Picture a nurse in Lagos filling in an online application for a hospital job in England. No recruiter called her. Nobody from the NHS visited her training school. She found the vacancy herself, paid for her own English test and exam, and will pay for her own flight.
Under England’s code of practice on international recruitment, that distinction matters enormously. Nigeria is on the UK’s red list, which means employers and agencies must not actively recruit health workers from there. But the code explicitly allows employers to consider direct applications from individuals in red-list countries, provided no third party is involved.
So the rule is kept, and the nurse still leaves. That small loophole says a lot about the global debate on health worker migration, which tends to swing between two framings. One calls it brain drain: rich countries hollowing out poor countries’ health systems. The other calls it brain circulation: skills, money and knowledge flowing back and forth, to everyone’s benefit.
My argument is that “circulation” mostly describes what destination countries would like to be true, and that the ethical rules built to manage migration are aimed at the wrong actor. They police recruiters. The real decisions are made by health workers weighing pay and conditions, and by governments on both ends that find the current arrangement convenient.
The scale of the pull
The pull from high-income systems has been large. According to the Nursing and Midwifery Council’s registration data, internationally educated professionals made up nearly half of all new joiners to the UK register in 2023-24, before the share fell back the following year.
The UK is one destination among many. What makes it a useful case is that it has tried harder than most to be seen to recruit ethically, and the results are instructive.
What the red list actually does
The WHO publishes a Health Workforce Support and Safeguards List of countries whose health systems are most vulnerable to losing staff. The 2023 edition names 55 countries, identified by a density of doctors, nurses and midwives below the global median of 49 per 10,000 people and low coverage of essential services. The WHO asks destination countries not to actively recruit from them, and to invest in their health workforces instead.
England turns that list into its red list. Active recruitment is barred. But the direct-application route stays open, and so it should: nobody wants to bar individual nurses from moving for a better life. The effect, though, is that the code shifts the cost and effort of migration onto the migrant without reducing the loss to the source country very much. The recruiter’s fee disappears. The departure does not.
This is the first uncomfortable point. Ethical recruitment codes are mostly about the conduct of employers, which is what destination countries can regulate and what makes them look responsible. They are much weaker at addressing the flow itself.
Why circulation rarely happens
Brain circulation requires people to come back, or at least to move knowledge and money back in meaningful ways. Remittances are real and often substantial. But the idea that migrant nurses and doctors will return after a few years, bringing new skills, runs into how destination immigration and employment systems work.
Visas are often tied to an employer. Professional registration is national and hard-won. Pension rights, children’s schooling and mortgages all accumulate on the destination side. After five years, a nurse who returns home often goes back to lower pay, and sometimes to a public system that cannot promise her a post. Every incentive runs toward staying.
Circulation, in other words, is not something that happens naturally when borders are open. It has to be engineered, with portable pensions, recognised career credit for time abroad, and jobs held open at home. Few destination countries have any interest in building that, because the point of recruiting a nurse is to keep her.
The source-country side of the bargain
It would be too easy to cast this purely as rich countries exploiting poor ones. Source-country governments have their own incentives, and some are uncomfortable.
Remittances support households and bring in foreign exchange, which gives governments a reason to tolerate outflows even while their clinics are short-staffed. Some countries have gone further and signed government-to-government agreements with destinations. England’s code lists India, Malaysia, the Philippines and Sri Lanka as green-list countries with such agreements, where active recruitment is allowed. Kenya and Nepal sit on an amber list: they would otherwise be restricted, but their agreements with the UK permit managed recruitment within agreed terms.
Those deals are where the real debate should be. If a country is going to lose health workers anyway, the question becomes what it gets in return. Training funds? Guaranteed return pathways? Co-financing of nursing schools? The difference between drain and circulation is not the direction people travel. It is whether the terms are negotiated or simply absorbed.
The mechanism: who pays for the training, who gets the return
Underneath the moral language, health worker migration is a transfer of an investment.
A nurse or doctor is expensive to train. In most source countries, much of that cost is paid by the public: subsidised tuition, public teaching hospitals, clinical placements supervised by salaried staff. The return on that investment comes over a career of thirty or forty years of work. When the worker migrates a few years after qualifying, the source country has paid for the training and the destination country collects most of the return.
Destination countries rarely describe it that way, but their own planners know it. Recruiting an experienced nurse from abroad is quicker and usually cheaper than training one at home, and it avoids the political difficulty of expanding domestic training places, which requires university funding, clinical placements and years of lead time. International recruitment is, in part, a way for a rich health system to outsource its workforce planning failures.
Source countries face a mirror image. Their governments are often constrained in how many health workers they can employ, because public wage bills are tightly limited. A country may train more nurses than its public sector can afford to hire at decent pay. Those nurses then face a choice between unemployment, low-paid private work, or migration. Seen from that angle, migration is not only a loss. It is what happens when training capacity and employment capacity are planned separately.
A scenario: one cohort, ten years on
Picture a nursing school in a country on the WHO list, graduating a cohort of a hundred nurses. This is a thought experiment, not a statistic.
A few years later, some have joined the public sector and some work in private clinics. Some are unemployed or working outside health. A significant number have left, mostly for the UK, the Gulf or North America. Those who left are disproportionately the best qualified, because they could pass the language tests and licensing exams. Several were the nurses the school had hoped would become tutors.
Their families receive remittances, which pay for school fees, housing and, occasionally, the training of younger siblings, some of whom will also become nurses in the hope of migrating. The source country’s nursing school is now partly a pipeline for export. Its best potential teachers are abroad. The public hospitals nearby still have vacancies.
Is that brain drain or brain circulation? The honest answer is that it is both, and that which one dominates depends on things the source country’s health ministry does not control on its own.
The strongest counterargument
The best argument against my position is that the prospect of migration raises the total stock of health workers in source countries. When nursing becomes a route to a high-paying job abroad, more young people train as nurses, and families invest more in education. Not all of them leave. The ones who stay add to the domestic workforce. Economists have described this as a possible “brain gain”: emigration opportunities increasing human capital at home.
This argument has real force in some contexts. The Philippines is the case most often cited: a country whose nursing education has long been shaped by demand from overseas employers. Remittances are a major source of income for many families in source countries. Restricting migration would harm individual health workers and their families, and it would be ethically questionable in its own right.
But the argument holds only under certain conditions. It requires training capacity to expand in response to demand, which requires money and teachers. It requires those who stay to find jobs in the domestic health system. And it requires the migrants to be replaced by people of similar skill. Where training is capped by public budgets, where public employment is frozen and where the most experienced staff leave, the brain gain does not materialise. The loss lands heaviest on the countries with the fewest health workers to start with, which is precisely what the WHO list was created to flag.
Second-order effects
The effects of migration spread beyond headcounts.
Losing experienced staff hurts more than losing new graduates. Senior nurses and specialists supervise juniors, teach students and hold institutional knowledge. When they leave, the training system itself weakens, which reduces the country’s capacity to replace them.
Destination countries also develop dependencies. When a large share of new nurses in a health system are recruited internationally, the system’s staffing becomes exposed to immigration policy, exchange rates and the politics of source countries. A sudden tightening of visa rules or a source country’s decision to restrict outflows can leave wards short.
Migrants themselves face risks the codes do not fully address. Workers who pay their own way, sometimes with debt, and whose visas are tied to a single employer can find it hard to leave poor conditions. Ethical recruitment is meant to protect them too, but the direct-application route that keeps the rules clean can leave them with less support.
What this means for each actor
- For destination health ministries: treat international recruitment as a bridge, not a strategy. Pair every major recruitment drive with an expansion of domestic training places, and publish both numbers.
- For source-country ministries: plan training and employment together. Training nurses the public sector cannot afford to hire is, in effect, training for export.
- For hospital leaders in destination countries: support international recruits properly, with fair contracts, clear career routes and no hidden fees. It is ethically right and it reduces turnover.
- For funders: fund faculty and clinical training capacity in source countries, not only scholarships. Teachers are the bottleneck.
What to watch next
Watch the next revision of the WHO safeguards list and whether destination countries adjust their rules to match. Watch whether more government-to-government agreements include binding commitments on training investment rather than general statements of cooperation. And watch destination countries’ domestic training numbers: the most reliable sign that a country is serious about reducing its dependence on recruitment is how many of its own students it trains.
What a fairer arrangement looks like
- Price the training. Destination countries that recruit at scale should contribute to training replacement staff in source countries, as a condition of access rather than as charity.
- Build return into the visa. Pathways that let workers move back and forth without losing registration or pension rights make circulation possible rather than rhetorical.
- Fix the push, not just the pull. Source-country governments that train health workers but cannot fund posts or decent pay are exporting staff by default.
- Measure outflows honestly. Many source countries do not know how many of their graduates leave. Negotiating without that number is negotiating blind.
Migration of health workers is not going to stop, and it should not be stopped by force. But calling it circulation while doing nothing to make people circulate is a comforting fiction. The honest word, for most of the countries on the WHO list, is still transfer. The question is whether anyone pays for it.
If you work in a source country, what would a fair deal with a destination country actually need to include?
