In response to a significant shortage of medical personnel, Germany has been actively recruiting healthcare workers from around the world. Politicians have visited countries like Brazil, Vietnam, and Morocco, promoting the German labor market. Tunisia, in particular, has become a popular source of nursing recruits, especially after a new German law on skilled worker migration was passed in 2020. According to the German Federal Foreign Office, 2,060 working visas were issued in 2023 for Tunisian nurses alone, making Tunisia the second-largest supplier of healthcare workers for Germany outside the European Union.

A new law was passed last year, promising to further expedite the migration process for healthcare workers. However, the process still takes at least a year, assuming all documents are valid and correctly submitted. This long and costly process takes a toll on Tunisian nurses, both financially and mentally.

A bureaucratic jungle

Before Amira can start working in Germany, she must send in her references of professional qualifications and work experience to the Immigration Office and start studying the German language. Nurses need a language level of B2, which shows good control of the German language. Some can reach that level within a year, but normally, it takes longer. 

As a response to her references, she gets handed out her so-called deficit notice ( Defizitbescheid), which lists the necessary qualifications she needs to acquire before she will be considered fit to work in Germany. To be fully recognized as a nurse, the 24-year-old is then required to pass an exam to test her qualifications. 

Parallel to that, Amira has to apply for a work permit, which allows her to work as an assistant nurse in Germany until she successfully passes the exam. To obtain this document, she must again send her references to various German authorities.

If all this sounds confusing and hard to handle, that’s because it is. To master all these steps, Amira, like many others, decided to consult an agency. “I'm so glad to deal with an agency. Without them, I would be lost”, she says. All these bureaucratic steps - most of them only available in German - are barely manageable on top of Amira's thirty-eight-hour work week and the daily German lessons. 

Flourishing market for agencies

In a small café in the German town of Hannover, 26-year-old physiotherapist Aymen scrolls through thousands of messages exchanged with his recruitment agency. Three years ago, when he picked this agency, he was, in his own words, “young and inexperienced”. Positive reviews shared in Facebook groups led him to take a chance. Two frustrating years and 2500€ later, he finally arrived in Germany.

New recruitment agencies are popping up all over Tunisia, each offering a range of services: German language classes, document translation and even application coaching. There are always new companies surfacing, but the quality of their services can differ drastically.

In September 2019, the Tunisian Ministry of Labour revoked the licences of two Tunisian recruitment agencies, citing fraud, extortion, and trading in forged job offers. To prevent such malpractice in the sector, the law forbids charging workers any fees. Skilled workers are advised to work only with licensed agencies, of which there are currently 48.

Despite these regulations, many active recruitment agencies are not listed as licensed. Some are not officially based in the country, others masquerade as consultancies, and some simply operate without registering. Stories of scams and rip-offs are common. Some agencies demand exorbitant fees, while others issue contracts that make workers dependent on the agency, threatening them with hefty fees if they leave. In more extreme cases, it’s just blatant fraud: after a payment has been made, the agency never gets in touch again.

Finding a reputable agency is difficult. Online reviews and testimonials vary widely, with some contradicting each other or being spread by the agencies themselves. This makes some doubt if it is responsible at all to even trust an agency in the first place. 

Aymen was unaware that the agency was not registered in Tunisia. Even if he had known, "it might not have mattered at the time", he admits. He just wanted to get to Germany as quickly as possible. 

The agency exploited this, demanding more payments that were not initially agreed upon as the process dragged on. He was never given receipts for his payments, which he had to deliver in cash—often in an envelope to an anonymous woman in the streets, rather than at the agency's office.

Today, Aymen would never reach out to an agency again. “If you undergo the process once, you know how it works.” 

Although he sometimes feels ashamed of his naivety, he also recognizes the desperate situation that drove him to take the risk. 

New law, old problems

The need for change in the recruitment process became clear to German lawmakers. The German Federal Office of Statistics declared in January this year that up to 700,000 additional nurses would be needed over the next 25 years. The situation is urgent and has German politicians and employers on their toes.

Well-educated foreign workers are considered a potential of the German economy. They should “secure the prosperity of Germany” says Nancy Faeser, Germany’s Minister of the Interior, who enacted a new law on immigration policies for skilled labor in July 2023. The law, implemented in November last year, aims to attract skilled workers to the German job market by emphasising speed and efficiency. 

This infographic illustrates the trend in the number of work visas issued to Tunisian nurses in Germany from 2020 to 2024, highlighting a significant increase in 2023.

However, a closer look into the bill reveals that it introduces few groundbreaking changes, particularly for nurses. What is new? First, it allows people without formal degrees to work in Germany. This relaxation of the highly formalized German labor market is the “essence of the new law” according to political scientist Holgar Kolb, who works at the Expert Council for Migration and Integration (Sachverständigenrat für Integration und Migration, SVR).

Basically, the bill allows foreigners who can prove their work experience to enter the country and start working without the hassle of a lengthy recognition procedure of certificates.

The bill also introduces an "opportunity card" ( Chancenkarte), a points-based system that allows candidates to earn points for their various work experiences. If a candidate accumulates enough points, they are granted the possibility of entering the country and searching for a job.

Adjustments without improvements

What sounds attractive on paper is unfortunately tainted by a whole array of problems. “There is no good assessment strategy to evaluate individual work experience”, Kolb criticizes. Additionally, the diversity of applicants' backgrounds makes it difficult to categorize them into suitable work fields. Kolb predicts that in the future, German administrators will struggle to process the high number of applications. 

Meanwhile, it is difficult to even assess how many people will make use of the opportunity card. “If you meet the requirements for the opportunity card, you can also choose a different route to enter”, says Martin Varga, a lawyer at the German Trade Union Confederation (Deutscher Gewerkschaftsbund, DGB) in the department for employment and skilled worker migration. 

Another route is, for example, to connect directly with a German employer, bypassing the tedious recognition process of work experience, which, as was pointed out, can be confusing and time-consuming. The new law allows workers to enter the country faster through this route, even before receiving the deficit notice. In this case, the employer takes responsibility for the new worker, allowing them to start working while their paperwork is processed.

But this regulation also has its drawbacks. Currently, the visa is tied to one's job. If a worker loses their job and cannot find a new one immediately, they risk losing their right to stay in Germany. 

While finding a new job as a care worker is supposedly easy in Germany, scheduling appointments with the Immigration Office can be challenging. People sometimes wait months for their appointments due to understaffing. This situation gives employers significant power over their employees, which could be exploited. 

Unfortunately, the changes introduced by the new bill do not apply to most regulated professions, including nursing—a field in which Germany is desperate to attract more workers as Kolb points out. He questions the bill’s effectiveness in increasing the number of skilled workers hired from abroad, as it leaves the two main obstacles —bureaucratic visa and recognition processes— untouched. 

“For job seekers, the process remains relatively the same”, Kolb sums up. 

This means that the recruiting agencies are likely to continue to act as gatekeepers on the road to Germany. The new law makes no provision for regulating these agencies, allowing many to continue profiting from the booming skilled labor migration industry driven by the increasingly difficult economic conditions in Tunisia. Even agencies struggle with the complicated bureaucracy, often underestimating the challenges involved.

Quality control

The number of agencies mediating between Tunisia and Germany remains unclear because recruitment agencies are not required to register in Germany. As a result, monitoring their work is nearly impossible.

One of few control mechanisms is a quality seal introduced in 2021 called “Faire Anwerbung Pflege Deutschland” (Fair Recruitment Care Germany). This seal is intended to guarantee “ethically justifiable recruitment and more transparency“ in the daily operation of recruitment agencies that voluntarily apply for the certification.

Around 50 agencies currently hold the seal and commit to its requirements of ethical recruiting. 

Most importantly, this includes the “Employer-Pays-principle” which prohibits charging workers any fees, including those for language classes and document translation. 

If an agency collaborates with other companies, such as language schools, it is responsible for ensuring that these standards are upheld throughout the service chain. “To control this, we established verification by random sampling and are checking the document history of candidates", says Ann-Christin Wedeking, head of the Quality Association's office that awards the seal. “Care workers who work with an agency that has the seal can contact us at any time with their complaints.” However, she acknowledges that few people are aware of the seal, highlighting the importance of raising awareness in the countries of origin.

While the seal is a step toward more ethically governed recruitment practices, it falls short of addressing the realities of the industry. To counter exploitation, the question of implementing a mandatory mechanism to control agencies should be raised. “We made it very clear that voluntariness won’t help at all”, says Varga pointing to a 2021 position paper from the DGB (German Trade Union Confederation) concerning the seal. 

“In the meantime, the big players acquired the seal, but the great mass of the recruiting business is handled, to our knowledge, by small enterprises with domestic or foreign headquarters.”

13 of the listed agencies are recruiting from Tunisia. Most of them are big ones, which is less surprising: to get the seal the agency pays 5100€ (~17 000 dinars) to cover the inspection process. To continue working as a certified ethical agency, the control procedure must be repeated after two years. This means another 5100€ for the agency. Taking in consideration that a significant number of agencies are small companies, the majority are operating without this seal.

Already in 1997, the International Labour Organization (ILO) presented a set of guidelines for fair recruitment practices, which serves as a model for many European countries in regulating labour recruitment. 

But to this day, Germany hasn’t ratified them. According to a parliamentary request, this is because of the brokerage fees, which the ILO guidelines prohibit. 

The German law allows charging up to 2000€ (6 700 dinars) for recruiting services. For comparison, a Tunisian care worker with job experience makes around 1400 Dinar per month.

Charging the workers themselves allows the agencies to pay less for the recruiting process and offer cheaper recruiting services to the employers. This may diminish the risk for agencies and employers but puts an extra burden on the workers’ shoulders. 

“The economic risks will be transferred to the migrating person, who is the weakest link in this relationship”, says Martin Varga. 

“Economically, this makes sense but morally it should not be allowed for agencies.” He sees the regulation of recruitment agencies as a necessary measure to protect foreign workers.

Filtering Migrants

Amira and Aymen are now working in Germany. Amira passed her exam, and is now a recognized nurse. She’s adapting well to her new life, which surprises her: "I really didn't expect it, I was very scared". She cried frequently in the month before her arrival, overwhelmed by the thought of leaving her family and traveling so far from home. Today, she stays in touch with her relatives by phone and has reconnected with an old school friend who has been working as a nurse in a nearby town for several months. The two young women now meet regularly at various locations in the region.

Aymen broke off the ties with his agency facing threats from its boss. He took on the complicated paperwork on his own, and found himself a new job and an apprenticeship. Now, he is comfortable navigating German bureaucracy: recently, his girlfriend also arrived in Germany to work in the healthcare sector, and Aymen assisted her in managing the process without the help of an agency. 

The road to Germany remains a hurdle race. Viewed from a broader perspective, the complicated process and stringent entry conditions to Germany seem part of a larger political strategy.

With a controversial new agreement between the EU and Tunisia, which provides Tunisia with substantial loans in exchange for tighter border controls, European countries continue to externalize their borders in order to contain migration. At the same time, countries like Germany, France, and Italy, facing ageing populations, are in desperate need of skilled healthcare workers such as doctors and nurses.

To make sure that these kinds of immigrants can enter and work, European countries are attempting to balance loosening regulations just enough to allow the “right” migrants in while keeping the “wrong” ones out. At the same time, they are neglecting the consequences of brain drain on countries like Tunisia, where the economic hardships since 2011 have severely impacted the public health sector.

And while the conditions under which trained professionals migrate remain secondary for German officials, they can count on the fact that many Tunisian care workers still have to make the journey out of economic pressure.