reduce the coun- from the outset be temporary working stays try’s already limited human resources. In with an obligation to return, or whether rural areas in particular – in the Eastern any return would be voluntary. Finally, Cape, Mpumalanga, and Limpopo provinces there is agreement on a mobility-oriented – there is a severe shortage of nursing staff. approach, according to which the decision The development community soon voices is left to the migrants themselves. This criticism of the process. In reaction to this, could encourage circular migration, if this the BMZ feels compelled to launch new pro- is in the migrants’ interest. In order to safe- grammes to strengthen the South African guard this mobility approach and freedom health care system in parallel with the “To- of choice, the South African government gether We Care” agreement. These pro- demands a “mobility promotion package” grammes are aimed primarily at strengthen- from the German government. It should ing rural health care systems, and also pro- include financial and practical support for mote medical technology cooperation be- returnees to South Africa, but at the same tween German and South African companies. time offer them the opportunity of re- At the same time, the training partner- migrating to Germany with a work permit. ship has direct consequences for neighbour- When the German government accepts, ing Zimbabwe, which is still governed by the South African Mail and Guardian carries Emmerson Mnangagwa and the Zimbabwe the headline: “Germany and South Africa African National Union – Patriotic Front. finally seeing eye to eye.” Finally everything After the country slid into a serious eco- is set for the agreement to be signed. nomic and food crisis in 2020 and the government’s repression of the population intensified, more Zimbabweans emigrated A Look into the Future: to South Africa. The distressing conditions African Context of the Zimbabwean health system only became visible in 2021 and 2022 as the pan- Once the negotiations are concluded, the demic spread in rural areas – a fact the German side urges its new partner country government tried to conceal. Hardly anyone South Africa to rapidly implement the from Zimbabwe wants to return to the agreements on the assignment of nurses. crisis-torn country. Despite warnings from the BMZ, there is no A large proportion of Zimbabwe’s health pilot phase. All 10 nursing schools are to be care workers have been in exile in South set up at the same time, and the first 2,500 Africa since the end of 2020. This is mainly “direct assignments” to Germany will take because the government reacted to the place as early as March 2024. strikes and protests by doctors and nurses This ambitious schedule creates con- in Zimbabwe in June and July 2020 with cerns. Instead of being purely beneficial, the increasingly harsh responses and arrested new cooperation also poses problems for journalists who exposed corruption in South Africa’s health care system, which the health sector. Those who could, left the is characterised by a sharp imbalance be- country. As a result, the health system has tween the public and private provision of become so decrepit that access to health health care. Although South Africa has care has deteriorated even further.

SWP Comment 64 December 2020

5 Figure 1

The “Together We Care” agreement has to employ qualified Zimbabwean health additional implications for Zimbabwe. Until care workers. But the new partnership Germany and South Africa reached an agree- creates additional jobs in South Africa. As ment, it had been difficult for South Africa a result, even more health care workers in

SWP Comment 64 December 2020

6 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. © Stiftung Wissenschaft und Politik, 2020 All rights reserved A Look into the Future: European Cooperation This Comment reflects the authors’ views.

For the German government, the agreement The online version of with South Africa represents a hard-earned this publication contains negotiation success, and it knows how to functioning links to other present this achievement to the public for SWP texts and other relevant sources. its own benefit. However, the representatives of the various ministries concerned SWP Comments are subject with the issue know that the German– to internal peer review, fact- South African agreement can only be a first checking and copy-editing. step on the long road to eliminating the For further information on our quality control pro- shortage of skilled workers in the health cedures, please visit the SWP care sector. In the meantime, many wealthy website: https://www.swp- states have intensified their recruitment berlin.org/en/about-swp/ efforts on the African continent and in quality-management-for- South East Asia. China is gaining ground swp-publications/ in several potential partner countries that SWP Germany is also competing for with its Stiftung Wissenschaft und European neighbours. In view of the ob- Politik vious disadvantages of this internal EU German Institute for competition, the European Commission International and presents a proposal for a European recruit- Security Affairs ment strategy in autumn 2025. It is based Ludwigkirchplatz 3–4 on the assumption that pooling the nego- 10719 Berlin tiating powers of all EU member states Telephone +49 30 880 07-0 makes as much sense in the recruitment Fax +49 30 880 07-100 of skilled workers as in other policy areas. www.swp-berlin.org This brings new momentum to the discus- [email protected] sion on a common European labour migra- ISSN 1861-1761 tion policy, which the European Commis- doi: 10.18449/2020C64 sion believes should in the future focus more on economic sectors and their needs than (English version on the individual qualifications of workers. of SWP-Aktuell 87/2020)

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.

SWP Comment 64 December 2020