Core Message 1: Skilled workers with a migration background are crucial to the German healthcare system

Health and social care in Germany, when not carried out by family members, depends to a great extent on people who have either migrated to Germany themselves or who come from families with a history of migration. Over four million people work in the health and social care sector. In 2019, nearly a quarter of these had a migration background. This includes, for example, doctors as well as care staff. Approximately four out of five of all those in paid work in the sector are women.

The proportion of those with a migration background is particularly high in geriatric care, where three out of ten workers are migrants or come from migrant families, often from Eastern or south-eastern Europe. The proportion of doctors in Germany with a migration background is also higher than average in relation to the general population; more than a quarter of all practising doctors either migrated to Germany themselves or were born to parents who migrated here. Around 14 per cent are foreign nationals, with the most common countries of origin being Syria and Romania. Compared to their German colleagues, non-German doctors tend to work more often in clinics and in more rural areas. In the federal states in eastern Germany, excluding Berlin, the proportion of non-German doctors is as high as 15 per cent – around three times as high as the proportion of foreign nationals in the general population of those states. At the same time, a number of doctors trained in Germany now practise abroad, for example in Switzerland.

In recent years, an increasing number of health and social care workers born and trained abroad have moved to Germany. The number of non-German migrants (that is, migrants who were born abroad and do not have German citizenship) working in the healthcare system nearly doubled between 2013 and 2019. In addition, an increasing number of skilled workers in the sector were born to migrant parents in Germany and have gone through the German education system.

For more information and recommendations, see Chapter A.2.

Core Message 2: Fast-track the recognition of foreign qualifications and simplify compensation measures

In response to a significant shortage of skilled workers, legislation has been put in place in recent years to make it easier for qualified foreign nationals to immigrate to Germany. Skilled workers are especially needed in the health and social care sector. However, to work legally in Germany they must prove that their qualifications meet German standards; if this is not the case, they are required to obtain additional training in Germany to enable full recognition. The success of any recruitment strategy aimed at attracting skilled workers from abroad therefore depends on how such recognition procedures are implemented in practice.

Overall, the federal states (Länder) are responsible for recognition procedures. To bring about greater efficiency and transparency, the states need to make their procedures simpler and bring them into alignment, while also ensuring that the relevant authorities work in a more joined-up way. Further, the authorities involved in the migration process – such as German consular services abroad, immigration offices, government bodies responsible for assessing foreign qualifications and the Federal Employment Agency – must improve how they work together. Migration must be understood as a holistic process in which each individual step is dependent for its success on all the others. The SVR also recommends pooling competences in each federal state and making full use of the opportunities offered by a more digitalised administration. To build expertise and accelerate the recognition process, it could be useful to assign responsibility for specific countries of origin or occupations to specific federal states. The relevant authorities also need significantly more staff in order to process applications more quickly.

Where applicants need further training in order to gain full recognition, it is important to ensure that they can complete such training as soon as possible. The SVR therefore recommends expanding compensation measures (as this additional training is known) on a modular basis while ensuring better coordination of existing offers not only within each federal state but also between neighbouring states. Courses should always include an element of (specialist) language training; language skills are essential, not only to guarantee the success of the training itself, but also to ensure that the applicant can carry out their profession successfully in Germany and to facilitate integration into their workplace. In addition, capacity for providing the necessary knowledge or aptitude test to prove that an applicant meets the recognition requirements should be increased to the point where applicants can take the relevant test within six months.

For more information and recommendations, see Chapters A.1.2. and A.1.3.

Core Message 3: Encourage migration for educational purposes and improve education and training in Germany

Along with recruiting (qualified) health and social care workers, the SVR also recommends stepping up recruitment abroad for training in Germany. Migrants who complete the whole of their training in Germany avoid lengthy recognition procedures, while the contact to other students facilitates language learning and social integration. This would also avoid potential transfer problems that can arise where the job profile and training differ substantially between the country of origin and the target country. This, in turn, facilitates workplace integration. Recruiting students, rather than fully qualified professionals, also helps to avoid the ‘brain drain’ effect in the students’ country of origin. However, for such a measure to be successful, it is important that potential students have all the relevant information before making a decision. They need to know what they will learn and to understand what their chosen profession is likely to entail, as well as what it is like to live and work in Germany. This is essential in order to manage expectations and develop a realistic picture of what their future in Germany might look like.

To address the skills shortage in health and social care in the long term, the SVR also recommends that policy-makers turn their attention to Germany as well as abroad. It is important to consider recruitment strategies for people who already live here. Besides school-leavers, these might also be migrants who have not yet completed any vocational training or whose qualification and/or work experience in their country of origin has not yet been recognised. Staff working at assistant level or who are training to become health and social care assistants should be encouraged to go on to train as skilled workers. To reduce the current high drop-out rate for students in the sector, especially among those training as care workers, it is also essential that working conditions in the health and social care sector are fundamentally improved (see also Core Message 4).

For more information and recommendations, see Chapters A.1.3. and A.2.4.

Core Message 4: Retain skilled workers: encourage workplace integration, improve working conditions

Skilled workers recruited from abroad have to work hard to adapt their knowledge and professional experience to their new working environment. To enable them to fulfil the expectations and requirements of their new role, and to encourage them to want to stay in Germany long-term, they need appropriate support, especially during the initial period when they are ‘learning the ropes’. Not only language can be a challenge, but also often different ways of working and a different understanding of what the role entails. If health and social care providers want to recruit staff from abroad, it is in their own interest that they should prepare adequately for their arrival, develop an integration concept and identify staff members who can support the newly-arrived workers. Existing staff must be involved in the process from early on. The induction process takes time and initially creates more work for those training the new recruits. This means that it is important to have enough personnel available to undertake this work.

Encouraging language competence is particularly important. Working with patients and in multi-professional teams requires excellent communication skills. Organisations should already start planning in enough time for thorough, sector-relevant language training during the recruitment phase. A professional induction should go hand-in-hand with support to assist the integration of the new staff and their families. New recruits need information and advice on a wide range of subjects, from how to find accommodation, childcare and potentially employment for accompanying family members, to information about the local infrastructure, for example public transport. To help develop such support for skilled workers and their families, health and social care providers could work together with local organisations and local authorities. This is especially important in structurally weak regions.

To retain skilled workers in the long term, the SVR also believes it is essential to improve working conditions in the health and social care sector, particularly in social care. Migration alone cannot solve the structural shortage of skilled workers in this area.

For more information and recommendations, see Chapter A.1.4.

Core Message 5: Make health worker migration fair and transparent

Migration in the health sector is not just a German or European phenomenon. Across all OECD countries, around one quarter of all doctors and one sixth of nurses were not born in the country where they now work. Mobile professionals can often achieve a higher salary abroad than they can at home, and can also enjoy better working conditions or career perspectives. Meanwhile, their countries of origin can profit from remittances, or, in the case of returning migrants, from the skills and knowledge they have gained abroad. But there can also be disadvantages; when healthcare professionals emigrate, this can affect the availability of healthcare and thus the general living standards in their country of origin.

To help prevent this negative impact, skilled healthcare workers should be actively recruited only in countries where there is a surplus. Bilateral agreements could ensure that both sides benefit from this form of migration. Skills partnerships that promote capacity-building in the country of origin as well as the destination country are particularly valuable.

Bilateral agreements of the kind described above can also minimise the risks associated with migration for skilled workers if the latter are comprehensively informed about their rights and obligations and, for example, the agreements clarify which costs are borne by the destination country or future employer. Skilled workers already come to Germany via government schemes. Most, however, are recruited directly by companies, come via private brokerage agencies or organise their travel to Germany independently. But these options carry risks – for example, businesses or workers may be unlucky enough to encounter disreputable agencies. The seal of quality ‘Faire Anwerbung Pflege Deutschland’ (‘Fair Recruitment for Care in Germany’) is a government initiative aiming to increase transparency in recruitment in the sector. The SVR therefore recommends that it should be subject to an evaluation process. The SVR believes it is essential to guarantee the greatest possible transparency in healthcare recruitment, ensure that new recruits are provided with comprehensive information in advance and support them in dealing with the authorities.

For more information and recommendations, see Chapters A.1.3. and A.1.5.

Core Message 6: Ensure that live-in care provided by foreign nationals is carried out legally and fairly

Many older people would like to spend their last years in their own home, even if they are no longer capable of managing everyday tasks independently. The live-in care model (often marketed, misleadingly, as ‘24-hour care’) offers a chance for them to do so. Care workers – who mostly come from Eastern Europe – live in the person’s home and support them in their everyday lives.

This model can have advantages, both for the person who requires care and their family. It makes care more affordable, and it means that family members who work are more able to fit in supporting their relatives around their other commitments. For the care workers, it offers a form of labour migration that usually does not require any particular qualifications or language skills. However, this kind of employment often operates in a legal grey area; frequently, employers fail to comply with the relevant legislation, especially when it comes to working hours and paying the minimum wage.

The SVR therefore recommends ensuring that all those involved are systematically provided with information about their legal rights and obligations. To protect care workers from overworking and exploitation, and to manage the expectations of the person in need of care and their family, a clear job description is vital. Further, there should be no agreements that result in a single individual providing ‘24-hour care’; this is illegal under German law. Rather, care workers should only be employed where the need for support in everyday life is moderate, or to complement other forms of care provision – for example, as part of a multi-disciplinary support package involving outpatient services and/or community care, care by family members and other forms of support. Should the person require care for significantly more than 40 hours per week, two or three care workers could be employed in parallel who would be responsible for dividing up the work between themselves. However, employing such a team of workers legally and on fair pay is an option that would only be available to well-off families.

For more information and recommendations, see Chapter A.3.

Core Message 7: Social factors, rather than a history of migration, play the greatest role in determining health 

Apart from biological and ecological factors, a person’s health is mainly determined by their social position, level of education, conditions of employment and living arrangements, rather than by their ethnic background. A history of migration, however, can play a role in health inequality insofar as even today, having a migration background is statistically more likely to be associated with socio-economic disadvantage. Likewise, barriers preventing equal access to health and social care services are often closely associated with migration. For example, some migrants newly arrived in Germany have only limited access to publicly-funded healthcare under existing legislation, even though this situation is mostly temporary. Language barriers or discrimination can also make it more difficult to access the healthcare system. But besides considerations related to the country of destination, the health of migrants is also influenced by risk and protective factors in their country of origin and during their individual migration process.

People with a migration background form a heterogeneous group. It is therefore impossible to draw any general conclusions about the health of this particular demographic, especially as the data is extremely patchy. However, a few general principles in relation to migrant health can be identified. One is what is known as the ‘healthy migrant effect’. Newly migrated individuals often demonstrate better health and/or lower mortality rates. This is partly because people who migrate are usually healthier both physically and mentally. Once arrived in their destination country, however, the effect gradually fades, in part due to the long-term effects of socio-economic disadvantage. A closer examination of this phenomenon also reveals differences within different groups of migrants. For example, refugees are statistically more likely to enjoy good physical health because of their age, but at the same time, they may often experience psychological difficulties because of trauma experienced in their country of origin or while fleeing abroad.

For more information and recommendations, see Chapters B.1, B.2.1. and B.3.

Core Message 8: Migrants generally have good legal access to healthcare provision, but there are gaps

Most people who live without a German passport in Germany today are properly insured in case of illness. However, access to publicly-funded healthcare and to the health insurance system is legally restricted for certain groups: those whose asylum applications have not yet been decided or with an obligation to leave the country, who in addition have been in Germany for less than eighteen months, as well as anyone who is living illegally in Germany. In exceptional cases, these legal restrictions also apply to EU residents who have lost their right to free movement.

The overall proportion of persons officially recorded as uninsured in Germany is less than 0.1 per cent of the population. Among those with a migration background it is just under 0.2 per cent and among those without a German passport just under 0.3 per cent. Most people, whether or not they have a migration background, are members of a statutory health insurance scheme. Where migrants in Germany are not adequately insured in case of illness, this is usually not because they do not have a legal right to insurance or because of flawed legislation. Instead, those affected are often not in a position to overcome the various bureaucratic hurdles on their own, either, for example, because of their circumstances and/or because the rules that apply to them are (perceived to be) too complicated. To address this situation requires targeted advice and support that is easily available to all, with as few barriers as possible to accessing it. This would be an important foundation for a health system that is responsive to diversity. The SVR therefore believes that the federal states and local authorities should consider expanding the availability of advice and support centres to help people clarify their rights to medical services and/or access health insurance options (‘Clearingstellen’).

The situation for migrants without a legal residence status in Germany is especially precarious. Although the provisions of the Asylum Seeker Benefits Act give them the right to healthcare, the legal situation also means that in practice they cannot access such care without risking deportation. The SVR therefore recommends that Article 87.1 of the Residence Act should be amended to clarify that the healthcare sector (including but not limited to emergency care) is exempt from the duty of public bodies to pass on information about undocumented migrants to the immigration authorities. The rules and procedures for means testing in relation to reimbursements from the social welfare offices should also be developed and aligned across all federal states.

For more information and recommendations, see Chapter B.2.

Core Message 9: Diversity-responsive healthcare is good for everyone

The way in which people use healthcare services, and their satisfaction with the services they receive, depend on a number of individual factors and the interrelationships between these, as well as on the structural framework conditions affecting healthcare provision itself. A focus on a migration background alone is not enough to understand what may be preventing access to healthcare services or how effective these are. It is true that some challenges are closely connected to migration, such as in particular language and communication barriers, discrimination and a lack of knowledge of how to navigate the healthcare system in Germany. But even these challenges are not experienced automatically by all migrants, nor are they experienced only by migrants.

Apart from the necessary language support for those who lack competence in German, it therefore makes little sense to offer targeted healthcare provision exclusively for migrants as a discrete category. Rather, in order to strengthen health equality for people with a migration background, health and social care services generally need to develop a greater awareness of and responsiveness to diversity. This would benefit everyone. Specific services for migrants could be helpful in some areas of care, as a way of complementing existing regular services, but they should not become an entirely separate service. Communication in healthcare needs to become more responsive to diversity overall, with the additional option of targeting particular groups (irrespective of whether or not they are directly affected by migration).

In Germany, discussions about the most effective way to implement a diversity-responsive healthcare system are still very new. What is certain is that this kind of system requires framework conditions that make it possible to respond to the individual needs of patients; for example, patients who need more time or personal care allocated to them due to a physical or mental disability, or patients who are experiencing language barriers, uncertainty or a greater need for help in understanding their situation. It could also mean, for example, paying greater attention to individual patient values when exploring treatment options; improved responsiveness to diversity could potentially affect many areas of healthcare provision. However, time pressures and the drive towards ever-greater efficiency in healthcare could act as barriers to implementing this. The SVR recommends funding more studies to investigate the efficacy of diversity-responsive approaches as well as the requirements and challenges of such approaches in both in-patient and out-patient care.

For more information and recommendations, see Chapter B.3.