Picture: Advertisement on M.G Road, Kochi. Credit: Sibille Merz

India has become a key source of nurses globally, and nursing students in India are sold a dream of a ‘global’ career. In this blogpost, Dr Sibille Merz reports findings from a recent research article highlighting how the reality is quite different. Rather than the freedoms implied by a ‘global’ career, nurse training leads to specialisation in ways that limits travel and migration opportunities to specific locations and jobs and leaves nurses at risk of exploitation in a volatile global policy environment.

India has a large, young population with huge demand for employment opportunities and social mobility. At the same time, there is a global shortage of 30 million nurses and midwives. In this context, nurse training and migration has emerged as a fast-growing industry for India (as well as several other countries). The country is a vital supplier of nurses to healthcare systems in other countries such as the UK, where as of March 2021, there were 19,912 India-trained nurses working in the NHS.

India’s evolving and heterogeneous nurse migration industry is comprised of an eclectic mix of both public and private actors, including commercial agencies, professional associations and trade unions. While some specialised in one service, multi-speciality brokers offer a combination of services, including academic course enrolment, and interview and exam training. Key players also include nursing colleges, private hospitals and language schools. Nursing colleges include international elements into their curricula, for example by employing faculty members from abroad and by offering instruction for the specific language tests or licensing exams. They also collaborate with recruitment agencies, usually on a commission basis. The latter advertise their services at the college, which, in turn, gives the college a competitive edge for promoting international employment opportunities. Language schools also collaborate closely with recruitment agencies, selling their databases or collecting referral fees. Private hospitals contribute to shaping international careers by offering post-study work experience, which is generally required when seeking employment abroad.

Post-Fordist specialisation

While these actors and processes train and prepare nurses for a broadly framed ‘global’ career, training is also often geared towards specific countries. For example, we found that a range of Indian recruitment agencies offer training specifically for licensing exams and have developed nationally-specific training modules. Moreover, recruitment agents procure training and simulation equipment which is used in the target country or even a specific hospital. Training for this equipment is then conducted in India in order to save on training cost. Lastly, the migration industry offers soft skills training for different clinical cultures and value systems. Examples span brief introductory sessions, month-long induction packages and even plans for opening a finishing school for nurses to embody the clinical culture of the UK NHS.

The production of nurses thus involves both the large-scale production of emigratory nurses and the niche production according to nationally-specific standards. This resembles a Post-Fordist model of production, characterised by flexible specialisation, decentralised management and a networked structure for manufacturing with a global orientation. The demand for workers is no longer seen as only a mass market but a fragmented one that is best served by specialised services and ultimately workers.

Individual risks

While providing career opportunities, this might therefore also have negative consequences for the nurses as the knowledge and skills taught to them are not selected on a needs-based approach but governed by highly volatile domestic and international market opportunities. Post-Fordist production entails principles of flexibility which in turn afford substantial leverage to global ‘buyers’ (in this case hiring healthcare providers, usually in high-income countries) who can make new demands at short notice. This leaves ‘suppliers’ (in this case the training institutions and nurses themselves) in a state of dependency. There is a real risk that cohorts of trainee nurses could find themselves trained to work in a market that no longer needs them.

Moreover, given the commercial nature of these services, they are often offered at a significant cost. While the UK adheres to the WHO Global Code of Practice for International Recruitment which stipulates that receiving countries must cover the cost of recruitment, fees for additional and customised training as well as additional attempts to clear mandatory licensing exams are often born by the nurses themselves. Not least, nurses are often required to pay back the cost of their migration, or parts thereof, when breaking the clause of their contract. As such, these trends might critically increase the precarity of nurses migrating abroad and pose a challenge to the problem-free representations of the ‘global’ nurse.

This blogpost reports findings from an open-access article published in BMJ Global Health. This work was part of a research project: Analysing the transnational provisioning of services in the social sector. The project was funded by the UK Economic and Social Research Council. For more information on the project click here.