Justice as recruitment

Countries have a duty to see that migrants who leave their birthplace for richer countries do so under conditions that make sense.

If Australia’s public health services actively recruit nurses from other countries, and that recruitment contributes to a significant loss of health workers from countries already struggling, then our public health services should have a funded commitment to help expand those countries’ health-training capacity directly. These commitments should formally be part of our national policy. We can no longer take the world’s best and leave them to their own devices to replenish their numbers.

As it happens, Australia is relying heavily on internationally qualified nurses. In 2023-24, 16,622 internationally qualified nurses registered to practise in Australia, three times the number in 2018-19.

In 2024-25, the number fell slightly to 16,155, but the trend remains sharply elevated overall. In January 2025, the Commonwealth reported that 27,810 nurses had registered from overseas over the preceding two years, 70 per cent of them through the Trans-Tasman Mutual Recognition pathway. Australia’s growing workforce shortage will not be easily resolved, as the Commonwealth’s nursing supply and demand work projects a baseline undersupply of 70,700 full-time-equivalent nurses by 2035, or about 79,500 nurses, if no strategic action is taken.

An individual nurse has the right to decide whether to seek to migrate to Australia. She does not belong to the country’s health system that trained her, and if there are no unjust restrictions on her movement, her freedom to choose the destination of her labour deserves respect.

The people of her birthplace have no claim to her decision to leave and should not impose any exit tax or compulsory service in a particular field because she possesses an in-demand skill. Requiring someone, by accident of birth, to use their skills in a poorer country, while imposing no comparable expectation that those with the same skills born in a richer country remain in the country that trained them, is no basis for a just world.

Ethically, the obligation lies with institutions: governments, hospital networks or recruitment agencies in richer countries that actively recruit from overseas.

The WHO’s voluntary, non-binding Global Code of Practice on the International Recruitment of Health Personnel formally upholds health workers’ right to migrate. Still, it also sets out ethical principles governing international recruitment. It calls on countries to promote the health of vulnerable populations and avoid recruitment that undermines those countries’ health systems.

The WHO’s 2023 safeguards list identified 55 countries under particularly serious pressure regarding their health workforces. The WHO identified these countries as requiring particularly strong safeguards against active international recruitment.

This May, WHO member states amended the code to encourage international recruitment of health personnel in ways that produce proportional benefits for source countries, including co-investment in health systems and health workforces. Guidance published this August recommends refraining from active recruitment from countries with severe workforce vulnerabilities and says that, where recruitment does occur, it could take place through “government-to-government agreements”, after consultation with source-country health ministries and with support provided in nationally identified priority areas.

If our public health services are going to recruit overseas on a large scale, the first step in making WHO’s latest approach national policy would be to negotiate such obligations with those countries from which Australia is, or will be, a major recruiter. These would be funded commitments to expand that country’s health-training capacity, attached to agreements under which major public health services or large-scale recruitment programs will actively recruit from there.

These commitments could be framed in many ways to suit particular countries, and they may evolve as the process is worked out more carefully. For example, an agreement to finance nursing-school places, clinical training positions, nurse educators, laboratories, or scholarships could be made with a country if Australia recruits several hundred nurses from there. These efforts should also target any particular shortages of health workers in those regions or specialities that are part of the shortage being addressed through recruitment. Moreover, the country should identify for itself what our help will go towards. We should not presume to decide for them what they need. After all, some countries, most notably the Philippines, have deliberately trained nurses for international labour markets, and so not every country can expect the same level of aid from us simply according to its share of our foreign recruitment.

What practical objection could there be to the commitments arrived at in this way? If you assume that recruiting people trained overseas is a cheap option, then surely adding to its cost by funding priorities in their country of origin would result in the seeming paradox of pushing the price up rather than, for example, making it possible to spend less. But this paradox only arises if you assume that part of the cheapness of obtaining the services of people whose initial training costs Australia did not bear lies in not paying for those costs. If we really are, as we should be, putting an end to that practice, then it would be entirely natural for the price to go up.

This initiative will be another nudge for Australian governments to confront and act on Australia’s domestic nursing shortage. Happily, Jobs and Skills Australia has identified the same underlying pressures across a variety of occupations, not just nursing. Insufficient numbers of suitably qualified applicants remain a major driver of shortages, especially in health, while poor conditions and retention problems contribute to shortages in care and service roles. Headed in the right direction, greater attention to Australian nursing careers and growing domestic capacity should therefore start to diminish, if not eliminate, an over-reliance on international recruitment to disguise the fact that Australia is still not training and retaining enough nurses to meet projected demand.

Recruiting someone else’s nurses cannot become a substitute for making nursing here attractive enough to sustain our own workforce.

It’s easy to assume that each nurse who migrates is a clinical loss for their country. Remittances sent home by nurses can benefit families and source countries. Still, the harder policy question is how to address migration from the source country’s short- and long-term perspective. The question is whether its interests extend beyond remittances and whether recruitment can be structured as a partnership, with nurses able to leave under a two-way traffic understanding rather than being seen merely as money sent back home.

However, Australia still needs to do much more to recruit and retain overseas-trained health workers, and a national framework could focus attention on many pertinent areas. A national framework could require major recruiters in Australia, including those that recruit overseas nurses, to regularly provide information on where the internationally trained health workers they employ received their primary qualifications and the scale of their active overseas recruiting. Releasing this information alongside regular updates on health-workforce planning in Australia could also illustrate which countries trained the health workers on whom Australia increasingly relies.

This would recognise and raise the profile of the issues surrounding health worker recruitment and bring greater precision to several areas involved.

WHO’s emphasis on co-investment is an important principle in recognising the wider implications of recruiting health workers whose initial training costs Australia did not bear. This is also relevant when considering Australia’s international recruitment of nurses and the recruitment practices of countries such as Canada and the UK.

If the various health domains were responsible for such reporting, this would include responsibilities associated with some of Australia’s recruitment of overseas health workers in recent decades, including doctors, allied health professionals and care workers, in addition to nurses.

Australia’s readily identifiable pressures in nursing stem from sectors such as aged care and a rapidly ageing population. These pressures occur against a backdrop of growing international competition for nurses.

At the global level, however, the care workforce itself is becoming vulnerable. Wealthier countries, with greater capacity to pay for health care, can draw health workers from countries whose populations face even greater healthcare problems.

A bit late in the game, Australia is now heading in a decent direction towards advancing the ethical recruitment of internationally qualified health professionals, increasingly consistent with WHO’s approach. The Commonwealth has recognised the need to open pathways for these professionals to come to Australia, help Australian employers recruit internationally qualified staff where they can, and examine what it can do to keep these professionals here.

It should now also recognise, ethically as well as practically, that this process requires close attention to source-country workforce plans so their populations are not disadvantaged by large-scale active recruitment. Canada’s ethical recruitment framework already recommends bilateral arrangements that provide source countries with proportionate benefits, including technical or financial support. Recruiters and source countries both put a great deal into making health workers available.

We should be pleased if that signal now comes clearly from the Commonwealth to source countries, and indeed to people here. Australia already assesses internationally qualified health professionals against the relevant health and skills requirements; it should work most closely with countries where recruitment can be matched by constructive co-investment. Large-scale recruitment should include a funded commitment to help replenish the health-training capacity from which Australia benefits.