“Most of these other agency heads are, in my opinion, car salesmen. They would sell anything and would probably also somehow sell their grandmother’s washing machine, probably also their grandmother if they could get money for it.” This is how one CEO of a German nurse recruitment company explained to us what distinguished his enterprise from the many unprofessional and unethical “traffickers” out there.[1] And, importantly, why they snatched away recruitees from other agencies. Our interviewee was positive that he in effect saved nurses from competing agencies, especially when these agencies had “parked” experienced theatre nurses in care home jobs. They offered a better service and they deserved the nurse.
Private recruitment firms are part of Germany’s expanding field of international nurse recruitment, where development agencies, hospitals, embassies, Goethe Institutes, language schools and even individual nurses are all mobilized for the project of luring foreign-trained nurses into Germany. Over the last decade and a half, a wide array of government-initiated recruitment activities have sought to meet growing demand for nurses in an ageing society, amid exacerbating retention issues in a sector that offers less and less decent working conditions (Pillars of Health 2022). New migration legislation has made it easier for foreign-trained professionals to enter Germany and have their nursing degrees recognized (even if the process remains lengthy and laborious for both workers and employers), and a series of bilateral treaties with origin countries support the migration of nurses.[2] Following a strong focus on recruitment from Western Balkan countries, in particular Bosnia and Herzegovina and Serbia, in the late 2010s, Germany’s international nurses now increasingly originate from non-European countries, notably the Philippines, India, Tunisia, Brazil, and Mexico (Hanrieder and Janauschek 2025). Next to state-managed recruitment programmes, an estimated three quarters of international nurses come through private recruitment agencies (Pillars of Health 2022) like the one cited above. Recruitment firms are only subject to voluntary certification instead of being bindingly regulated, and they compete for nurses, clients, and legitimacy.
While the editors of this series came across middlemen when studying claims about fake pharmaceuticals (Hodges et al. 2026), we encountered them as major protagonists when studying contentious and diffused debates about the ethics of recruiting international health workers to high-income countries (Hanrieder and Janauschek 2025). In Germany, the reluctance of state actors to regulate nurse recruitment, but also the reluctance to offer countries of origin tangible compensation or co-investment in return for their skilled labour export, shifts the focus to the “(un)ethical conduct” of the middlemen, especially the recruitment agencies. Yet, by letting agencies compete in a largely unregulated market, the meaning of ethical recruitment remains deliberately vague and becomes part of a narrative justification of one’s “ethical” business practices that is viewed as offering a competitive edge over “fake” or rogue agencies.
This essay argues that Germany’s effort to create a reliable pipeline of qualified and committed immigrant nurses while also addressing ethical concerns about nurses’ rights and the brain drain which is exerting contradictory pressures on middlemen, who are asked to deliver efficiently but ethically. Similar to other groups of middlemen investigated in this special issue, recruitment agencies’ relational labour is expected to bridge contradictions and mediate between conflicting pressures (Hodges et al. 2026). Navigating this ambiguity, recruitment agencies strive to legitimize their services to regulators, employers (mostly hospitals), and nurses. A key legitimizing strategy is to demonstrate how an agency differs from variously defined “bad apples” in the business. Agencies seek to set the bar by denouncing the “fakeness” of competitors as not being real businesses, invoking private sector values such as business integrity, reliable service delivery, and professionalism. Yet they also claim moral superiority over competitors due to their genuine, instead of “fake”, care for migrant workers. Price becomes an important marker of one’s proclaimed sincerity and trustworthiness as a middleman, with established recruiters often charging double or triple per nurse compared to the ~5,000€ offered by “fake” agencies who are described as acting like “human traffickers”. Importantly, reliance on private self-regulation has shifted the moral debate about a contested practice – poaching nurses from lower-income countries – to a debate about rights and obligations between recruiters and nurses. Consequently, firms have begun questioning the right of nurses to change recruiter or employer. The harmful effects of nurse-poaching from countries of origin and their health systems, by contrast, are barely addressed.
Internationally, the active poaching of health workers from low-middle income countries has long been criticized in global health. The practice not only epitomizes North-South asymmetries, but also a general lack of equity-oriented regulation in global health. Also labelled “meta-governance”, global health policy falls back on soft standards and best practices instead of well-resourced and binding public policy (Jones and Hameiri 2022). This is also true of health worker migration governance, with the 2010 WHO Global Code of Practice as the central instrument listing important principles such as migrant rights and support for sending countries, but lacking any teeth (Yeates and Pillinger 2019). Such vagueness combined with a strong reliance on private sector dynamics leaves ample space for middlemen to define “business standards” in Germany. Given the German health sector’s growing demand for trained professionals and recognition of the public sector’s incapacity to train or recruit the numbers needed, the loosely governed and largely self-regulated nature of the intermediary space between employers and nurses is set up by design.
Global health scholars have pointed out the role of recruitment agencies as brokers and mediators (Merz et al. 2024) next to nursing colleges (Masselink and Lee 2010) and professional associations (Walton-Roberts 2021). As Merz and colleagues argue in the case of India, recruiters’ profit orientation contributes to exacerbating inequality among nurses, where recruiters skim off the most experienced nurses for employment abroad, and entrench poor access to nurse services in the regions left behind (Merz et al. 2024). Our observations echo such critiques but also take up insights about other types of middlemen in global health – traders and brokers who through their practices shape the normative contours of a field. For example, middlemen in the gamete market have been shown to negotiate complex and hybrid values and thereby also moral boundaries (Bärnreuther 2020). These (dis)qualifications are expressive of various evaluative standards invoked by players in the field – and thus echo observations about eclectic, contextual and expressive “fake-talk” about pharmaceuticals (Hornberger and Hodges 2023). A difference is that talk of “fake drugs” has strong connotations of crisis and urgency – insinuating a need for the hard hand of the state (Hornberger and Hodges 2023). Talk of unauthentic, unreliable, unprofessional, uncaring (and thus in some sense fake) recruiters, by contrast, is not securitized and rather serves to create a sense of moral certainty (and business stability) for a contested practice that affects and mobilizes actors and rationales from various sectors – health providers, human resource experts, diplomats, bureaucrats, development specialists (see Bärnreuther 2020).
Our contribution is based on a study of nurse recruitment initiatives in Germany conducted in 2022 and 2023. We have reviewed the laws, bilateral agreements, and available documented information about the plethora of public and private organizations that co-produce international nurse recruitment. We also interviewed 31 key informants – recruitment agencies, employers, nurse representatives from trade unions, activists, experts, and public officials in the various governmental and quasi-governmental agencies mobilized for recruitment. We mostly spoke with persons based in Germany, but also with experts, union representatives and public officials in international institutions and origin countries. Since many of the actors and institutions we trace are quite recent and only started engaging in international nurse recruitment during or after the pandemic, we can only provide a snapshot of a dynamic field.
Make or buy – a middleman for every occasion
“Make or buy” – this is the typical business question that, according to the founder of another brand-new recruitment agency, health providers asked themselves regarding foreign nurse recruitment. He observes that quite a few hospitals now are “making” instead of buying the recruitment. They send delegations to other countries to advertise nursing jobs and find candidates, and handle the migration and recognition process themselves.
Yet they often reach out for middlemen. Finding willing candidates, teaching them the German language, and supporting their paperwork and the long immigration and skill adaptation process, even private integration, and family reunification – all these tasks can be and often are outsourced to middlemen. The required documentation – of nursing degrees’ equivalence and compatibility, visa, passports – is voluminous, and full accreditation can only occur in-country through special exams or complementary coursework. Candidates may drop out along the way, never reach the necessary level of German, or be shocked at the working conditions they find themselves in when in Germany, especially because most foreign nursing degrees are more medical and less geared towards basic physical care than the German nursing professions. Middlemen promise to manage this process and deliver employable workers who stay.
One option for employers seeking help with recruitment is to reach for public middlemen such as the GIZ. This is the German state-owned international development agency and more specifically, the GIZ’s commercial International Services department. GIZ operates the so-called Triple Win programme with selected countries. The name with the many winners postulates that German health industries win as they get workers, migrants win as they get jobs, and home countries win as they reduce unemployment and receive remittances. As a middleman, GIZ promises that clients can “benefit from our extensive experience and global presence”[3]. It manages the language training, paperwork, and travel of candidates. These services are paid for by the client, not the candidates, who upon passing the language exam are placed in German nurse aide jobs until their credentials are fully recognized. More recently, another public agency, the German Agency for International Healthcare Professionals (DeFA), has also begun offering recruitment services. Initially set up to help private employers and recruiters navigate the accreditation bureaucracy – thus at times functioning as a middleman for middlemen – DeFA has since morphed into a recruitment agency itself. Their activities are flanked by the support and brokerage of other public institutions – such as the Goethe Institute, which is responsible for German cultural diplomacy and offers German language classes tailored to the nursing profession – or embassies and chambers of commerce establishing business contacts.
Beyond state programmes, a large and diverse ecology of private recruiters offers their services. Given that Germany has not ratified the ILO Convention 181, which demands public licensing of recruitment agencies, practically anyone can become a middleman. Middlemen now come in many shapes and sizes – part-time individuals organising a few calls and some paperwork from their living-room desk to multinational corporations moving human capital in the thousands annually. A regulator described her observations of emergent private recruiters as follows:
There are those who are coming out of the language school model and realised job placement in language classes actually works quite well and they grew out of that. Then there are those who are coming out of the insurance risk management thing and want to calculate just any project with risk stuff. Then there are those coming out of the IT world who think we are doing it as a super amazing start-up because we digitalise everything and we don’t even need that many people and we can scale it up immensely. And then there are the carers who enter into it with their whole personality and should never calculate their hourly wage, they try with so much personal effort to be the best in the market. Then there are the ones who survive mainly on their marketing but don’t really have any structure behind there.
We encountered similar types. A start-up, having dealt in quite unrelated consumer goods before turning to nurse recruitment, bet on a model that can be scaled and rationalized. For example, before recruiting a candidate into their training programme, this start-up’s candidates must pass a tailored assessment of their language learning abilities. Yet we also encountered language school-based agents specializing in cultural integration, faith-based institutions with humanistic credos, and agents who professed that they would go the extra mile to make recruits feel at home in Germany – for example, find a mattress for the visiting family member, or be available on the phone when the hard time of the year, Christmas, hits the newly arrived.
Given this diversity, many properties seem to qualify individuals and businesses to become middlemen. Among these, international networks stand out. The CEO of a German recruiter active across East Asia, North Africa, and Latin America puts it quite bluntly: “It’s purely opportunistic, we have personal connections in each of our countries. And I have the theory that nearly every agency has only made a selection because they somewhere have an opportunistic reason to go to this country”. Given the importance of personal connections, it also does not surprise that we found ex-politicians or their relatives to be CEOs of recruitment agencies.
In other words, the agencies themselves also rely on middlemen to establish contacts and access recruits. And middlemen do not always need to be formal institutions. For example, many of our participants knew of hospitals or care homes turning employees into middlemen. Employers simply approach their foreign-trained staff and offer them cash rewards if they convince qualified colleagues or friends back home to migrate to Germany and start working with them.
Professionals versus bad apples, and a legitimate shared enterprise
This blend of improvisation and formalization leads to intensive debates about good versus bad business practice. Some of this was driven by clients’ (hospitals) concern about the reliability and identity of recruitment firms. We were told of prominent stories circulating among hospitals about fraudulent agencies – agencies one could name “fake” due to their phantom nature – they did not deliver the promised contingents of nurses, or even went bust or disappeared altogether. Likewise, occasional but highly alarming media reports about agencies’ abusive practices vis-à-vis nurses further increased legitimation pressure. It was indeed commonplace among our interviewees, both from public and private recruiters, to talk about the bad apples out there – middlemen who engaged in fraudulent or chaotic or unprofessional practice, or who were simply “traffickers”.
Private recruiters also use softer disqualification of competitors. They highlight that their own services can exceed the package offered by Triple Win, for example regarding post-arrival integration services such as matching with hospitals and support with a broad set of everyday challenges for new arrivals. This serves to justify higher prices and seeks to define what is needed for real and durable integration. One interviewee from an agency used the term “strategic recruitment” to explain that their services cost time and money. Employers looking for international staff, he said, often did not understand the requirements of strategic recruitment. He suggested that “most of them privately use Tinder and think we are a Tinder for nurses”. And while some middlemen might then just promise unrealistic things, the interviewee’s company would not engage in such reckless matching but be closer to the actual time and cost of recruitment.
To distinguish themselves from competitors, some recruiting agencies now resort to voluntary certification with a fair recruitment certificate. They form a community of currently over 70 certified agencies that, for example, guarantee to recruits that they need not bear the costs of migrating, and to employers that jobs will be filled.[4] As one agency explained to us, their offer within this context was to give a “one year warranty” – if within the first year a recruited worker leaves, the employer gets a replacement.
Having a certificate is good in terms of signalling trustworthiness. In fact, as one CEO told us, their company website displays logos of business associations, public organizations, and even from unrelated programmes from the start-up world, if they look good or have the German flag.
Additionally, having a certificate is good in terms of meeting and debating business standards. As noted above, members of that certificate association told us that they were warning each other of thieves – companies which snatched recruits from their programmes. Some agency heads described it as immoral and poor conduct that other recruiters offered head hunting fees to candidates who switched to their agency or employer. Other agency heads did not attribute blame to the workers themselves – who could blame someone who got 3000 Euros in cash to buy their first set of furniture? Yet vis-à-vis competitor firms, agencies mobilize moralized arguments. A private recruiter specialized in integration services says she did it “in order to protect the nurses”, another recruiter specified that Filipino nurses switching companies would risk the stain of a bad reputation as being unreliable. Some agency interviewees were grumbling that nurses were “overly protected” by the norms of the certificate, and might take advantage of the agencies’ services such as language courses without ultimately becoming a nurse in Germany.
In this contest to secure both workers and clients, participants seek to distinguish themselves as honourable businesses in order to gain access to, and hold on to, scarce workers. They try to co-shape the rules of the game at a business frontier where profit margins, scalability, and calculability are still being negotiated. Criticizing competitors’ bad practice here can address clients’ need for reassurance – given past debacles with phantom and in that sense fake recruiters and given the absence of public regulation. Yet furthermore, the registers of professionalism, business integrity, and worries about quality allow recruiters to criticize competitors as what one may call “substandard” (Sirrs 2023) – not entirely fraudulent, but still a sort of fake compared to functioning, and as we heard above, “strategic” recruitment.
What usually lies beyond such criticism of bad practice – but sometimes shines through when recruiters and officials mention that origin countries would like to get something in return for the lost workers – is the question of what this business does to origin countries’ health systems. Only one interviewee, who works for a big German employer, opined that the talk about decent business and fairness only served to rationalize the “modern colonialism” that Germany’s poaching of foreign nurses amounted to. For most middlemen, participating in this market, it is about populating a new niche with lots of need for problem solving, and making it both calculable and honourable through rationalization and legitimation.
Globally speaking, the market for middlemen in international nurse migration will foreseeably keep evolving, and remain ridden with tensions. States keep changing their immigration and emigration regulations, often struggling to reconcile a need for international labour with increasingly harsh and hostile immigration policies, employers keep looking for reliable but affordable workers, and the migrants look for recruiters they trust. Where they bet on the wrong middlemen as recently happened in UK-based proliferation on “dodgy” agencies recruiting care workers under post-Brexit visa schemes, migrants end up in exploitative contracts or with recruiters who can no longer sponsor their visas (Das et al. 2024; Das 2025). Yet notably, governments such as the German or British one also refrain from more binding regulation of recruitment agencies and more systematic inspections. Keeping the middlemen slightly in the shadows keeps the recruitment going without forcing governments to resolve its practical and ethical contradictions.
[1] All interview quotes translated from German.
[2] The Federal Agency of Labour has signed treaties with Bosnia and Herzegovina, the Philippines, Serbia, and Tunisia in 2013 (Serbia has meanwhile suspended its agreement); and in 2021/2 with Brazil, Colombia, Indonesia, Jordan, Kerala (India), and Mexico. For further detail see Hanrieder and Janauschek 2025.
[3] See link: https://www.giz.de/en/workingwithgiz/76712.html
[4] See link: https://www.faire-anwerbung-pflege-deutschland.de/guetegemeinschaft, last checked 21 March 2026.
References
Bärnreuther, Sandra. 2020. Traders of gametes, brokers of values: mediating commercial gamete donations in Delhi. Economy and Society 49:3, 455-473.
Das, Shanti; Kalanaki, Marjan and Zeke Hunter-Green. 2024. ‘Pretty dodgy’: alarm over suspect care agencies granted Home Office licence to act as visa sponsors. The Guardian 3 March, https://www.theguardian.com/society/2024/mar/03/alarm-over-suspect-care-agencies-granted-home-office-licence-to-act-as-visa-sponsors.
Das, Shanti 2025. Flawed UK visa scheme led to ‘horrific’ care worker abuse, says watchdog. The Guardian, 16 March, https://www.theguardian.com/world/2025/mar/16/flawed-uk-visa-scheme-led-to-horrific-care-worker-abuse-says-watchdog.
Hanrieder, Tine and Leon Janauschek. 2025. The ‘ethical recruitment’ of international nurses:
Germany’s liberal health worker extractivism. Review of International Political Economy 32:4, 1164–1188.
Hornberger, Julia and Sarah Hodges. 2023. Fake-talk as concept and method. Medical Anthropology Theory 10:3, 1–22.
Jones, Lee and Shahar Hameiri. 2022. Explaining the failure of global health governance during COVID-19. International Affairs 98:6, 2057–2076.
Masselink, Leah E. and Shoou-Yih Daniel Lee. 2010. Nurses, Inc.: expansion and commercialization of nursing education in the Philippines. Social Science and Medicine 71:1, 166-172.
Merz, Sibille; Hunter, Benjamin J.; Murray, Susan F. and Ramila Bisht. 2024. Market making and the production of nurses for export: a case study of India–UK health worker migration. BMJ Glob Health 9:e014096.
Othman, Mousa. 2023. Gesundheitsfachkräfte aus dem Ausland – Arbeitsumstände. Presentatiomn to Unterausschuss Globale Gesundheit im Deutschen Bundestag Berlin, 22.05.2023. https://www.bundestag.de/resource/blob/949642/ee4639627d6f4ce67b3926f46c3363cd/20_14-1_0040_Mousa-Othman_PPP_Gesundheitsfachkraefte-aus-dem-Ausland-data.pdf.
Pillars of Health. 2022. Country report on health worker migration and mobility in Germany. b3b4063d-pillars-of-health_country-report-on-health-worker-migration-and-mobility_germany.pdf (cstor.eu).
Sirrs, Christopher. 2023. Fluid fakes, contested counterfeits: The World Health Organization’s engagement with fake drugs, 1948–2017. Medicine Anthropology Theory, 10:3, 1-29
Walton-Roberts, Margaret. 2021. Intermediaries and transnational regimes of skill: nursing skills and competencies in the context of international migration. Journal of Ethnic and Migration Studies 47:10, 2323–2340.
Yeates, Nicola and Jane Pillinger. 2019. International health worker migration and recruitment: global governance, politics and policy. London: Routledge.
