Ave Lauren
OECD
José Ramalho
OECD
Jean-Christophe Dumont
OECD
Gaetan Lafortune
OECD
Agya Mahat
WHO
Tapas Nair
WHO
International Migration Outlook 2025
Abstract
This chapter is the result of a collaboration between the OECD and the WHO in the context of the Working for Health programme. It examines the evolution of international migration of health professionals, specifically doctors and nurses, to OECD countries since 2000/01, in the context of growing workforce shortages and increasing global competition for talent. It analyses recent trends in the mobility of foreign-trained and foreign-born health professionals, drawing on the latest available data. The chapter also considers the implications for countries of origin, including the risk of brain drain, and highlights the importance of ethical recruitment practices. Finally, it explores recent changes in migration policies affecting health professionals, as well as developments in the recognition of foreign qualifications and licensing across the OECD.
Key findings
Health workforce shortages have become a critical challenge across OECD countries, driven by ageing populations, increasing care needs, and growing demand for medical services. In response, many OECD countries have reinforced their training capacity of health personnel, but the international recruitment of doctors and nurses has also continued to increase.
The total number of migrant doctors and nurses in OECD countries has grown significantly over the past two decades, outpacing overall employment growth in these professions. In the OECD, the total number of foreign-born doctors increased by 86% and foreign-born nurses increased by 136%. Meanwhile, the number of foreign-trained doctors rose by 62% and nurses by 71% since 2010. This shows a high and growing reliance by OECD countries on migrant health professionals to staff their health systems and respond to population health and care needs.
The largest increases in absolute numbers of migrant health professionals were recorded in the United States, Germany and the United Kingdom. These three countries remain the primary destinations for foreign-born and foreign-trained doctors and nurses, together hosting the majority of migrant health professionals in the OECD.
The number of foreign-born doctors more than tripled over the past two decades in several countries, including Finland, Germany, Luxembourg, Norway, Spain and Switzerland. For foreign-born nurses, Finland saw an almost eightfold increase, while Germany, Ireland, New Zealand and Norway also saw their numbers more than triple.
In most OECD countries, the share of foreign-trained health workers is lower than the share who were born abroad, showing that many migrants finish at least part of their education or have to redo it in the host country.
About one in five migrant doctors and nurses in OECD countries originates from another European Economic Area (EEA) country, while 30% and 27% of migrant doctors and nurses respectively are from the broader OECD area. Asia is the main region of origin, accounting for approximately 40% of foreign-born doctors and 37% of foreign-born nurses working in the OECD.
India, Germany and China are the main countries of origin for doctors, while the Philippines, India and Poland are the top three countries for nurses. About 89 000 doctors and 257 000 nurses originate from countries on the WHO Health Workforce Support and Safeguards List (SSL), raising concerns about the possible impact of the international mobility of health workers on the fragile health systems of these countries.
Seven countries of origin have more doctors working in the OECD than at home and this number goes up to 15 countries for nurses. These are mostly small island states and less developed countries in Sub-Saharan Africa.
Migration policies are evolving to facilitate international recruitment in the health sector. Most OECD countries use shortage occupation lists and specific bilateral labour agreements while dedicated migration pathways for health professionals have become more common. The main receiving countries should, however, maintain efforts to increase training and improve health workforce retention in order to reduce domestic shortages and maldistribution.
Recognition of qualifications and licensing remain major barriers to the skills-appropriate labour market integration of migrant health professionals. Lengthy and complex procedures often delay labour market entry for foreign-trained professionals, prompting several countries to streamline procedures for the recognition of foreign qualifications and to reinforce the offer of bridging courses. This positive practice can serve as a reference and a roadmap for other countries to consider.
Recent crises, particularly COVID‑19, triggered a wide range of temporary policy responses concerning both migration and recognition/licensing systems. While many migration-related measures were short term, the experience has generated broader interest across the OECD countries in introducing new licensing approaches, notably temporary and conditional licensing.
It is crucial for all countries to implement the WHO Global Code of Practice on the International Recruitment of Health Personnel to its full scope. This may require strengthening international co‑operation to help developing countries build a sufficient health workforce and to reinforce their health systems, thereby mitigating the factors that drive health professionals to leave.
The international migration of health professionals has become an increasingly prominent global policy issue, particularly in light of global health workforce shortages and existing pressures on healthcare systems. Although international migration flows were temporarily disrupted during the COVID‑19 pandemic, the crisis highlighted the essential role that migrant health workers already present in OECD countries played in maintaining and recovering the provision of healthcare services and underscored their long-term importance to health systems’ resilience (OECD, 2020[1]). At the same time, ageing populations and growing healthcare needs have intensified competition for qualified personnel, prompting many OECD countries to revisit their workforce strategies and approaches to international recruitment.
Recent developments have further reshaped this evolving landscape. The United Kingdom’s departure from the European Union introduced new dynamics in the mobility of health professionals within Europe. Simultaneously, geopolitical and humanitarian crises have led to a notable increase in asylum applications across the OECD. The large‑scale displacement of Ukrainians in 2022 has been particularly significant, yet forms part of a broader trend of rising asylum flows globally. Among these displaced populations are many individuals with prior experience in health-related occupations, encouraging several OECD countries to explore more flexible and inclusive pathways for recognising foreign qualifications and supporting their integration into the health workforce.
These developments, together with the increasing competition for qualified workers (OECD, 2023[2]), are prompting a shift in how OECD countries plan their health workforce, manage international mobility, and integrate foreign-trained professionals – raising key concerns around sustainability, ethical recruitment, and impact on countries of origin. The WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted in 2010, continues to offer a relevant and effective framework. It promotes ethical recruitment and helps countries develop systems that balance the interests of both sending and receiving countries, while safeguarding the rights of migrant health workers.
Against this backdrop, this chapter examines the evolution of international migration of health workers to OECD countries over the past two decades, beginning in 2000/01. It also explores the implications for countries of origin, to assess the scale and patterns of brain drain of both doctors and nurses across a wide range of countries. These trends are analysed within the broader context of shifting labour migration policies and evolving approaches to skills recognition and licensing of foreign-trained health professionals.
The analysis draws on two principal data sources:
The most recent data (2023 or the latest) on foreign-trained doctors and nurses working in OECD countries, collected through the OECD/Eurostat/WHO-Europe Joint Questionnaire on Healthcare Statistics, offering internationally comparable time series dating back to 2000;
The latest available data (circa 2020/21) on foreign-born doctors and nurses working in OECD countries, sourced from the OECD Database on Immigrants in OECD Countries (DIOC), which compiles information from national population censuses and labour force surveys, with time series available since 2000/01.
This chapter is the result of a close collaboration between the OECD and the WHO in the context of the Working for Heath programme that builds on longstanding joint work on this issue between the two organisations. The 2007 International Migration Outlook included a dedicated chapter offering a comparative overview of migrant doctors and nurses across OECD countries, aimed at informing both national and international policy dialogue (OECD, 2007[3]). This analysis was subsequently updated in the International Migration Outlook 2015 (OECD, 2015[4]), the 2019 report on trends in the international migration of doctors, nurses and medical students (OECD, 2019[5]), and in two OECD Health Working Papers (Socha-Dietrich and Dumont, 2021[6]; Socha-Dietrich and Dumont, 2021[7]).The topic was also addressed in the 2016 OECD report Health Workforce Policies: Right Jobs, Right Skills, Right Places, which analysed how health and migration policies influence the inflow of foreign-trained doctors and nurses into OECD countries (OECD, 2016[8]), as well as in a 2020 policy brief highlighting the contribution of migrant health professionals during the COVID‑19 pandemic (OECD, 2020[1]).
Overall trends in health sector employment in the OECD
Since the turn of the century, the number of people working in the health and social care sector across OECD countries has grown by over 28 million, reaching almost 73 million in 2023. This expansion outpaced both population and overall employment growth, with the share of workers in the health and social care sector rising from 9% in 2000 to 11% in 2023 on average across OECD countries. The United States, the OECD’s largest health labour market, illustrates this expansion. Healthcare employment there rose from 9.3 million in 1990 to 18.1 million in 2022, an annual growth rate of 2.1%, almost twice that of non-health employment (1.1%). It overtook employment in manufacturing in 2006 and employment in retail trade in 2009 to become the largest sector in terms of employment (Gottlieb et al., 2025[9]).
In all countries, doctors and nurses are critical to the functioning of health systems, and their numbers reflect this role. In 2023, OECD countries had over 4.5 million doctors and 12.3 million nurses, compared to 2.8 million and 8.1 million in 2000, respectively. Over the past two decades, the growth in the number of these professionals has outstripped population growth in virtually all OECD countries. The 38 OECD countries represent 17% of the world’s population but account for about 39% of the world’s medical doctors, nurses, midwifes, dentists and pharmacists.
On average, the number of doctors per 1 000 population across OECD countries increased by 38%, reaching 3.9 doctors per 1 000 population (Figure 5.1). This growth was particularly noticeable in countries such as Norway, Germany, Denmark Australia and New Zealand, while it was less pronounced in the United States and Finland. Accession countries such as Croatia and Romania also registered considerable increases.
Note: The OECD average is unweighted. 1. The data for Colombia, the Slovak Republic and Türkiye refer to professionally active. 2. The data for Argentina, Chile, Greece and Portugal refer to license to practice (resulting in a large overestimation).
Source: OECD Data Explorer, Physicians, http://data-explorer.oecd.org/s/2i7.
Note: The OECD average is unweighted. 1. The data for Colombia, Portugal, the Slovak Republic, Türkiye and the United States refer to professionally active. 2. The data for Argentina and Chile refer to license to practice.
Source: OECD Data Explorer, Nurses, http://data-explorer.oecd.org/s/2i8.
Over the same period, the number of nurses rose by 25%, reaching an average of 9.1 nurses per 1 000 population across the OECD (Figure 5.2). Korea, Switzerland, Finland and Portugal experienced strong growth rates. However, the picture is more mixed in the 2013‑2023 period. In the last decade, a few countries, such as the Slovak Republic and Latvia, have experienced declines in the number of nurses per 1 000 population.
The overall supply of health professionals is shaped by a range of factors, from domestic education and training to the immigration of health professionals, as well as through outflows such as retirement or emigration. In the face of widespread health workforce shortages and growing demand for healthcare, it is imperative to understand these determinants. What role has migration played in the supply of labour in OECD countries’ health systems?
Foreign-born health professionals in the OECD
Migrant doctors and nurses have been instrumental to the rising number of healthcare professionals across many OECD countries over the past decade. Their contribution can be assessed using data on either foreign-born or foreign-trained health professionals in destination countries (Box 5.1). This section presents the most recent data on foreign-born doctors and nurses in OECD countries, with the next section focussing on the foreign trained.
As the international migration of doctors and nurses gains prominence in policy and public discussions, there is a growing need to monitor and better understand the associated trends. Effective monitoring should meet two key criteria: (1) relevance to both origin and destination countries, and (2) the feasibility of regular data collection. Migration patterns of health professionals can be assessed using nationality, place of birth, or place of education and training – each with its own advantages and limitations.
Nationality is a weak indicator, as naturalised individuals are no longer counted as foreign nationals, and in some countries a considerable proportion of people born and raised in a country may hold foreign nationality. Place of birth offers a more consistent measure, as it reflects cross-border movement, but does not show where education occurred – an important factor when assessing impacts on origin countries. Some foreign-born individuals migrated at a young age or came for university and stayed, meaning the cost of their education was often covered by the host country or by themselves.
The place of education or training offers an alternative perspective but is more difficult to measure. In some countries, where medical education is highly regulated or costly, a significant proportion of nationals pursue their studies abroad and are consequently classified as immigrants based on place of education. Conversely, recently arrived immigrants who were fully trained as doctors or nurses prior to migration may be required to repeat their education in the host country and are therefore not recorded as immigrants under this classification. Furthermore, medical and nursing education may span multiple countries, further complicating classifications. The OECD/Eurostat/WHO-Europe Joint Questionnaire defines foreign-trained professionals as those who obtained their first medical or nursing degree abroad. In addition, data is also captured on the distribution of foreign trained health workers by place of birth, which provides further insights on the internationalisation of health education.
This chapter uses both the place of birth and place of training approaches. Data on foreign-born professionals come from recent population censuses and Labour Force Surveys (LFS), which identify health workers using the ISCO‑08 classification. Data on foreign-trained professionals are collected through the Joint Questionnaire, with most countries relying on professional registries or government sources.
Over the past two decades, the overall share of foreign-born health professionals in OECD countries has increased steadily. In countries with consistent data over the period, the total number of foreign-born doctors rose by 86% between 2000/01 and 2020/21, while the number of foreign-born nurses grew by nearly two and a half times (Table 5.1 and Table 5.21). In both cases, this growth outpaced the general increase in the total number of doctors and nurses, which rose by 41% and 48%, respectively. At the country level, several OECD countries saw marked increases in the absolute number of foreign-born doctors between 2000 and 2020/21. In Luxembourg, it grew nearly sixfold, while in Finland it rose more than fourfold. Germany, Norway, Spain and Switzerland also recorded increases of over threefold. Among the main countries of residence (Table 5.1), Germany and Australia saw the number of foreign-born doctors nearly triple. The United Kingdom experienced a doubling, and more moderate increases were observed in the United States and France.
A similar pattern is evident among foreign-born nurses. Finland saw the steepest rise, with numbers increasing almost eightfold though starting from a very low level in 2000/01. In Norway, they increased more than fourfold. In Germany, Ireland and New Zealand, the numbers more than tripled, while in Australia and Spain, they nearly tripled. Switzerland also recorded a significant increase. Among the other major countries of residence, Canada, the United Kingdom and the United States all saw their numbers more than double. For detailed figures, see Table 5.2.
These trends also reflect deliberate efforts to address health workforce shortages amid an ageing population and increasing care needs. Finland for example has expanded its educational offer to attract international students, with several Universities of Applied Sciences now providing nursing degree programmes in English, combined with Finnish language training, enabling international graduates to enter the national workforce more easily.
Across the reporting countries for which data is available for all years, the proportion of foreign-born doctors among all doctors increased from 21.2% in 2000/01 to 27.9% in 2020/21. For nurses, the share rose from 11% to 17.6% over the same period. However, the overall share varies considerably across OECD countries. In 2020/21, the share of foreign-born doctors ranged from 4% or less in Mexico, Poland and the Slovak Republic to over 50% in Australia, Luxembourg and New Zealand, and exceeded 40% in Ireland, Israel, Switzerland and the United Kingdom. Luxembourg, Switzerland and Ireland recorded the largest increase in the shares of foreign-born doctors over the period. For nurses, the lowest shares were in Poland (0.2%), Mexico (0.6%) and the Slovak Republic (2.0%), and the highest in New Zealand (42.7%), Australia (41.1%) and Israel (40.5%). Ireland, New Zealand, Australia and the United Kingdom experienced the most significant increases in the share of foreign-born nurses since 2000/01.
1. OECD Total for foreign-born doctors includes 19 countries, for which data is available for all years (2000/01, 2010/11 and 2020/21). Only countries with 1 are included.
2. For Mexico, figures include dentists. For Ireland, the 2020/21 total is an estimate.
Source: DIOC 2000/01, DIOC 2010/11, DIOC 2020/21, EU-LFS 2021.
1. OECD Total for foreign-born nurses includes 22 countries, for which data is available for all years (2000/01, 2010/11 and 2020/21). Only countries with 1 are counted. The OECD Total includes an estimation for Greece in 2010/11.
Source: DIOC 2000/01, DIOC 2010/11, DIOC 2020/21, LFS-EU 2021.
While the share of foreign-born health professionals has increased in most OECD countries, it has declined in a few. Over the past decade, the share of foreign-born doctors decreased in Estonia, France, Israel and Portugal, while the share of foreign-born nurses declined in Denmark, Estonia, Israel, the Netherlands, and several other countries. There are different reasons for these trends. For instance, the share of foreign-born doctors in France, Israel and Portugal has decreased as the number of domestic-born doctors increased more rapidly than the foreign-born. In Israel, this reflects significant increases in domestic training capacity over recent decades. Meanwhile in Estonia, the decrease reflects, among other factors, the retirement of many Russian-born health professionals who had arrived in the country during the Soviet period.
In absolute terms, the United States remains the primary country of residence for both foreign-born doctors and nurses (Figure 5.3). Among all foreign-born health professionals in OECD countries, 36% of all foreign-born doctors and 42% of nurses were practising in the United States in 2020/21. Other key countries of residence for doctors include the United Kingdom (13%), Germany (11%), Australia (7%), and France (6%). Together, these five countries account for nearly three‑quarters of all foreign-born doctors in the OECD, with the remaining 27% distributed across other member countries. Similarly, the main countries of residence for foreign-born nurses – after the United States – are Germany (14%), the United Kingdom (11%), Australia (7%) and Canada (7%). In this case, the top five destinations host an even greater share (81%), with the remaining 19% of foreign-born nurses residing in other OECD countries.
Note: Data for foreign-trained doctors does not include Costa Rica, Iceland, Korea, Luxembourg, Portugal, Spain, Japan, Mexico and Türkiye; Data for foreign-trained nurses does not include Costa Rica, Greece, Iceland, Korea, Japan, Luxembourg, Mexico, Portugal, the Slovak Republic, Spain and Türkiye.
Source: OECD Data Explorer (DF_HEALTH_WFMI) for foreign-trained and DIOC 2020/21 for foreign-born.
Although the international migration of doctors and nurses is typically considered part of highly skilled migration in policy terms, the share of foreign-born health professionals in OECD countries does not always mirror the overall share of skilled immigrants in the workforce. Moreover, distinct patterns emerge between foreign-born doctors and nurses.
Over recent decades, highly skilled migration has been increasing overall; however, in the case of migrant doctors, the trend is even more pronounced. This partly reflects the challenges destination countries face in matching domestic training capacities and physician demand, given the high cost and lengthy duration of medical education, although other factors also play a role. In most OECD countries, the percentage of foreign-born doctors in the country tends to be higher, on average, than the percentage of immigrants among highly educated workers (Figure 5.4). In countries such as the United Kingdom, Switzerland, the United States, Australia and Sweden, the difference between these two groups exceeds 10 percentage points (p.p.). However, there are also countries where foreign-born doctors are underrepresented compared to the share of highly educated immigrant workers – most notably Estonia, Italy, Latvia, Austria and Portugal.
Note: High-level of education refers to ISCED 2011 Level 5/6/7/8.
Source: DIOC 2020/21, LFS-EU 2021.
Trends for nurses are less clear. The share of foreign-born nurses is in most cases similar to or lower than the share of immigrants in the skilled workforce of the respective countries (Figure 5.5). The difference is particularly striking in Luxembourg, where foreign-born individuals account for nearly 68% of the highly educated workforce, but only 34.5% of nurses. The only OECD countries where the share of foreign-born nurses exceeds the average share of immigrants among highly educated workers by more than 1 p.p. are Israel, Ireland and the United Kingdom.
Note: High-level of education refers to ISCED 2011 Level 5/6/7/8.
Source: DIOC 2020/21, LFS-EU 2021.
Foreign-trained health professionals in the OECD
In most OECD countries, the share of health workers who were trained abroad is lower than the share who were born abroad. This reflects the fact that many migrants receive part of their education and training in their country of destination, sometimes because their previous qualifications are not transferable or recognised in the host country.
Most OECD countries are both receiving and sending countries of migrant health workers. Although they have often been viewed primarily as destinations, patterns of international mobility vary substantially between countries and over time, highlighting the need for a more nuanced analysis.
In 2023, OECD countries reported over 606 000 foreign-trained doctors and 732 000 foreign-trained nurses, representing increases of 62% and 71%, respectively, compared to 2010. The distribution of foreign-trained doctors and nurses reflects differences in national labour markets, education and recruitment policies, and migration regimes. In 2023, just three countries – the United States, the United Kingdom and Germany – accounted for 58% of all foreign-trained doctors working across OECD countries (Table 5.3). The concentration was even greater for nurses, with the same three countries hosting 61% of all foreign-trained nurses (Table 5.4). The top 15 OECD countries together accounted for 94% of foreign-trained doctors and 98% of foreign-trained nurses.
While foreign-trained doctors and nurses remain concentrated in this small group of countries, their share fell slightly between 2010 and 2023, signalling a modest diversification in foreign-trained professionals’ destinations.
In nearly all OECD countries, the number of foreign-trained doctors has grown more rapidly than the number of domestically trained doctors over the past decade. As a result, the share of foreign-trained physicians among all practising doctors has increased in most countries. This trend points to the growing role of international recruitment in meeting the unabating demand for medical care.
English-speaking countries have some of the highest shares of foreign-trained doctors. In 2023, foreign-trained physicians accounted for 43% of the medical workforce in Ireland, 42% in New Zealand, 36% in the United Kingdom and 31% in Australia. Only Israel (59%) and Norway (44%) recorded higher shares, while Switzerland was comparable at 40%.
The reliance on foreign-trained health professionals is not limited to doctors. In almost all OECD countries, the share of foreign-trained nurses has also increased over the past decade, pointing to their growing importance in national health systems. The highest shares in 2023 were observed in Ireland (52%), New Zealand (33%), Switzerland (27%), the United Kingdom (23%) and Australia (18%) (Table 5.4).
Ireland stands out, with nearly 52% of its nursing workforce trained abroad in 2023. This heavy reliance reflects ongoing domestic shortages, particularly in hospitals. To address chronic staffing gaps, Ireland’s Health Service Executive has conducted international recruitment campaigns targeting countries such as the Philippines and India, both of which have well-established nursing diasporas in Ireland. At the same time, a significant number of Irish-trained nurses have emigrated to other English-speaking countries, attracted by better working conditions and pay. This has further worsened domestic shortages and increased the health system’s dependence on foreign-trained nurses (OECD/European Commission, 2024[10]).
Notable increases have also been observed in the United Kingdom and Switzerland, where the share of foreign-trained nurses rose by around 12 p.p. over the past decade, and the absolute number more than doubled. In both countries, international recruitment – particularly from neighbouring countries or from countries where one of the official languages is widely spoken – has become a key element of strategies to address persistent nursing shortages.
Although Belgium still has a comparatively small share of foreign-trained nurses, it recorded the fastest growth in relative terms. Between 2010 and 2023, the number of foreign-trained nurses working in Belgium quadrupled, signalling a marked shift towards international recruitment in response to domestic workforce pressures (Box 5.2). All three Belgian regions – Flanders, Wallonia and Brussels – face ongoing challenges in attracting and retaining nurses and have developed region-specific strategies to address these issues.
Notes: For Germany the data refer to foreign citizens (not necessarily foreign-trained). For the United States, the 2021‑2023 data point refers to 2016, the latest year available. Data missing for Costa Rica, Iceland, Korea, Japan, Mexico, Spain and Türkiye. In Luxembourg, 100% of doctors have received their first medical degree in another country.
Source: OECD Data Explorer (DF_HEALTH_WFMI).
Note: For Germany the data refer to foreign citizens (not necessarily foreign-trained). Data missing for Costa Rica, Iceland, Luxembourg, Korea, the Slovak Republic, Japan, Mexico, Spain and Türkiye.
Source: OECD Data Explorer (DF_HEALTH_WFMI).
In most OECD countries, domestically trained doctors accounted for the majority of the overall increase in physician numbers between 2010 and 2023. However, in five countries, foreign-trained doctors contributed to more than half of the growth in the medical workforce – most notably in Switzerland (86%), Norway (70%) and Ireland (57%) (Annex Figure 5.A.1). In Norway, over half of this increase was driven by Norwegian students who studied medicine abroad before returning to complete their specialist training. Greece and Israel also show a high proportion of the foreign-trained doctors who are nationals who obtained their degrees overseas and then returned to practise. They illustrate a broader, two‑decade trend towards the internationalisation of medical and nursing education (Box 5.3).
Shortage occupation lists in Belgium are drawn up separately by each regional employment service – VDAB in Flanders, Le Forem in Wallonia, and Actiris in the Brussels-Capital Region. These lists, on which nurses consistently appear alongside other high-demand health occupations (such as healthcare assistants, physiotherapists, and occupational therapists), guide both domestic and international recruitment and underpin a range of incentive schemes (Directorate-General for Migration and Home Affairs, 2023[11]).
To address local nursing shortages, Brussels launched its first international recruitment partnership with Lebanon in 2012 and has since expanded this channel. Flanders, meanwhile, links mandatory integration training for low-skilled newcomers to shortage occupations such as nursing. Across all three regions, bespoke programmes allow jobseekers to train as nurses while retaining welfare benefits, and accelerated conversion schemes support foreign-trained nurses in obtaining a Belgian qualification (Cedefop - European Centre for the Development of Vocational Training, 2016[12]).
Despite these efforts, non-EU foreign-trained nurses continue to face structural barriers to full integration. A key challenge lies in the recognition of foreign qualifications. Complex or lengthy procedures often delay or prevent recognition, forcing many qualified nurses to take up lower-skilled roles as healthcare assistants (Belgian Health Care Knowledge Centre (KCE), 2025[13]). This mismatch between skills and employment highlights the need for more transparent and efficient pathways for recognising foreign credentials, to ensure that Belgium’s growing reliance on international recruitment leads to sustainable and meaningful integration of workers into its health system.
Ireland and Romania sit among the three OECD and accession members with the highest rate of new medical graduates per 100 000 population – more than double the OECD average (OECD, 2025[14]). Yet a sizeable share of these graduates are international students. In Ireland, around 50% of all enrolled medical students came from outside the country in recent years. In Romania, around one‑third of places in medical schools in recent years are taught in foreign languages (mainly in English, but also in French and to a lesser extent in Hungarian). Without these foreign students, both countries’ graduation rates would fall to – or below – the OECD average.
Irish medical schools have actively recruited abroad since the mid‑2000s, when cuts in state subsidies – accompanied by a cap on Irish/EU places – made high non-EU tuition fees an essential revenue stream. However, limited residency programme posts and priority for Irish/EU citizens means that most of these foreign graduates leave after obtaining their first medical degree. In Romania, eleven public and two private universities have expanded intakes since the early 2010s, partly to offset emigration of Romanian doctors and partly because multilingual, moderately priced programmes are attractive to students from Moldova, Israel, France and other European and Mediterranean countries who often have not been admitted in their home country due to limited capacity or “numerus clausus” policies. As in Ireland, most foreign graduates return home or move elsewhere in the EU to pursue their specialty training and career (WHO, 2025[15]).
Sources: Health Education Authority 2025 dashboards for Ireland, and annual government decrees on the nomenclature and specialisation in tertiary education for Romania.
Ireland has faced a paradoxical situation in recent years: while Irish medical schools have provided basic medical education to a very large number of both domestic and foreign students, the country has had to rely increasingly on the international recruitment of fully-trained doctors (Annex Figure 5.A.1) to address doctor shortages because many new graduates do not stay in the country after graduation (OECD, 2019[5]).
The Irish and Romanian examples make clear that the internationalisation of medical education can expand the capacity and diversify funding streams of medical schools and offer students wider education and career opportunities. It can also bolster supply in countries that struggle to scale their own training systems. At the same time, cross-border student flows add layers of uncertainty to national workforce planning regarding the country in which they might end up working, and – unless postgraduate training places and long-term career incentives keep pace – they cannot guarantee that the countries hosting the programmes will be able to count on this growing education effort to meet their own staffing needs.
As previously noted, the international migration of foreign-trained nurses has generally been more limited than that of doctors. Several countries have relied heavily on foreign-trained nurses to expand their nursing workforce. In the United Kingdom, 83% of the increase of nearly 120 000 nurses between 2010 and 2023 relied on nurses trained abroad. Switzerland also recorded a high share (58%), followed by New Zealand (54%) (Annex Figure 5.A.1). While the time series is more limited for Ireland, available data indicate that foreign-trained nurses accounted for 92% of the growth in the nursing workforce – nearly 12 500 nurses – between 2021 and 2024.
Notably, Switzerland was the only country where foreign-trained professionals accounted for more than half of the growth in both the medical and nursing workforce. This may, in part, reflect a relatively modest expansion of domestic training capacity over the past two decades. The number of medical graduates per 100 000 people remained broadly stable between 2000 and 2016, with only a slight increase in more recent years. Admissions to medical schools rose by just 28% between 2013 and 2022, well below the growth rates observed in neighbouring countries such as Italy or France, where intakes more than doubled. This limited expansion of domestic training capacity, coupled with relatively high wages and favourable career prospects, has made Switzerland an attractive destination for foreign-trained doctors and nurses, particularly from neighbouring countries.
In 2023, foreign‑trained professionals were an important source of inflows of new doctors and nurses in many OECD countries compared with new domestic medical and nursing graduates. In more than half of OECD countries in 2023, at least one in every four new doctors – and on average, 36% – had trained abroad. The contribution of international recruitment to nursing was more modest: only six countries saw foreign‑trained nurses make up more than one‑quarter of the annual inflow, and the OECD average stood at 17%. Figure 5.7 underlines this difference. In most countries, the proportion of inflows attributable to foreign‑trained is higher for doctors than for nurses; Ireland and Austria are the notable exceptions.
Another easy-to-grasp way of gauging reliance on international recruitment is to express inflows as the number of foreign-trained professionals admitted for every 100 domestically trained graduates – the foreign-trained dependency ratio (Annex Table 5.A.1).
In 2023, the United States, despite hosting the largest stock of foreign-trained doctors, recruited just 33 foreign-trained doctors for every 100 new medical graduates, whereas the ratio topped 200 in other OECD countries (Annex Table 5.A.1). Reliance is lower for nurses overall, but cross-country variation remains wide (Annex Table 5.A.2). Between 2010 and 2023 the United Kingdom’s doctor-dependency ratio quadrupled, while Norway cut its reliance by expanding training places at home.
These contrasts sit against a broader backdrop of rising training capacity. Across the OECD, the number of new medical graduates per 100 000 population grew by over 70% – reaching over 14 graduates per 100 000 people – between 2000 and 2023. Every country recorded growth, with Lithuania, Poland and Portugal tripling their output, whereas increases in countries such as Germany and Norway were in the low double digits. A similar, though less pronounced pattern is observed for nurses: average graduate numbers climbed by 50%. Although a handful of countries registered declines, most had increases, with some such as Australia, the Netherlands and the United States more than doubling their capacity (OECD, 2025[14]).
Taken together, the figures highlight two distinct policy paths: some health systems continue or are increasingly reliant on international recruitment to cover their workforce needs, while others are investing on larger domestic trained cohorts to build a workforce strategy that is more resilient and sustainable over the longer term.
Relying on just two reference years can obscure sudden shifts in international recruitment. Figure 5.8, which traces annual inflows of foreign-trained doctors, shows how divergent the trajectories can be. Switzerland’s intake has been broadly stable, hovering around 1 800 a year, which is a particularly high level. The United Kingdom followed a pronounced boom-and-bust cycle: a rapid rise from a little over 6 000 in 2000 to more than 13 000 in 2003 was driven by an NHS recruitment campaign (Bach, 2004[16]) (UK Department of Health, 2004[17]) and the 2004 EU enlargement, which gave doctors from the ten new member states immediate and automatic access to UK registration and training posts. Numbers then fell to about 5 000 for most of the 2010s following tighter migration rules in 2006 for non-EU doctors, before surging again after 2017 as post-Brexit staffing gaps, streamlined registration routes, and the removal of visa caps for doctors and nurses (UK Visas and Immigration and Home Office, 2018[18]) prompted renewed hiring abroad by trusts, lifting inflows above 18 000 in 2023.
Note: The OECD average is weighted. The share of annual inflow attributable to foreign-trained doctors is the number of new foreign-trained doctors divided by the same‑year total inflows (foreign-trained plus domestic graduates). This measure assumes all domestic graduates enter the labour market or proceed to postgraduate training.
Source: OECD Data Explorer (DF_HEALTH_WFMI and DF_GRAD).
Source: OECD Data Explorer (DF_HEALTH_WFMI).
Source: OECD Data Explorer (DF_HEALTH_WFMI).
Canada shows yet another pattern. Its inflows trace a near‑linear upward path. Provincial “practice‑ready” schemes, targeted immigration streams, and, from 2015, the federal Express Entry system – a points‑based fast‑track for skilled professionals – have sustained growth so that by 2023, arrivals were more than three times higher their 2000 level, despite minor year‑to‑year fluctuations and a brief slowdown in 2020.
Figure 5.9 shows that inflows of foreign-trained nurses also follow very different trajectories across countries. In Ireland, arrivals stood at about 700 in 2008, fell to only a few hundred during the post-crisis hiring freeze, and remained low until 2015 (Office of the National Director of Human Resources, 2009[19]). They then rose sharply – to almost 3 300 in 2017 – partly because nurses who might otherwise have moved to the United Kingdom chose Ireland while the implications of Brexit were unclear and new English language requirements came into force. After dipping to around 2 200 in 2019/20, inflows climbed again in the wake of the pandemic to exceed 5 000 in 2023 – more than six times the 2008 level.
The United States offers a longer time series dating back to 2000. Annual inflows grew from about 6 000 to over 24 000 between 2000 and 2007, when Schedule A fast-track green cards and buoyant hospital demand opened the door to large‑scale recruitment of foreign-educated nurses (US Citizenship and Immigration Services (USCIS), 2025[20]). They then fell back to roughly 5 000 after the global financial crisis. Numbers began to climb again from 2016 – interrupted only by a single pandemic-year dip in 2020 – and reached more than 23 000 in 2022.
Inflows of foreign-trained nurses to the United Kingdom have also risen sharply since 2018, topping 23 000 in 2022. This expansion has helped to ease staffing gaps but growing living costs and reports of challenging working conditions mean the United Kingdom is now often perceived as a stepping-stone to other destinations. Evidence from the Nursing and Midwifery Council (NMC) supports this view. Applications for Certificates of Current Professional Status (CCPS) – the document a UK-based nurse must obtain before registering abroad – jumped from about 3 300 in 2019/20 to almost 12 500 in 2022/23. Non-EU/EFTA, foreign-trained nurses lodged nearly three‑quarters (72%) of these requests, compared with just 23% three years earlier (The Health Foundation, 2024[21]). More than four‑fifths of CCPS applications were for three English-speaking countries: the United States, Australia and New Zealand. Data regarding time since NMC registry point to increasingly shorter stays in the country. In 2018/19 only 27% of foreign-trained nurses seeking a CCPS had been on the UK register for fewer than three years, whereas by 2023/24 that share had risen to 77%; just 3% had been in the United Kingdom for ten years or more (down from 50% in 2018/19).
Onward migration is not a new phenomenon or unique to the United Kingdom. New Zealand has long experienced similar patterns, with many nurses moving on to Australia under the Trans-Tasman Mutual Recognition Arrangement. A 2024 Ministry of Health brief noted that, between July 2022 and August 2023, 80% of the Nursing Council’s letters of good standing were requested by foreign-trained nurses, and most were sent to Australia. Of more than 760 letters issued in July 2023, over 60% were sought within one month of gaining New Zealand registration and a further 15% within one and six months (New Zealand Ministry of Health, 2024[22]). These data suggest that headline inflows understate the extent of nurse mobility and the difficulties of solely relying on foreign-trained professionals.
The contribution of foreign-born and foreign-trained to the total stock of health professionals
Data from various sources confirms that the proportion of both foreign-trained and foreign-born health professionals – particularly nurses – has grown in most OECD countries over recent decades. However, there are notable differences in the overall share of each category, with foreign-born health professionals outnumbering those who are foreign-trained. According to the most recent available data, foreign-born individuals account for over 25% of all doctors in the OECD area, compared to 20% who are foreign-trained. Among nurses, the gap is even wider: 18% are foreign-born, while just under 9% are foreign-trained. The differences in these proportions offer valuable insights into migration pathways, the internationalisation of medical education, and the socio‑economic and educational integration of migrants.
Countries with high shares in both categories suggest a broad reliance on international migration to address domestic workforce shortages and rising demand. The variation between the two groups, however, may reflect differing use of specific recruitment and training pathways. A higher share of foreign-trained professionals relative to the foreign-born may indicate greater reliance on international recruitment or the overseas training of domestic health professionals, alongside a more inclusive system for recognising foreign qualifications. Conversely, a higher share of foreign-born professionals compared to the foreign-trained may suggest a more restrictive system for recognising foreign qualifications, higher retention of international students who remain in the host country after completing their studies, or – reflecting both aspects – a requirement for migrant professionals to retrain domestically before entering the workforce.
In France, for example, far more doctors are foreign‑born than foreign‑trained for the main countries of origin (Figure 5.10). For Algeria, Morocco and Tunisia, the gap runs to several thousand physicians, indicating that many migrants from these countries receive their medical training in France rather than arriving with a qualification earned at home. Romania is the only sizeable country of origin where foreign-trained doctors outnumber those who are foreign-born. This reflects the rapid internationalisation of medical education in Romania where about one‑third of medical undergraduate programme positions are in English, French or Hungarian, with French nationals forming the largest group of international students (OECD, 2019[5]). At the same time, this does not preclude Romanian-born doctors from also training in Romania and later being recruited to practise in France, particularly in less populated or rural areas.
In Switzerland, where most migrant doctors come from neighbouring countries, the numbers of foreign-born and foreign-trained physicians are broadly similar, suggesting greater reliance on medical training completed abroad (Figure 5.11). Austria is the only country of origin where the number of foreign-trained doctors slightly exceeds that of the foreign-born, indicating that some Swiss nationals obtain their medical degree in Austria before returning to practise in Switzerland.
Notes: The size of the bubble corresponds to the share of the country in the total number of foreign-trained doctors. Bubbles are coloured grey when the number of foreign-trained doctors from that country is higher than the number of foreign-born doctors, and blue when the reverse is true.
Source: OECD Data Explorer (DF_HEALTH_WFMI) for foreign-trained and DIOC 2010/11 and DIOC 2020/21 for foreign-born.
Notes: The size of the bubble corresponds to the share of the country in the total number of foreign-trained doctors. Bubbles are coloured grey when the number of foreign-trained doctors from that country is higher than the number of foreign-born doctors, and blue when the reverse is true.
Source: OECD Data Explorer (DF_HEALTH_WFMI) for foreign-trained and DIOC 2010/11 and DIOC 2020/21 for foreign-born.
Among nurses, foreign-born numbers far exceed foreign-trained in both Australia (Figure 5.12) and Canada (Figure 5.13).This suggests that many foreign-born nurses obtained their qualifications after arriving in the destination country, either as children or as international students. Additionally, some may have been required to retrain in the country in order to practise.
Notes: The size of the bubble corresponds to the share of the country in the total number of foreign-trained doctors. Bubbles are coloured grey when the number of foreign-trained doctors from that country is higher than the number of foreign-born doctors, and blue when the reverse is true.
Source: OECD Data Explorer (DF_HEALTH_WFMI) for foreign-trained and DIOC 2010/11 and DIOC 2020/21 for foreign-born.
Notes: The size of the bubble corresponds to the share of the country in the total number of foreign-trained doctors. Bubbles are coloured grey when the number of foreign-trained doctors from that country is higher than the number of foreign-born doctors, and blue when the reverse is true.
Source: OECD Data Explorer (DF_HEALTH_WFMI) for foreign-trained and DIOC 2010/11 and DIOC 2020/21 for foreign-born.
Census data make Canada one of the few OECD countries able to cross‑tabulate country of birth and country of first medical or nursing qualification for every practicing health worker (Table 5.5). Between 2006 and 2021, the number of doctors grew from 56 000 to just over 80 000, yet the composition of the workforce shifted. Canadian-born, foreign-trained (CB‑FT) doctors increased eight‑fold, accounting for 4% of all practising physicians in 2021, up from 0.6% in 2006. The subgroup of foreign-born, foreign-trained (FB‑FT) doctors rose by 68% between 2006 and 2016, but then fell by 12% between 2016 and 2021.
Notes: CBCT – Canadian born and Canadian trained; CBFT – Canadian born and Foreign-trained; FBCT – Foreign born and Canadian trained; and FBFT – Foreign born and Foreign trained.
Source: Personal communications from Rabiul Islam and Arthur Sweetman (Department of Economics, McMaster University) based on 2006, 2016 and 2021 Canadian Census data.
Nursing numbers also climbed significantly over the same 15‑year period. Foreign-born, Canadian-trained (FB‑CT) nurses increased by 68%, and FB‑FT nurses by 46% – much higher than the 4% increase among Canadian-born, Canadian-trained (CB‑CT) nurses. As a result, the share of CB‑CT nurses among all working nurses declined from 81% to 74%.
Canada’s data also highlight a significant “brain waste” problem. In 2021, only 73% of all physicians were working in medicine, down from 80% in 2006, with participation rates varying considerably across subgroups. Just 36% of FB‑FT and 74% of CB‑FT doctors reported working in their trained profession. This implies that 26% of CB‑FT and 64% of FB‑FT doctors were under-utilised in 2021.
The loss of clinical skills is even more pronounced among nurses: only about 62% were working in their trained profession. While most subgroups saw improvements, the rate among FB‑FT nurses fell by 10 p.p. to just 34%.
Canada thus experiences both “brain gain” (through CB‑FT inflows) and “brain waste” when graduates, especially FB‑FT, cannot secure licences or suitable positions. Key factors include licensing hurdles and lengthy bridging programmes, more lucrative opportunities in non-clinical roles, and geographical or specialty maldistribution (OECD, 2019[5]).
As OECD countries strive to meet their own health workforce needs, there is a risk that shortages may be exported both within and beyond the OECD area, placing an undue burden on some of the poorest countries in the world. This section provides evidence on the composition of migration of doctors and nurses to the OECD, by region and countries of origin.
Intra-OECD and EEA movements
Migration flows to the OECD are characterised by a combination of movements within the OECD area, including between EEA countries, as well as inflows from third countries. In the case of health professionals, intra-OECD and EEA mobility is facilitated by a number of mutual recognition agreements for qualifications, which tends to facilitate mobility.
In total, more than 243 000 migrant doctors and 463 000 migrant nurses are originating from another OECD country, corresponding respectively to 29.6% and 26.7% of all migrant doctors and nurses. The corresponding percentages for those originating from another EEA country are 21.1% for doctors and 18.5% for nurses. There are, however, important differences across destination countries. Unsurprisingly, the highest shares of EEA migrants are recorded in OECD-EU countries (Figure 5.14). In countries such as Austria, Czechia, Denmark, Luxembourg, Hungary, the Slovak Republic, Norway or Switzerland, close to, or more than half of all migrant doctors and nurses originate from another EEA country. Italy also records a high share of doctors born in another European country, while Belgium reports a high share of nurses from within Europe.
Source: DIOC 2020/21, LFS-EU 2021.
In most destination countries, the share of migrants originating from OECD countries is higher than that from EEA countries. However, this pattern does not hold in specific OECD-EU countries, where the number of migrants originating from EEA non-OECD countries, such as Bulgaria and Romania, is particularly important. Romanian nurses are especially numerous in Italy, Germany and Hungary. Romanian doctors are present in large numbers in France, where they rank as the second-largest, foreign-born group after Algeria and ahead of Morocco, as well as in Germany and Hungary. Bulgarian doctors also constitute a sizeable group in Germany.
Overall, the share of OECD migrant doctors and nurses, who do not originate from EEA countries is most evident in Japan, with inflows primarily from Korea. It is also high in New Zealand and Ireland, mainly due to arrivals from the United Kingdom, and to a lesser extent in Canada and the United States.
Movements of health professionals within the OECD are becoming increasingly complex. However, only a few countries within the OECD area are net gainers, meaning that they receive more doctors and nurses from other OECD countries than they lose.
The United States stands out, with a net gain of more than 55 000 doctors and 144 000 nurses compared to the rest of the OECD. Other countries with net positive gains for both doctors and nurses include Australia, Austria, Luxembourg, Norway, Sweden and Switzerland. Germany is the third largest overall net gainer of nurses. New Zealand, Spain, France and the Netherlands each receive at least 1 000 more doctors from other OECD countries than they send. Conversely, countries such as Poland, Hungary, Greece or the Slovak Republic are net senders for both doctors and nurses to other OECD countries.
Within the OECD, international flows of both doctors and nurses often follow a cascade‑like pattern, where movements from one country to another create a domino effect, generating recruitment needs in other countries to fill the resulting gaps. Figure 5.15 illustrates these interactions between OECD countries for doctors (see also Annex 5.B). Arrows between countries X and Y indicate that there are at least 500 more doctors originating from country X residing in country Y than the reverse. Where no arrow is shown between two countries, the difference in the number of migrant doctors is less than 500.
The United States, Australia and Switzerland are the only three countries that are net gainers in relation to every other OECD country. The United Kingdom and Germany are net gainers vis à vis eight and seven countries respectively but are also net senders to four and seven countries. Countries such as France or Austria fall in the middle of the cascade. Both lose doctors to Switzerland but gain from Italy, which in turn is a net recruiter from Greece. Greece, Hungary and Poland appear at the very bottom of the graph, experiencing net losses of doctors to six or seven other countries.
Note: Countries highlighted in blue should show arrows towards the United States. Those with dotted lines should show arrows towards the United Kingdom. Belgium, Denmark, Estonia, Finland, Lithuania, Luxembourg, Latvia and Portugal are not represented because they do not have a net stock over or below 500 with no other country. Colombia, Costa Rica, Chile, Mexico, Slovenia, Türkiye, Korea and Iceland are not included in this graph because no data is available for these destination countries.
Source: DIOC 2020/21, LFS-EU 2021.
Main regions of origin for migrant doctors and nurses in the OECD
Broadening the perspective to all regions of origin highlights the importance of Asia as the main region of origin for both doctors and nurses. Almost 40% of migrant doctors in the OECD and 37% of migrant nurses were born in an Asian country.
In Australia, Japan, the United Kingdom and the United States, more than one in two migrant doctors were born in Asia (Figure 5.16). Asia is also the predominant region of origin for migrant nurses in non-EU OECD countries and in Ireland. More than 20% of migrant nurses in Finland, Norway, Sweden and Germany were also born in Asia. A similar trend is observed for doctors in Germany and the Netherlands.
Doctors born in African countries form the largest group only in France (49.4%) and Portugal (39.6%), while doctors born in Latin American countries are the most numerous only in Spain (76.9%). Similar patterns are observed among migrant nurses (Figure 5.17). Latin American nurses also represent a significant share in Italy (12%) and the United States (13.8%). Oceania is important region of origin mainly for nurses in New Zealand (12.8%) and in Australia (8%) as well as for doctors in New Zealand (8%).
Source: DIOC 2020/21, LFS-EU 2021.
Source: DIOC 2020/21, LFS-EU 2021.
Impact of the international mobility of health professionals on origin countries
One of the key issues concerning the international mobility of health professionals, and a major focus of the political attention in recent decades, relates to its impact on countries of origin. Despite considerable efforts to gather information at regional and national levels, statistical evidence by origin country remains limited and difficult to compare. The data presented in Table 5.6 and Annex 5.C aim to address this gap by presenting data for foreign-born doctors and nurses in OECD countries, disaggregated by detailed country of birth for 2020/21 and 2000/01.
In 2020/21, there were slightly less than 100 000 doctors born in India working in the OECD. Germany, China and Pakistan each had about 30 000 emigrant doctors in OECD countries. Romania and the United Kingdom followed with around 25 000. Among migrant nurses, the Philippines was by far the main country of origin, with nearly 280 000 nurses abroad. India ranked second, with 122 000 – less than half the number from the Philippines. Poland followed in third place, with about half the total of India. Nigeria and Germany completed the top five.
Looking at changes since 2000/01, all main countries of origin have experienced outstanding growth rates, with the exception of the Philippines for doctors and Canada for nurses. In most cases, the growth rates largely outpace those observed for migrants in general, including highly skilled migrants. This reflects the strength of longstanding migration corridors from specific countries and raises concerns about the potential impact on health systems in countries of origin.
Overall, the number has more than doubled in 14 of the 25 main countries of origin for doctors. The increase is even more marked for nurses, with 16 countries witnessing at least a tripling in the number of emigrants. The most significant growth rates for doctors are observed in Romania, Nigeria and Greece, while the largest increases for nurses are found in Cameroon, Portugal and Zimbabwe. Very high growth rates are also recorded for Ukraine, Romania and India in the case of nurses.
Since 2000/01, Russia, Nigeria, Ukraine and Romania each climbed more than ten places in the ranking of origin for doctors. By contrast, Viet Nam and Algeria fell by more than ten places, despite experiencing continued outmigration. The Philippines also dropped out of the top ten countries of origin, losing eight places.
For nurses, the most significant changes were recorded for Kenya and Zimbabwe, which rose from the 45th to the 20th place and from the 38th to the 11th place respectively. Romania and Ghana also gained more than ten places each. Conversely, Jamaica lost six places.
Source: DIOC 2020/21, LFS-EU 2021.
Migrant health workers from countries on the health workforce support and safeguards list
As part of the revision of the WHO Global Code of Practice on the International Recruitment of Health Personnel, the WHO established in 2023 a health workforce support and safeguards list (SSL) comprising 55 countries. These countries face the most pressing health workforce challenges in relation to universal health coverage. These countries have: 1) a density of doctors, nurses and midwives below the global median (49 per 10 000 population); and 2) a universal health coverage service coverage index below a defined threshold. Active recruitment from these countries, unless accompanied by compensatory measures, should be avoided and, instead, increasing international support for the strengthening of health system in these countries is recommended.
Overall, in 2020/21, about 89 000 doctors and 257 000 nurses working in the OECD were born in an SSL country. The main countries of origin for SSL doctors included Pakistan (29.6k), Nigeria (17k), Afghanistan (5k), Bangladesh (4.9k) and Cameroon (3k). For Nurses, the main countries of origin were Nigeria (55k), Haiti (35.8k), Ghana (21.4k), Zimbabwe (20.8k) and Cameroon (17.2k).
By country of destination, more than one in four migrant doctors in Portugal, Ireland and the United Kingdom originated from an SSL country, notably Nigeria and Angola. Similarly, one in four migrant nurses originates from an SSL country in Belgium (the Democratic Republic of the Congo and Cameroon) and France (Congo, The Democratic Republic of the Congo, Cameroon, Côte d’Ivoire and Madagascar). Sizeable shares and absolute numbers of migrant doctors and nurses from SSL countries are also recorded in Canada and the United States.
It is, however, important to note that these figures are based on country of birth. Several destination countries also play an important role in training students from SSL countries in their medical and nursing education systems. This is the case for Portugal with Angola and Cape Verde, Belgium with the Democratic Republic of the Congo, France with several African countries, the United States and Canada with Caribbean countries, and Australia and New Zealand with Pacific countries.
Source: DIOC 2020/21, LFS-EU 2021.
What is more, assessing the impact of migration on specific countries of origin solely on the basis of data from OECD destination countries may provide a partial and potentially misleading picture. A significant share of global health workforce migration occurs also outside the OECD area. From this perspective, data collected through the National Health Workforce Accounts (NHWA) from non-OECD countries, via nationally appointed focal points, can usefully complement OECD data. Together, these sources can provide a more comprehensive understanding of global and regional levels, trends and patterns in health workforce mobility levels (Box 5.5 and Box 5.6).
WHO has been actively engaged at the global, regional and national levels to strengthen data and information on the health and care workforce. A key effort in this area of work is its ongoing collaboration with the OECD to improve the measurement and monitoring of health worker mobility. The Joint Questionnaire serves as an official reporting mechanism of data on the health and care workforce to the National Health Workforce Accounts (NHWA), and it is one of the primary sources of data on health workforce migration along with the National Reporting Instrument and the country-reported and validated data by NHWA focal points directly via the NHWA online data platform. The advantage of the NHWA is its ability to cover a wider range of health and care workforce occupations beyond medical doctors and nursing personnel.
Since the launch of the NHWA in 2018, there has been a substantial improvement in health workforce data availability and quality, with focal points nominated in 190 out of the 194 WHO Member States for annual reporting either directly on the NHWA data platform or indirectly through other channels (such as the Joint Questionnaire), as of June 2025.
In 2023, WHO published the WHO report on global health worker mobility, based on consolidated data on health worker mobility from 134 countries overall (including OECD Member states and other countries) gathered across diverse data sources.
The evidence indicates that health worker mobility depends on various factors such as the fundamental influences of language and geographical proximity, the levels of bilateralism and multilateralism operating between countries and regions, and the levels of remuneration and opportunities for better career prospects.
In addition to the OECD high-income countries, the cluster of destination countries now includes the Gulf Co‑operation Council (GCC) countries – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, which have a substantial proportion of foreign-born health personnel (50% or higher).
Meanwhile, the cluster of source countries has expanded to include Egypt, Germany, New Zealand, Romania, Russian Federation and the United Kingdom of Great Britain and Northern Ireland, compared with earlier evidence, which primarily focussed attention on India, Pakistan, the Philippines and South Africa.
Thanks to the progressive implementation of NHWA at national level, data on health workforce migration continues to improve on an annual basis. The latest status of data availability for distribution of health workers by either place of birth or place of training is presented below for medical doctors, nursing personnel, dentists and pharmacists, according to the NHWA 2024 data release (Table 5.7).
Source: NHWA data portal – December 2024 update.
The latest available data on health workforce migration from the NHWA, building on key insights from the WHO report on global health worker mobility, highlights significant disparities in the global distribution of health workers and reveals complex migration patterns:
The ten major destination countries with the maximum number of foreign trained or born doctors and nurses are Australia, Canada, France, Germany, Ireland, Saudi Arabia, Switzerland, the United Arab Emirates, the United Kingdom and the United States (in alphabetical order). These ten high-income countries, which account for just 9% of the world’s population, host 23% of the world’s doctors, nurses and midwives. In contrast, the 55 countries in the WHO health workforce support and safeguards list 2023 (SSL) represent 21% of the world’s population but account for only 5% of the world’s doctors, nurses and midwives.
The traditional distinction between source and destination countries is increasingly blurred. For example, two of the major destination countries for foreign-born or -trained nurses and physicians – Germany and the United Kingdom of Great Britain and Northern Ireland – are also key source countries. Meanwhile, in 26 low- and middle‑income countries, more than one in five health workers of at least one health occupation (doctors, nurses, dentists or pharmacists) is foreign trained.
In 79 destination countries, approximately 72 000 of the foreign trained physicians and 164 000 of the foreign trained nurses originate from the 55 SSL countries, representing 11% of the stock from these source countries.
There is growing evidence of substantial intraregional and South-South migration patterns. For example, about 80% of foreign trained doctors in Argentina are trained in either Bolivia, Colombia or Ecuador; nearly 40% of foreign trained doctors in Sierra Leone are trained in either Ghana, Kenya or Nigeria; and nearly 40% of foreign trained doctors in Sri Lanka are trained in Bangladesh, India or Nepal.
Small island developing states (SIDS) may not be major suppliers of health workers, but emigration of their health workers is an area of concern to sustain health service delivery. More nurses from Antigua and Barbuda, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Liberia and Saint Vincent work in other countries than domestically.
Source: WHO (2023[23]), WHO report on global health worker mobility. Geneva 2023, World Health Organization, Geneva, https://iris.who.int/handle/10665/370938; WHO (2023[24]), National health workforce accounts: a handbook, second edition, World Health Organization, Geneva, https://iris.who.int/handle/10665/374320; WHO (2024[25]), Bilateral agreements on health worker migration and mobility: Maximising health system benefits and safeguarding health workforce rights and welfare through fair and ethical international recruitment, World Health Organization, Geneva, https://iris.who.int/handle/10665/376280; WHO (2025[15]), National Health Workforce Accounts data portal – December 2024 update [database], World Health Organization, Geneva, https://apps.who.int/nhwaportal/.
Among the top ten high-income countries with the highest numbers of foreign trained or born medical doctors and nurses, eight are members of the OECD. While the first section of the report focusses on the health workforce migration levels and trends within OECD Member states, this box highlights trends in the other two major destination countries – Saudi Arabia and the United Arab Emirates.
Both countries have been actively engaged in the NHWA and have reported data on health worker distribution by place of birth for the period 2015‑2023, covering four key health and care workforce occupations – medical doctors, nurses, dentists and pharmacists. Data indicate that both countries have a high reliance on foreign born health personnel (Figure 5.19). However, while the share of foreign-born doctors, nurses, dentists and pharmacists has remained stagnant in the United Arab Emirates, it has declined over time in Saudi Arabia.
A variety of factors such as health labour market dynamics and health workforce policies may account for these divergent trends, such as health workforce education and training capacity, level of interest among young nationals to enrol in health workforce education and training programmes, attractiveness of careers in the health workforce, insufficient national born health personnel to meet population health needs, policy measures aimed at reducing dependence on international health personnel, etc.
Source: NHWA data portal – December 2024 update.
Emigration rates of doctors and nurses to the OECD by country of origin
Beyond absolute numbers, assessing the impact of emigration on countries of origin requires placing migration figures in the context of health workforce situation in the origin country. Emigration rates can be calculated by dividing the number of migrant doctors and nurses by the sum of those abroad and those in the country. This calculation requires robust and comparable data on the total number of health professionals in all countries of the world. The National Health Workforce Accounts (NHWA), maintained by the WHO, provide such data. However, limitations in data comparability across countries and over time mean that the nominal values of the emigration rate estimates presented in this section and in the Annex 5.C should be interpreted with caution.
While the absolute numbers of emigrant health professionals were dominated by Asian countries, emigration rates reveal a different picture. African and Caribbean countries stand out as disproportionably affected by the emigration of health professionals. Most of the countries with expatriation rates above 50% – implying that there are as many doctors or nurses born in these countries working in the OECD as there are working in their home country – are either small island states in the Caribbean or Pacific, or lower-income countries in Africa (Table 5.8). Notably, several small French-speaking countries, including Cameroon, Haiti, Senegal and Togo, appear to be among the most affected.
By contrast, large countries of origin such as China, India, the Russian Federation, the United Kingdom and Germany all have emigration rates below 10% (Annex 5.C). The Philippines, however, has more than a third of its nurses working abroad (37%). Emigration rates for Romanian doctors (28%) and nurses (24%,) as well as for Irish doctors (25%), and for Polish (23%), Latvian (23%) and Slovak (21%) nurses, are also notably high.
Source: DIOC 2020/21, LFS-EU 2021.
Over the past two decades, emigration rates for doctors and nurses have been influenced not only by the increase of migrant stocks, as presented above, but also by efforts undertaken by countries of origin to train and retain health professionals. As a matter of fact, significant variations of emigration rates over time can be observed, pointing to either improvements or deteriorations in the health workforce situation. In most cases, trends have been broadly similar for doctors and nurses (Figure 5.20).
Countries that have experienced the largest increases in emigration rates for both doctors and nurses include Afghanistan (16 p.p. for doctors, 25 p.p. for nurses), Albania (24 and 27 p.p.), Cameroon (35 and 53 p.p.), Somalia (17 and 40 p.p.), Suriname (29 and 47 p.p.) and the Slovak Republic (20 and 18 p.p.).
Conversely, some countries have recorded substantial decreases in the emigration rate for doctors, notably in North Africa and certain sub-Saharan African countries, such as Benin (‑23 p.p.), Tanzania (‑41 p.p.) and Uganda (‑22 p.p.). For nurses, the situation has improved notably in several Central American and Caribbean countries such as Belize (‑16 p.p.), Barbados (‑17 p.p.), Grenada (‑11 p.p.), and Trinidad and Tobago (- 13 p.p.).
Source: DIOC 2020/21, LFS-EU 2021.
In many OECD countries, due to past and current under-investment in health professional education the growing demand for health workers cannot be met without the international recruitment of migrants. This need is reflected in migration management systems across the OECD, which increasingly aim to facilitate the mobility of health professionals, including doctors and nurses.
The international migration of doctors and nurses has traditionally been managed through general labour migration pathways, and this approach remains predominant across the OECD. Highly skilled national migration schemes are widely utilised for medical and nursing professionals in many OECD countries, including Australia, Belgium, Canada, Czechia, Denmark, Estonia, Finland, Iceland, Korea, Latvia, Lithuania, the Netherlands, New Zealand, Norway, Poland, Sweden and Switzerland. Among EU OECD countries, the EU Blue Card system provides an important additional pathway for admitting skilled foreign health workers, particularly in Germany and Italy.
However, there is an increasing trend towards implementing additional measures to facilitate the recruitment of foreign health workers within broader migration systems. These policy developments are examined further in this section and include the widespread inclusion of healthcare professionals on shortage occupation lists, the establishment of specialised migration schemes and pathways, the negotiation of bilateral agreements and training programmes, as well as temporary policy adjustments introduced in response to public health and migration crises.
Shortage lists are a popular tool across the OECD
Shortage occupation lists continue to be widely used to address labour market imbalances by identifying occupations or skills in high demand but with a shortage of qualified domestic workers. Their use enables countries to bypass standard labour market tests, thereby streamlining and accelerating recruitment processes. In nearly all OECD countries that use such lists to facilitate migration, healthcare professionals are included, either across the sector or in specific categories. Examples include Australia, Austria, Belgium (Flanders and Wallonia), Canada, Denmark, Finland, France, Ireland, Italy, New Zealand, the Slovak Republic, the United Kingdom and the United States. A notable exception is Costa Rica, which does not include health professionals on a shortage list due to an oversupply of generalists in the health sector. While specialist roles are in demand, the country has yet to define its requirements for specialised medical personnel.
Despite the widespread use of shortage lists, the types of healthcare workers included vary between countries. In many cases, doctors and nurses tend to fall under highly skilled migration pathways that already have preferential terms, so shortage lists are often utilised for medium-skilled or lower-skilled health and care workers. For instance, in Italy and Flanders (Belgium), doctors are not listed as high-skilled professions but are automatically exempt from labour market testing. However, medium- and lower-skilled healthcare roles are included. In Italy, care workers employed in healthcare facilities are listed under the migration shortage category within the country’s quota system. Similarly, in Flanders, healthcare assistants and nursing assistants, classified as medium-skilled professions, are included on the shortage list.
In Canada, a distinction is drawn between short-term and long-term migration pathways. While healthcare professionals are not included in temporary foreign worker shortage lists, they are prioritised for permanent residency through the Express Entry track, which prioritises candidates with experience in specific healthcare occupations.
In some cases, the migration of health professionals is facilitated by removing restrictions that would otherwise limit their employment. For example, while Hungary does not maintain a shortage occupation list, it has a list of professions where third-country nationals are prohibited from working. Certain healthcare roles, such as dentists, physiotherapists, and medical assistants, are included on this list. However, doctors and registered nurses have been removed, enabling them to obtain a work permit.
Dedicated pathways for health professionals are emerging across the OECD
Over the past decade, there has been a notable shift towards the development of specialised schemes, permits, and visa categories specifically designed for healthcare workers. This trend suggests a potential move away from reliance on general skilled migration pathways. These specialised pathways for healthcare professionals vary widely in scope and scale, encompassing diverse approaches. Some focus on tailored mobility programmes for postgraduate training or short-term practice in host countries, while others involve permits linked to the complex recognition or licensing processes that healthcare professionals must navigate. Additionally, some countries have introduced special tracks or even fully dedicated visa and permit pathways exclusively for health professionals.
Some countries have introduced special mobility programmes for postgraduate medical training. For example, Ireland’s International Medical Graduate Training Initiative (IMGTI) enables overseas doctors to undertake structured postgraduate medical training within Ireland’s public health service. The IMGTI provides suitably qualified overseas medical graduates with the opportunity to complete a fixed period of clinical training, typically lasting 24 months, as developed by an Irish postgraduate medical training body. The programme is designed to address the clinical needs identified by health services in participants’ home countries. While trainees are expected to return home upon completion – as the IMGTI is not intended to provide a route to settlement in Ireland – between 2015 and 2020, approximately 32% eventually returned to Ireland for at least a year, following a period back in their country of origin (NDTP, 2024[26]). There is also a special scholarship programme associated with the general IMGTI scheme, primarily aimed at doctors from countries with less developed healthcare sectors. Currently, participants include doctors from Pakistan and Sudan.
In other instances, general training and education pathways may include exceptions for health professionals, allowing them to extend their stay in the host country. For example, the United States offers the Conrad 30 Waiver Program for physicians who entered under the J‑1 Exchange Visitor Program. Typically, J‑1 visa holders are subject to a two‑year foreign residency requirement, which mandates them to return to their country of nationality or last residence before they can apply for an immigrant visa, adjustment of status, or a new non-immigrant visa. However, Section 214(l) of the Immigration and Nationality Act (INA) provides a waiver for foreign medical graduates who agree to work full-time in H‑1B classification for a minimum of three years in a designated health worker shortage area.
Foreign-trained doctors, nurses, and other licensed medical professionals often face complex qualification recognition and licensing procedures before they can practice in a host country. These processes may require them to remain in the country to undertake additional training or work, necessitating a legal basis for their stay. To address this, some OECD countries have introduced permits specifically for the duration of recognition, licensing, or authorisation processes. For instance, in Austria, foreign-trained doctors and nurses can obtain a Red-White‑Red card, enabling them to work in qualified roles while completing compensatory measures for full recognition. Similarly, Denmark and Germany issue visas and residence permits to facilitate the recognition of professional qualifications in the health and care sector obtained abroad.
The United Kingdom allows overseas-qualified nurses and midwives to work while preparing for the Objective Structured Clinical Examination (OSCE), the second stage required for professional registration with the Nursing and Midwifery Council (NMC). Candidates have up to 12 weeks from the start date on their certificate of sponsorship, provided by their employer, to complete their first OSCE attempt. During this time, they receive support and practice opportunities. Upon successfully registering with the NMC, they can transition to their substantive roles without needing to apply for a new visa.
Some countries have introduced dedicated schemes to facilitate the immigration of specific health workers, particularly those in low- and semi-skilled health professions. These workers are in high demand but often do not qualify through conventional skilled migration pathways. For instance, in Australia, aged care providers can recruit overseas workers through the aged care industry labour agreement. This scheme allows roles such as nursing support workers, personal care assistants, and aged or disabled carers to benefit from exemptions to standard skilled visa requirements, provided they are sponsored by an eligible employer. These exemptions include waiving post-qualification work experience requirements and, in certain cases, relaxing English language criteria. Employers seeking to hire under this agreement must first establish a memorandum of understanding with the relevant union. Once in Australia, foreign direct care workers employed through the aged care industry labour agreement may qualify for permanent residency after completing two years of full-time work, provided they are under the age of 45. Australia also uses Designated Area Migration Agreements (DAMA), formal arrangements between the government and regional or state authorities. These agreements enable aged care providers in approved regions to recruit overseas workers for caregiving, nursing, and medical roles with specific concessions.
In some cases, OECD countries have established fully dedicated visa and permit pathways specifically designed for healthcare workers. Japan, for instance, has for a long time used specialised migration tracks known as Status of Residence (SoR) for a variety of different types of occupations, including various types of health professionals. The SoR for Medical Services applies to registered physicians, dentists, and nurses, while the Nursing Care SoR, introduced in 2016, is designated for certified care workers. In 2022, 2 467 individuals held the Medical Services SoR, and 6 284 were under the Nursing Care SoR (OECD, 2024[27]).However, these specific residency statuses are typically granted to foreigners already residing in Japan, as eligibility requires acquiring Japanese training and certification first.
In 2020, the United Kingdom introduced the Health and Care Worker Visa, tailored for doctors, nurses, and other healthcare professionals with a valid job offer from an approved UK employer in the healthcare or social care sector. To qualify, the role must meet minimum skill and salary requirements. This visa offers several advantages over the Skilled Worker Visa, including faster processing times (within three weeks after biometric submission), a dedicated support service, reduced application fees, and exemption from the healthcare immigration surcharge for applicants and their families.
Since its launch, various modifications have been made to the visa, periodically adjusting eligibility criteria, inclusion in shortage lists, and family reunifications rules, which have resulted in significant fluctuations in application numbers over the first years. In the year ending September 2022, 61 274 Health and Care Worker Visas were granted to main applicants, 143 990 in 2023, and 50 591 in September 2024 (UK Home Office, 2024[28]).
In 2024, France announced plans for a multi-year residence permit for medical and pharmacy professionals, expected to be implemented in the coming years. This pathway targets non-EU trained doctors, dental surgeons, midwives, and pharmacists who are licensed by French health authorities to practise and meet the required salary thresholds. The initiative is part of country’s broader efforts to enhance talent attractiveness.
Bilateral agreements and training programmes are used to foster skills development, while addressing skills shortages in host countries
Several OECD countries have introduced bilateral agreements to facilitate the migration of health workers. These agreements are tailored to the specific priorities and circumstances of the countries involved, reflecting diverse approaches to managing health workforce challenges. By combining mechanisms to ease mobility with commitments to ethical recruitment and mutual capacity-building, these arrangements underscore the growing reliance on bilateral frameworks to strengthen healthcare systems and promote shared development objectives.
Canada has facilitated the mobility of practicing nurses and teaching or research physicians through agreements such as the Canada-Chile Free Trade Agreement (since 1997) and the Canada-United States-Mexico Agreement (formerly NAFTA, since 1994). These arrangements have contributed to cross-border mobility of healthcare professionals within the Americas.
The United Kingdom has established six government-to-government agreements for health and social care workforce recruitment with Sri Lanka (since 18 January 2021), Kenya (since 29 July 2021), the Philippines (since 8 October 2021), Malaysia (since 8 November 2021), India (since 21 July 2022) and Nepal (since 22 August 2023). Among these, the agreement with Nepal is a pilot and is more nuanced due to the country’s inclusion on the WHO’s Health Workforce Support and Safeguards List. As such, Nepal falls under the “red list” of countries that must not be actively targeted by health or social care recruiters unless a government-to-government agreement is in place to ensure managed recruitment under specified terms. The Nepal pilot agreement is designed with strict parameters to uphold these safeguards. Active recruitment is limited to a single NHS Trust, ensuring a controlled and ethical approach to hiring. By September 2024, 41 nurses had been recruited through this pilot initiative. An additional 700 Nepal-trained nurses joined the NMC register between October 2023 and September 2024 through other routes.
Since 2012, the Netherlands has maintained an agreement with Suriname that allows medical specialists from Suriname to stay for one year to practice and further develop their specialisations in Dutch hospitals. Approximately 120 medical professionals have utilised this pathway.
Meanwhile France does not have bilateral labour migration agreements explicitly targeting health workers, but agreements have existed to facilitate the stay of postgraduate medical students from Gulf countries, including Bahrain, Dubai, Qatar and Saudi Arabia.
In February 2024, Denmark and India signed a “Mobility and Migration Partnership Agreement”, which, among other things, stipulated that the two parties would explore the potential for recruiting qualified Indian professionals for employment in the Danish healthcare and medical services sector, with the aim of assessing whether bilateral co‑operation could be expanded in this area.
In addition to bilateral labour migration agreements, a growing number of OECD countries are introducing training programmes for healthcare workers abroad, particularly nurses, to facilitate potential labour migration to the host country. These initiatives are led by national and sub-national authorities in countries such as Australia, Belgium, Canada, Finland, Germany, Italy and Japan, often in partnership with private sector organisations.
Japan has established Economic Partnership Agreements (EPAs) with Indonesia (2008), the Philippines (2009), and Viet Nam (2014) to provide training, promote knowledge exchange, and facilitate the entry of nurses and care workers. These agreements are jointly managed by the Japan International Corporation of Welfare Services (JICWELS) and government organisations in the partner countries. For the nursing pathway, all candidates must have completed relevant nursing education in their home country and either hold a nursing licence or have at least two years of professional experience. Under the EPA framework, candidates undergo training in Japan for up to three years for nursing and four years for care work.
After completing their training, candidates are eligible to sit the Japanese national qualification exams. Those who pass are eligible for the SoR of Medical Services, discussed in a previous subsection on dedicated pathways, and permitted to remain in Japan indefinitely. However, despite the training provided, pass rates remain relatively low (OECD, 2024[27]). By 2021, a total of 1 587 nursing candidates and 6 454 care worker candidates had participated in the EPA programmes. Of these, only 529 nursing candidates and 1 762 care worker candidates successfully obtained their Japanese qualifications. In 2021, just 20.9% of nursing candidates passed the national exam, compared to a 90.4% pass rate for Japanese candidates. For care workers, 36.9% of EPA candidates succeeded, compared with 72.3% of their Japanese counterparts.
In Germany, there are no publicly funded programmes for training nurses in their countries of origin; however, private sector-funded initiatives play a key role. Since 2013, over 6 200 highly qualified nurses have been placed in Germany through various projects and agreements, involving countries such as Bosnia and Herzegovina, Colombia, India, Indonesia, Jordan, Mexico, the Philippines and Tunisia.
One example here is the Global Skills Partnerships Nursing Programme, implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ). This programme collaborates with universities in the Philippines and Mexico and facilitates the selection of participating students by future employers, with support from the Federal Employment Agency (ZAV) or private recruitment agencies accredited under the “Fair Recruitment for International Nurses” framework. It provides student nurses in partner countries with additional training based on a jointly approved curriculum tailored to the requirements of the German procedure for recognising nursing qualifications. The curriculum includes German language courses enabling students to achieve B2‑level proficiency, alongside the necessary practical experience in elderly care.
Similarly, the Aurora project in Belgium, initiated by private stakeholders in 2021, focusses on the recruitment and training of Indian nurses for the Flemish healthcare system. The pathway from recruitment to qualification as a certified nurse in Belgium spans approximately two years. It begins with a six‑month training programme in Kerala (India), offered free of charge. This programme includes an intensive Dutch language course up to level B1, alongside introductory lessons on Belgian geriatric care, psychiatric care, and healthcare model. Upon successful completion of the training in India, candidates undertake a one‑year training programme in Belgium, which combines further language instruction with practical experience as healthcare assistants. Candidates who successfully complete the programme are awarded the qualification of registered nurse.
Finland is currently piloting a programme to provide supplementary training for experienced health and social care professionals in other EU/EEA countries that could facilitate their future employment in Finland. The initiative targets licensed professionals, including physicians, registered nurses, nursing assistants, and other healthcare specialists. At its core, the programme combines recruitment with training to address employer needs in the health and social care sectors. A specialised service provider manages the process by identifying qualified candidates, assessing their credentials, and matching them with employers in Finland. Selected candidates receive tailored supplementary training, which includes cultural orientation and Finnish or Swedish language instruction. The training is customised to meet the specific requirements of both employers and professionals, with the goals, content, duration, and delivery method jointly agreed upon. The programme is co-funded by employers and the economic affairs and employment administration, with the state covering 50% of the costs.
Interest in establishing similar training arrangements is growing among other OECD countries. For example, Lithuania’s Ministry of Health has introduced the 2024‑2029 Action Plan to attract and retain healthcare professionals. This strategy aims to address the uneven distribution and shortage of specialised health workers, with ongoing discussions about incorporating training schemes within this framework.
Recent crises have prompted a wide range of temporary policy responses
The COVID‑19 pandemic created unprecedented challenges for healthcare systems worldwide, prompting several OECD countries to temporarily adjust migration policies to address urgent shortages of healthcare professionals. These measures varied across countries but generally aimed to facilitate the entry, employment, and retention of foreign healthcare workers to strengthen national pandemic responses (EMN/OECD, 2021[29]). Designed as temporary solutions, they were intended to remain in place only for the duration of the health crisis.
To meet critical needs in their healthcare sectors, many countries implemented exemptions from general entry bans for healthcare workers (EMN/OECD, 2020[30]). These measures aimed to ensure the continued provision of essential health services and public health support. In the United States, healthcare professionals and medical researchers engaged in work deemed critical to the COVID‑19 response or broader public health objectives were granted entry under specific visa categories, including the skilled temporary visa (H‑1B) and the intracorporate transfer visa (L‑1). Canada prioritised health workers delivering essential services, such as emergency care, the maintenance and installation of medical equipment, and medical supply logistics, by exempting them from entry restrictions. Australia and Japan also introduced limited exemptions for foreign nationals providing critical or specialist medical services, provided their contributions were deemed essential for strengthening national healthcare systems.
In addition to being exempt from entry restrictions in many cases, several OECD countries, including Belgium, Ireland and Spain, prioritised permit applications for healthcare professionals, implementing measures such as accelerated processing times. Similarly, New Zealand prioritised visa applications for critical healthcare roles.
In some cases, new bilateral agreements were established between countries to secure the necessary health workforce. In 2020, Italy signed an agreement between the Calabria Region and the Cuban Government to temporarily hire 497 Cuban doctors during the COVID‑19 pandemic. These medical professionals, specialising in emergency care, surgery, and anaesthesiology, were recruited under the Blue Card permit system. The agreement is set to remain in effect until 2025.
In most cases, countries focussed on maximising the availability of healthcare workers already residing within their borders, easing regulations to allow foreigners to remain and work (EMN/OECD, 2020[30]; EMN/OECD, 2021[29]). For example, Poland and Portugal waived work permit requirements for certain categories of medical workers to enable rapid deployment during the pandemic. Spain introduced an exceptional provision in 2020 permitting healthcare professionals not recognised as specialists to practise for a 12‑month period, extendable in three‑month increments until the end of the health crisis.
The Slovak Republic similarly allowed foreign doctors (including EU citizens and third-country nationals) to practice under eased terms during the public health crisis, requiring only diploma recognition. Similarly, France adopted several measures to address workforce shortages. These included authorising temporary healthcare sector workers to remain and work in the country and relaxing practice conditions for foreign doctors. Notably, those without full practising rights were allowed to perform non-medical roles, such as care assistance and reception, to support healthcare teams managing the crisis. Additionally, foreign doctors with refugee status were permitted to work in public health establishments as associated contract workers without the need to pass knowledge verification tests Box 5.7).
While most measures implemented during the pandemic were temporary, they provided an opportunity in some cases to initiate contingency planning and assess the capacity of existing migration systems to respond to future crises. This included examining ways to improve pathways for skilled healthcare workers. For example, Germany and Spain used the COVID‑19 pandemic as a catalyst to develop new strategies for attracting talent, particularly skilled professionals in healthcare and nursing. Evaluation of the regulatory flexibilities taken during COVID‑19 pandemic for domestic health workers is also necessary to identify measures that could limit reliance in international health professionals (WHO 2024).
The COVID‑19 pandemic is not the only recent crisis to prompt action from host countries; many OECD nations have also experienced significant increases in the arrival of asylum seekers and refugees (OECD, 2024[31]). In response, several countries have developed initiatives to support skilled refugees, such as doctors and nurses, in resuming their professions. While most efforts focus on facilitating rapid labour market entry by improving qualification recognition and licensing procedures, a number of countries have also introduced targeted migration policy measures and alternative pathways for highly skilled refugee professionals, particularly in the health sector.
Australia
Australia’s Skilled Refugee Labour Agreement Pilot (SRLAP), launched in 2021 in partnership with Talent Beyond Boundaries (TBB), enables skilled refugees to access employment through employer-sponsored visas (subclass 186, 482, and 494). The programme provides targeted concessions, including waivers for labour market testing, reduced English requirements, and lower income thresholds, and covers over 900 occupations, including doctors and registered nurses.
Extended in 2023, SRLAP allocated 500 primary visa places for the period 2023‑2025. Employers are responsible for verifying candidates’ qualifications. Licensing requirements for regulated professions, such as those set by the Australian Health Practitioner Regulation Agency (AHPRA), remain in place.
United Kingdom
In July 2021, the UK Government launched the Displaced Talent Mobility Pilot, in partnership with TBB, to identify and address administrative and legal barriers that prevent displaced individuals from migrating internationally as skilled workers. Under this initiative, TBB UK facilitated several healthcare pilot programmes, successfully placing over 200 displaced nurses and healthcare professionals in both the NHS and private sector.
The United Kingdom has focussed particularly on integrating nurses into the health system. In collaboration with TBB, the Nursing and Midwifery Council (NMC) – the UK’s independent regulator for nurses, midwives, and nursing associates – developed a new policy to support registration for eligible applicants. The two‑stage process includes a qualification review, a test of competence, and final checks on health, character, and language, allowing for individualised assessment.
Canada
Canada’s Economic Mobility Pathways Pilot (EMPP), introduced already in 2018, facilitates refugee migration through existing economic immigration streams at both federal and regional levels. It offers flexible entry routes with streamlined processing, waived fees, and support services such as settlement loans and travel assistance.
The EMPP is implemented in collaboration with NGOs that have formal agreements with Immigration, Refugees and Citizenship Canada (IRCC). These organisations identify suitable candidates and help match them with job vacancies, ensuring the process is accessible and fee‑free.
Healthcare professionals migrating under the EMPP must still meet provincial or territorial licensing requirements. Accreditation and certification are handled independently of the migration process by regional regulatory bodies to ensure national standards are met before entry into the health workforce.
The recognition of foreign qualifications and the licensing of health professionals is a particularly complex, time‑consuming, and multi-stage process, designed to ensure that health workers meet the standards of their host country. While these procedures are essential for maintaining the quality and safety of healthcare services (Box 5.8), they can be lengthy and significantly delay the integration of skilled migrant health professionals into the workforce. These administrative barriers often discourage migrants from continuing in the sector, contributing to the phenomenon of “brain waste”.
Although some OECD countries, particularly within the European Union (Box 5.9), have longstanding measures to facilitate the recognition of foreign health qualifications, growing labour shortages in the health sector have prompted calls to further streamline and improve recognition and licensing systems for migrant health professionals across the OECD. Over the past five years, much attention has been given to expanding access to bridging programmes and compensatory measures required for full accreditation. These courses help migrants build on their existing education and training, supporting entry into regulated professions, targeted job roles or further study.
Several OECD countries are undertaking reforms to improve the recognition and licensing of foreign-trained health professionals. In Germany, a shift towards skills-based assessments now allows candidates to demonstrate their competencies through practical tests, rather than relying solely on documentation. Following the Independent Review of Australia’s Regulatory Settings Relating to Overseas Health Practitioners (Kruk Review), and as part of its 2021‑2031 National Health Workforce Strategy, Australia has introduced expedited registration pathways for both foreign-trained doctors and nurses. From October 2024, specialist international medical graduates from the United Kingdom, Ireland or New Zealand in general practice, anaesthesia, psychiatry, obstetrics and gynaecology – soon to be joined by paediatrics, general medicine and diagnostic radiology – may register on the basis of substantially comparable qualifications, subject to six months’ supervision as well as cultural-safety and orientation training. Beginning in 2025, a new standard will offer two faster and easier routes to registration for registered nurses who have practised for at least 1 800 hours since 2017 in the United Kingdom, Ireland, the United States, Singapore, Spain or the Canadian provinces of British Columbia and Ontario, while maintaining all existing patient-safety checks.
Despite these efforts, significant challenges remain. This is particularly the case in ensuring that migrant health professionals are able to meet national clinical standards, acquire the necessary language skills, and secure placements within a highly regulated sector. Going forward, sustained collaboration between national authorities, professional bodies, health practitioner regulators and educational institutions will be vital to developing long-term frameworks that uphold patient safety while expanding opportunities for refugee and other migrant health professionals.
For migrant health professionals, entering regulated health professions requires completing an equivalency process. While the specifics vary across countries (see the country case studies below), the overall approach remains largely consistent. Depending on the country’s governance structure, this process may be managed at either the national or regional levels in federal states. It can be lengthy and costly, often requiring candidates to pass both theoretical and practical examinations, as well as language proficiency tests. Additionally, registration with the relevant professional body is usually necessary before full authorisation to practise is granted.
The initial steps involve verifying and assessing educational credentials and professional qualifications. Degrees, diplomas, and transcripts from foreign institutions must be authenticated and assessed for equivalence with national educational standards. Completed clinical training, internships, and specialisations are also evaluated to ensure they meet national professional requirements. In some cases, migrant health professionals may be required to repeat certain aspects of their studies. The validation of credentials, including education and work experience, is typically overseen by the Ministry of Health or designated regulatory bodies.
To facilitate and streamline the recognition of health qualifications, some countries have long-established bilateral or multilateral agreements. Notable examples include the EU Directive 2005/36/EC, which enables the mutual recognition of qualifications among EU Member States, as well as mutual recognition agreements (MRAs) between the United States and Canada and within ASEAN (since 2006 for nursing and 2009 for medicine and dentistry). Similar agreements also exist between individual states and regions, such as the France‑Quebec mutual recognition agreement, which now covers around 30 medical specialties along with other professions.
Once qualifications are recognised, the next step is obtaining a licence and registering with the relevant professional bodies. Migrant health professionals are typically required to pass national medical board examinations, demonstrate a high level of language proficiency, and submit a certificate of good standing. In some cases, they may also need to complete additional training, supervised practice, or other compensatory measures before being granted full licensure.
EU legislation facilitates the recognition of professional qualifications across member states, allowing EU citizens to practise their professions in other EU countries. This is governed by Directive 2005/36/EC on the recognition of professional qualifications. The professional qualifications directive was modernised in 2013 by Directive 2013/55/EU. Further changes are in the process of being introduced through Directive (EU) 2024/505, which facilitates the recognition of certain Romanian nursing diplomas obtained prior to Romania’s EU accession, following completion of an approved upgrading programme. In 2023, the European Commission (2023[32]) also issued a recommendation to EU countries to simplify the recognition of qualifications for third-country nationals.
These legal frameworks are based on the principle that a professional qualified in one EU member state is deemed qualified to practise the same profession in another. They establish, among other aspects, common rules for the recognition of professional and academic qualifications, language skills, and conditions for practising in another EU country.
For health professionals, the Directive 2005/36/EC provides for the automatic recognition of qualifications in six professions where training standards have been harmonised across the EU: doctors, dentists, nurses responsible for general care, midwives, pharmacists, and veterinary surgeons. Although national licensing procedures may still differ, the directive significantly simplifies the recognition of qualifications among EU member states.
The COVID‑19 pandemic led many OECD countries to temporarily relax recognition and licensing procedures for migrant health professionals
During the COVID‑19 pandemic, many OECD countries implemented temporary measures to address urgent labour shortages in the health sector (OECD, 2020[1]). These efforts focussed on facilitating the recognition and licensing of migrant health professionals already residing in the country but not yet practising in their professions, to expedite their entry into national healthcare systems. Some countries authorised the hiring of migrant doctors and nurses, even if their certification had not yet been validated, while others introduced emergency licensing pathways, waiving standard requirements to allow foreign-trained professionals to contribute to the pandemic response.
One approach taken by several OECD countries in the early months of the pandemic was to expedite the recognition of foreign qualifications, enabling internationally trained professionals to enter the workforce more quickly. Belgium, Ireland and Luxembourg, for instance, streamlined application processes for the recognition of foreign credentials, while Lithuania reduced language test requirements.
Other countries relaxed employment restrictions for migrant health professionals who had not yet received full recognition of their qualifications. In France, non-licensed foreign-trained healthcare workers were permitted to work in non-medical support roles. Similarly, Argentina, Chile and Peru authorised their national health services to employ foreign health professionals regardless of formal recognition. In Colombia, such facilitations were specifically targeted towards Venezuelan health workers already in the country. Meanwhile, Australia allowed international nursing students to work in an expanded capacity before completing their training and exceed the usual 40‑hour work limit.
Another widely adopted measure involved temporary and conditional licensing, allowing migrant health professionals to work under supervision while completing full accreditation. In 2020, Italy introduced a decree permitting the temporary licensing of foreign-trained health professionals. Temporary “contingency” licenses were introduced also in Spain (Box 5.10). In Germany, doctors from third countries who are undergoing the recognition procedure may obtain a professional licence valid for up to two years; this licence, which can be issued with restrictions and ancillary provisions, enables them to practise while they finalise full recognition.
Similarly, in the United States, several states introduced limited licences. For example, New York and Massachusetts granted international medical graduates a restricted permit with a reduced training requirement – one year instead of three in New York, and two years in Massachusetts. New Jersey established a pathway for foreign-licensed physicians to obtain a temporary emergency licence to practise medicine. In Canada, the province of Ontario allowed international medical graduates who had either passed their exams to practise in Canada or graduated within the previous two years to apply for a Supervised Short Duration Certificate, a temporary 30‑day medical licence.
While many of these measures were temporary, the pandemic highlighted the need for more flexible and responsive licensing frameworks for migrant health professionals. Some jurisdictions have since considered making these changes permanent. In the United States, for instance, Tennessee introduced a permanent pathway for internationally trained doctors, removing the requirement for a US-based medical residency and replacing it with a two‑year supervised practice period. Altogether 11 US states have implemented similar policies to ease entry into the healthcare workforce for foreign-trained professionals (Box 5.15). These new pathways, often employer-led and based on supervised practice, aim to assess clinical competence while maintaining patient safety. Some states, such as Colorado, now offer full and permanent licensure through these routes, signalling a shift toward more inclusive and sustainable licensing models.
Spain’s longstanding shortage of physicians – estimated at nearly 6 000 in the Ministry of Health’s 2024 workforce assessment (Barber and López-Valcárcel, 2024[33]) – has resulted in the country receiving the third-largest inflow of foreign-trained doctors in the OECD, after the United Kingdom and the United States. Between 2003 and 2023, Spain admitted 92 000 doctors trained abroad. Eight to nine out of every ten obtained their first degree in one of ten South or Central American countries, with Colombia, Argentina, and Venezuela alone accounting for nearly half of the total (Figure 5.21) This is a classic example of how language also factors in and influences migratory patterns (WHO 2023).
Inflows of foreign-trained doctors peaked just before the 2008 global financial crisis, declined sharply during the fiscal consolidation following the sovereign-debt crisis, and began to rise again from 2016. Following a brief dip during the onset of the COVID‑19 pandemic, inflows reached a new record in 2023 – despite a concurrent expansion of domestic training capacity. Annual admissions to Spanish medical schools almost doubled, rising from 4 300 in the 2003/04 academic year to 8 300 in 2023/24. Nevertheless, foreign-trained doctors remain essential to the health system. During the first ten months of 2023, the Ministry of Health approved 8 585 applications for the recognition of non-EU medical degrees – exceeding the 8 550 residency programme (MIR) posts available and surpassing the number of Spanish medical graduates from the previous year by 36%.
Language and cultural proximity are clear pull factors, but national policies have amplified their impact. A 2014 Royal Decree codified a primarily documentary validation process (homologación) for non-EU medical degrees, and a 2022 Decree introduced an electronic portal along with a six‑month statutory deadline, significantly reducing administrative delays (Ministry of Science, 2025[34]). Spain’s ratification of the Andrés Bello Cultural Convention in 1996, and its subsequent adherence in 2009 to the broader Ibero-American degree recognition accord, created streamlined, low-bureaucracy validation procedures for medical diplomas from 22 Spanish- or Portuguese‑speaking countries.
During the 2000‑2015 expansion, these channels enabled thousands of Latin American physicians to obtain Spanish equivalence far more easily than other non-EU applicants. A more recent development has been the use of temporary “contingency” licences – first introduced at the height of the COVID‑19 crisis – which allow regions to employ non-EU doctors (and Spanish graduates awaiting specialist certification) under a provisional register while their homologación is processed. The measure proved effective in the post-pandemic period, particularly in family medicine and paediatrics, where MIR posts exceeded local demand. It has since been reauthorised in successive decrees, with regions such as Madrid and Valencia now activating it whenever staffing gaps arise. In parallel, several autonomous communities – notably Madrid, Valencia and the Basque Country – have launched targeted recruitment initiatives in Latin America.
Source: OECD Data Explorer (DF_HEALTH_WFMI and DF_GRAD).
Despite recent efforts, significant “brain waste” remains unaddressed within Spain’s health workforce. A Lighthouse Reports study based on EU-LFS data (Braun et al., 2024[35]) reveals that 34% of migrant health professionals with tertiary education are overqualified for their current roles, compared to just 24% of their Spanish-born counterparts. Moreover, the unemployment rate among highly educated migrant health professionals stands at 10%, compared to 6% among natives.
The issue is particularly acute for doctors. Although Spain recognised more than 8 500 non-EU medical degrees in the first 10 months of 2023 – more than in any previous full year – yet approved only 167 specialist-title applications. A further 13 000 applications lodged in 2023 were still awaiting a decision. As a result, many foreign-trained physicians are unable to practise at the level for which they were trained, exacerbating the underutilisation of their skills.
Streamlining recognition and licensing procedures is used to improve labour market outcomes for refugee healthcare professionals already in host countries
In response to the growing number of refugees with healthcare qualifications, over the past five years, more than 12 OECD countries have introduced targeted measures to facilitate their entry into the health workforce and address specific barriers such as missing documentation, limited host-country language proficiency, incomplete studies or internships, or prolonged professional inactivity due to displacement. These measures have been particularly common in European OECD countries, including Czechia, France, Hungary, Latvia, Poland and Switzerland, but have also been adopted in Australia, Colombia and Mexico. In the latter two, authorities implemented expedited mechanisms to recognise qualified and experienced refugee and asylum-seeker health workers to help address COVID‑19‑related healthcare shortages.
In Europe, many developments have been linked to the Ukrainian displacement crisis following Russia’s large‑scale invasion against Ukraine, which has led to nearly 5 million displaced Ukrainians arriving in OECD countries, most of whom remained in Europe. Many arrivals were highly educated, including individuals with previous experience in the health sector. This has prompted efforts to support their labour market integration at a level commensurate with their skills, including improvements to recognition procedures for Ukrainians as well as other refugees (OECD, 2023[36]; JRS France, 2025[37]).
Several OECD countries, particularly in Central and Eastern Europe, introduced temporary or conditional licensing measures to support the rapid entry of Ukrainian healthcare professionals into the workforce. These schemes allowed qualified individuals to practise under supervision or within defined conditions while initiating the formal recognition process. In Hungary, a government decree simplified access to the health sector for Ukrainian-trained professionals and Hungarian citizens arriving from Ukraine. Qualified individuals could begin working under supervision without full qualification recognition, provided they initiated the recognition process. Additional facilitations included waived procedural fees for applications submitted before 2023 and allowances for missing documentation. Poland also introduced a simplified procedure for Ukrainian doctors, dentists, nurses, and midwives, allowing them to practise for up to five years without diploma certification or a formal licensing exam. The Minister of Health granted temporary authorisations, with specific conditions set by professional councils. Similarly, Latvia issued five‑year permits for Ukrainian medical practitioners, pharmacists, and pharmacist’s assistants, a longer period than typically granted to other foreign-trained health workers.
Some countries developed solutions for Ukrainian students in health professions who had to flee at different stages of their studies. Rather than requiring them to restart their education, the Netherlands offered additional training in Dutch higher education institutions, contributing academic credits towards their Ukrainian diploma. These credits could be transferred to their home universities, allowing students to work towards completing their degrees.
Not all changes have been limited to Ukrainian arrivals; many facilitations have applied to broader groups of refugee health professionals. In recent years, common measures have focussed on improving access to training opportunities and alleviating financial burdens related to qualification recognition. These efforts have aimed to address barriers such as limited access to preparatory courses, language training, and examination fees, which often prevent refugees from re‑entering their professions.
In France, specific provisions exist for foreign-trained graduates in medicine, dentistry, midwifery, and pharmacy (PADHUEs) who are beneficiaries of international protection or are stateless. These individuals are exempt from the quota system that limits the number of places available for the annual knowledge verification tests (EVC), the first stage of the authorisation procedure. Additionally, while awaiting their EVC examination, they may apply for a certificate allowing temporary practice. If granted by the Director General of the Regional Health Agency (ARS) in their region, this certificate enables them to work in a healthcare facility on a temporary basis, provided they commit to taking the knowledge verification tests.
Similarly, Ireland has taken steps to support a wide range of refugee health professionals in gaining registration and employment. In collaboration with the Health Service Executive (HSE) and professional regulators, the Irish Department of Health allocated EUR 1 million in 2023 to cover training and registration costs, with an additional EUR 200 000 available in 2024. These funds have been used to provide English language training and support for professional registration, including covering the cost of professional competence exams for doctors and dentists. By removing financial and linguistic barriers, these initiatives have aimed to facilitate a smoother transition into the health workforce and ensure that refugee professionals can contribute effectively to national healthcare systems.
Another notable example is REACHE (The Refugee and Asylum Seekers Centre for Healthcare Professionals Education) in the United Kingdom, which has been active for over 20 years. REACHE assists refugee and asylum-seeker doctors, nurses, and allied health professionals by providing free language and clinical training, clinical placements, and support to help registered professionals secure their first NHS job.
Recognition and licensing procedures in selected OECD countries
This section reviews recognition and licensing procedures for migrant health professionals in Czechia, France, Germany, Poland, Sweden, the United Kingdom and the United States (Table 5.9). These countries were selected to reflect a diversity of experiences: some have long-standing histories of receiving foreign-trained health workers, while others are more recent destinations. The scale of arrivals also varies, with the United States receiving the largest numbers in the OECD, while Poland has seen relatively modest inflows, though the recent arrival of displaced Ukrainian professionals has brought these issues to the forefront. The group also includes examples of federal systems, illustrating how different degrees of decentralisation can shape credentialing processes.
Physicians and nurses trained in third countries (i.e. outside the EU/EEA/Switzerland) must undergo nostrification and approbation to obtain authorisation to practise in Czechia. The process begins with the nostrification of the medical diploma, conducted by authorised medical universities. The university assesses the foreign medical programme’s curriculum, duration, learning outcomes, professional rights conferred, and traineeships, comparing them to its own standards. Candidates are encouraged to apply to a university offering a programme like theirs. The outcome of the nostrification is fail or pass, though an appeal is possible. No compensatory measures are offered for rejected applications.
Some simplifications apply here to displaced Ukrainians. Applicants with temporary protection status are exempt from nostrification fees and face fewer documentation requirements, particularly regarding translations. Missing documents may be also replaced by an affidavit. Additionally, foreign diplomas issued in one of the republics of the former Soviet Union between 6 June 1972 and 27 February 2000 are automatically recognised under the “Protocol of equality of documents of education, academic titles and degrees, which are issued or awarded in the Czechoslovak Socialist Republic and in the Union of Soviet Socialist Republics”.2 Holders of these diplomas proceed directly to approbation.
1. Countries with automatic recognition of medical and nursing diplomas with the EU, EEA, and Switzerland.
2. Primarily in the context of special measures aimed at specific migrant groups (e.g. displaced Ukrainians).
3. Required in most cases, but waived for physicians who have passed a licensing exam in Australia, Canada or the United States – considered acceptable overseas registration clinical exams.
4. Third-country nursing degrees are generally not recognised in France, but if previously recognised in the EU/EEA/Switzerland, an equivalence assessment is conducted.
Once nostrification is completed, candidates must undergo approbation. For physicians, applications are submitted to the Ministry of Health. The process, conducted entirely in Czech, typically takes 16 months, excluding preparation or repeat exams. It includes three stages: written tests assessing medical knowledge and knowledge of the Czech healthcare and legal system, a six‑month rotating internship in internal medicine, surgery, intensive care, paediatrics, and obstetrics/gynaecology, and an oral examination. Previous postgraduate training or specialist experience abroad is not recognised in Czechia, and doctors must complete specialist training in the country. However, they may apply for a reduction in training time based on documented experience. For nurses, the approbation process is managed by the National Centre for Nursing and Non-Medical Health Professions (Národní centrum ošetřovatelství a nelékařských zdravotnických oborů, NCO NZO) in Brno. It includes written tests, an internship lasting 14 to 60 days at a healthcare or social services provider, and an oral exam. The written tests are available in Czech, English, French, German or Russian, but the oral examination, assessing professional knowledge and Czech language skills, is conducted exclusively in Czech.
Some facilitations exist for foreign-trained doctors and nurses. For instance, they may practise for up to three months under supervision before nostrification through a short-term internship (krátkodobá stáž), requiring an invitation from an authorised healthcare facility. Originally intended for visiting medical professionals, this pathway has helped third-country physicians and nurses, particularly from Ukraine, gain practical experience and improve their Czech while awaiting nostrification. After nostrification but before completing approbation, they may apply for a long-term internship (dlouhodobá stáž), lasting up to one year and renewable twice (maximum three years), enabling them to continue working under supervision while preparing for approbation exams.
In France, physicians trained outside the EU/EEA/Switzerland must pass the Knowledge Verification Test (EVC) and complete a two‑year Skills Consolidation Programme (parcours de consolidation des compétences) to obtain the right to practise. There is no formal equivalence assessment for foreign medical or postgraduate training, and specialist titles from third countries are not recognised.
The Knowledge Verification Test (EVC) is specialty-specific, allowing candidates to choose any medical specialty listed in France, regardless of their prior specialisation. To apply, candidates must preregister with the Centre national de gestion (CNG) and apply to a regional health agency (Agence régionale de santé, ARS). Required documents include proof of medical education, a B2‑level French language certificate (TCF-TEF or DELF), and certified translations if necessary. The EVC consists of two written exams assessing theoretical and practical knowledge, held once per year. Candidates may attempt the test up to four times.
Successful EVC candidates are assigned to a limited number of placements for the two‑year Skills Consolidation Programme, which involves supervised medical practice. Placement selection is competitive, with higher EVC scores improving the chances of securing a position. At the end of the programme, a committee of specialists evaluates the candidate’s performance. If the evaluation is unsuccessful, an extension may be granted. A favourable evaluation allows candidates to apply for authorisation to practise from the Licensing Commission (Commission d’autorisation d’exercice, CAE). After receiving this authorisation, the physician must register with the French Medical Council (Conseil National de l’Ordre des Médecins) by applying to the regional council in their intended practice area.
Unlike physicians, nursing degrees from third countries are generally not recognised in France, and foreign-trained nurses must repeat their training in France. The only exception is for nursing diplomas from the EU and Quebec (Canada), which are automatically recognised.
Additionally, Article L4 311‑4 of the Code de la santé publique stipulates that a candidate with a nursing diploma from a third country, which has already been recognised elsewhere in the EU/EEA or Switzerland, may apply for recognition through a regional professional association of nurses, provided they are also a national or long-term resident of the EU/EEA or Switzerland. In this case, an equivalence assessment is conducted, considering the candidate’s education, practical experience, and additional training. If significant differences are identified, compensatory measures may be required, such as an aptitude test or an adaptation period of up to six months. Upon successful completion, the candidate is granted authorisation to practise as a general nurse.
To minimise the burden, foreign-trained nurses who must retrain in France may take three so-called admissibility examinations (one written and two oral/practical). Based on exam results, a jury and the director of the Institute of Nursing Education (Institut de formation en soins infirmiers, IFSI) determine which parts of the French nursing curriculum can be waived, potentially reducing the duration of necessary training.
Since March 2022, Ukrainian physicians with temporary protection status may apply for a temporary permit to practise under supervision (praticien attaché associé), while Ukrainian nurses may apply for a temporary permit to work as auxiliary nurses. Applications must be submitted to the regional health agency, including proof of completed medical studies, temporary protection status, and language proficiency (French or English), as well as an employment offer from an authorised healthcare facility. Document requirements are more flexible, and missing documents may be replaced with a self-signed statement. In the case of physicians, the EVC must be taken at the first available opportunity, but they are not required to compete for limited places in the Skills Consolidation Programme. However, for nurses, there is no dedicated pathway to transition into full professional recognition as general nurses in France.
1. The data for Germany in the background box on both doctors and nurses refers to foreign citizens, not necessarily foreign-trained health professionals.
Germany’s recognition procedures for medical and nursing education follow a general framework but are fragmented across regional authorities, often resulting in lengthy processing times – at times up to three years, not including language training or compensatory measures. However, efforts are underway to harmonise, streamline, and accelerate these processes across the federal states.
The recognition process for physicians and nurses trained outside the EU/EEA/Switzerland begins with an equivalence assessment, which evaluates medical and nursing diplomas, as well as any postgraduate internships or practice periods, against German standards. If full equivalence is established and all other conditions are met (language proficiency, medical fitness, and a clean professional record), the applicant receives approbation (authorisation to practise).
Already upon application for the equivalence assessment, applicants must prove at least an intermediate knowledge of German. To obtain approbation, physicians must later pass a C1‑level language examination, typically administered by the regional Medical Association (Ärztekammer), covering oral and written skills. For nurses, the required language level is B2 under the Common European Framework of Reference for Languages (CEFR).
The equivalence assessment is conducted by competent authorities at the federal state level, with Bundesländer setting their own document requirements, which vary by region. However, once recognition is granted in one state, it is generally valid for general physicians and nurses nationwide. The responsible authority depends on where the candidate intends to practise, as well as their country of origin, education, and recent professional experience. Candidates can access detailed information via the Recognition Finder (anerkennung-in-deutschland.de), managed by the Federal Institute for Vocational Education and Training (BIBB), which also provides personalised counselling services (Box 5.11).
The ProRecognition initiative provides physicians and nurses from selected countries (Algeria, Brazil, Chile, Colombia, Ecuador, Egypt, India, Indonesia, Morocco, Peru, the Philippines, Tunisia, Türkiye, and Venezuela) with information and counselling on the German recognition process. Guidance is offered in the local language through the foreign offices of the German Chambers of Commerce Abroad (Auslandshandelskammern, AHKs). The initiative is organised and funded by the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF) and the Association of German Chambers of Industry and Commerce (Deutsche Industrie‑ und Handelskammer, IHK).
For applicants from any country of origin, counselling is available via the “Working and Living in Germany” Hotline (Arbeiten und Leben in Deutschland Hotline), operated by the Federal Office for Migration and Refugees (Bundesamt für Migration und Flüchtlinge, BAMF) and the Federal Employment Agency (Bundesagentur für Arbeit, BA). Support is provided by phone or email. Additionally, physicians and nurses outside Germany can receive step-by-step guidance through the recognition process from the Service Centre for Professional Recognition (Zentrale Servicestelle Berufsanerkennung, ZSBA), operated by the Federal Employment Agency (BA).
To improve consistency and efficiency, federal-level standards are being developed through the Assessment Office for Healthcare Professions (Gutachtenstelle für Gesundheitsberufe, GfG) at the Standing Conference of the Ministers of Education and Cultural Affairs (KMK). A key initiative is a database of expert reports on foreign qualifications, categorised by issuing authority and date range, to reflect changes in medical education and practice regulations. However, full centralisation of the equivalence assessment remains opposed by the federal states.
If substantial differences are identified in the equivalence assessment, candidates must undertake additional measures before full recognition is granted. For physicians, this may involve a knowledge test (Kenntnisprüfung) or a limited right to practise under supervision for up to two years to compensate for experience gaps. This approach allows candidates to continue working while awaiting full recognition. For nurses, besides a knowledge test, they may be also required to complete an adaptation internship and additional theoretical training.
Discussions are ongoing to streamline and accelerate recognition and licensing procedures. A federal legislative initiative introduced in July 2024 (Bundesrats-Entschließungsantrag) proposes bypassing the equivalence assessment and allowing candidates to proceed directly to the knowledge test. It also calls for mandatory electronic applications nationwide. The Nursing Studies Strengthening Act (Pflegestudiumsstärkungsgesetz), in force since December 2023, mandates harmonisation of the recognition process and opens a possibility to adopt regulations that would allow the nurses also to skip equivalence assessment and proceed directly to a knowledge test or adaptation internship, which would significantly shortening recognition timelines. Facilitations have been also introduced in the context of support displaced Ukrainians (Box 5.12).
Some practical steps have already been taken through targeted programmes. For instance, procedures for nurses have been accelerated and streamlined through the INGA Pflege (INGA Care) programme. This initiative provides an adaptation period for migrant nurses, combining professional recognition support with supervised practice, familiarisation with the German healthcare system, and language training. Initially developed for nurses from the Philippines, it has since been expanded to include professionals from a broader range of countries. Furthermore, an online practical handbook has been created to equip hospitals and care institutions with tools and resources to support the effective integration of migrant nurses into the healthcare sector.
Physicians who have already obtained approbation in Germany can apply for recognition of their medical specialty. The competent authority for specialist recognition may differ from the approbation authority, even within the same federal state. Due to regional variations, specialist recognition granted in one state is not always accepted in another. To promote harmonisation regarding specialisations, the German Medical Association (Bundesärztekammer) introduced a regulatory framework (Musterweiterbildungsordnung), though it is non-binding and serves only as guidance.
Physicians whose specialist titles were already recognised in an EU/EEA country or Switzerland, and who have practised for at least three years in that country, can have their specialty recognised in Germany under Directive 2005/36/EC, even if it is not covered by German federal state regulations.
For nurses, the European Professional Card (EPC), introduced in 2013, allows general care nurses to have their qualifications recognised across the EU/EEA and Switzerland without undergoing the full recognition procedure again. This also applies to nurses educated in third countries, provided they have already had their qualifications recognised in an EU/EEA country or Switzerland and have worked there for at least three years.
A significant number of Ukrainian applicants seeking recognition in Germany have completed the theoretical part of their medical studies in Ukraine but not the practical component (Клінічна ординатура; Інтернатура). Various initiatives have been proposed to enable these students to complete their training in Germany and obtain authorisation to practise without having to return to Ukraine.
One proposal suggested allowing one year of supervised practice in Germany, with the intention that Ukrainian authorities would recognise this period as fulfilling the missing practical training. This would have enabled graduates to qualify as physicians in Ukraine, thereby meeting Germany’s standard requirement that candidates for recognition must hold the right to practise in their country of education. However, no agreement was reached with the Ukrainian Government.
Under current German legislation, there is a possible pathway for these students to complete their training in Germany and obtain approbation (authorisation to practise). This mechanism relies on two key elements:
§10 of the Bundesärzteordnung (BÄO) (Federal Medical Practitioner Law) allows for supervised practice (Berufserlaubnis) if required to complete medical education.
A ruling by the Administrative Court (Verwaltungsgericht) in Bremen confirmed that an applicant can obtain approbation in Germany if their medical studies are deemed equivalent to German medical education, or they have fully completed their studies, including both theoretical and practical components.
Thus, if the Ukrainian theoretical training – with possible compensatory measures – combined with a substitute practical component completed in Germany is deemed equivalent to German medical education, the competent German authority would have a legal basis to issue approbation.
A separate initiative aims to introduce legislative changes allowing Ukrainian students to complete the practical components of German medical education without repeating theoretical coursework. However, such reforms would require amendments to the federal licensing regulations (Approbationsordnung) and are unlikely to be implemented before 2027.
Foreign-trained physicians seeking recognition of their qualifications in Poland have two options: nostrification or the Medical Knowledge Verification Exam (LEW – Lekarski Egzamin Weryfikacyjny). Nostrification, conducted by authorised medical universities, determines whether a foreign diploma is equivalent to a Polish one. The process, typically completed within 90 days, may result in recognition, rejection, or a requirement for compensatory measures, such as additional exams or traineeships. A fee usually applies, but exemptions may be granted based on financial circumstances.
Alternatively, physicians with at least five years of medical training, who have the right to practise in their country of qualification and proficiency in Polish, may opt for the LEW exam. Organised by the Centre for Medical Exams in Łódź (Centrum Egzaminów Medycznych), it is conducted twice a year, exclusively in Polish, and can be taken in multiple locations. Candidates must submit a certified copy of their diploma, authenticated and translated into Polish. The exam, currently costing around EUR 75, may be repeated if necessary.
After passing either nostrification or the LEW exam, candidates must obtain authorisation to practise, which includes completing a one‑year postgraduate internship and passing the Final Medical Exam (LEK – Lekarski Egzamin Końcowy). The LEK exam, also administered by the Centre for Medical Exams in Łódź, is available in Polish or English, depending on the language of the candidate’s medical studies. It is free of charge unless taken in English or retaken, in which case a fee of approximately EUR 75 applies. Foreign-trained physicians must also demonstrate sufficient Polish language proficiency (B2 level recommended), which may require passing a Polish language exam administered by the Medical Council. This exam, available upon request, costs approximately EUR 100.
Polish regulations allow the recognition of postgraduate internships or practice periods completed abroad, including in third countries. Applications are submitted to the Ministry of Health, which evaluates the documentation through the Centre for Postgraduate Medical Training (Centrum Medyczne Kształcenia Podyplomowego). A panel of experts convenes at least every three months, and a decision is issued within 14 days. If significant differences are identified, compensatory measures may be required.
Similarly, specialist training and practice from third countries can be recognised. Applications are submitted to the Ministry of Health, but candidates must first obtain authorisation to practise in Poland from the Polish Medical Council. If substantial differences exist that cannot be compensated by work experience, additional training at a designated healthcare facility may be required. This compensatory training cannot exceed three years.
The process for nurses differs slightly. Nursing qualifications from third countries can only be recognised through nostrification. The decision, issued within 90 days, may result in recognition, rejection, or compensatory requirements, such as additional exams or traineeships. Fees generally apply but may be waived based on financial need. To obtain authorisation to practise, foreign-trained nurses must meet two additional requirements: proficiency in Polish and completion of a six‑month adaptation internship at an authorised healthcare facility.
Over the past five years, Poland has introduced temporary simplified procedures to facilitate the employment of foreign-trained physicians and nurses, initially in response to COVID‑19 and later due to the influx of Ukrainian refugees. In 2020, during the pandemic, regulations were amended to provide fast-track clearance for foreign-trained health professionals, allowing them to bypass the standard recognition process. Instead, they could apply directly to the Ministry of Health for a conditional right to practise (valid for up to five years) or a limited scope of practice restricted to specific services and employers (also for a maximum of five years).
The conditional right to practise initially restricted doctors and nurses to supervised roles in public healthcare facilities treating COVID‑19 patients. However, specialists and nurses with at least three years of experience were required to work under supervision for only three months. In April 2022, restrictions on healthcare facility types were lifted, allowing those with conditional rights to work in any healthcare facility, provided they notified the Ministry of Health of employer changes. However, new applications for this pathway were also suspended.
The conditional license remains available for specialists and experienced nurses with sufficient Polish language proficiency, documented through a self-signed declaration. These professionals must undergo 12 months of initial supervision and can work in any facility providing the selected specialist services.
After these temporary authorisations expire, physicians and nurses must undergo standard recognition procedures to continue practising in Poland. However, public sector work experience under these temporary permits is now considered in the recognition process.
In March 2022, these simplified procedures were extended to Ukrainian health professionals with temporary protection status in Poland. Unlike other foreign-trained doctors and nurses, Ukrainians could still apply for the conditional right to practise beyond April 2022. Additionally, Ukrainian specialists and experienced nurses with documented Polish language skills can apply for limited scope practice rights, which have been available to Ukrainians under any legal status since 2020. Further modifications allow Ukrainian physicians to provide healthcare exclusively to other Ukrainian citizens under temporary protection status. Those with limited scope permits do not require additional approval to work in facilities serving only Ukrainian patients.
Since 24 October 2024, the Ministry of Health no longer accepts applications for conditional practice permits, although the limited scope practice pathway remains open. By April 2026, all Ukrainian physicians and nurses practising under these special measures must pass a Polish language exam, demonstrating at least B1 proficiency on the Common European Framework of Reference for Languages (CEFR).
As of September 2024, around 2 500 physicians held conditional practice rights, and 715 physicians were working under limited scope permits, as recorded in the Central Physician Register.
In Sweden, physicians and nurses trained outside the EU/EEA/Switzerland can obtain a license to practice through two pathways: recognition of qualifications or compensatory training. Both culminate in the submission of certificates to the National Board of Health and Welfare (Socialstyrelsen), which then issues the license. Applicants must also provide proof of language ability at C1 level in Swedish, Norwegian or Danish, even if they are Swedish nationals.
For both physicians and nurses, the recognition process consists of four steps: an assessment of medical or nursing studies, a proficiency exam, a course on Swedish laws and regulations, and clinical training. Applications for qualification assessment must be sent to the National Board of Health and Welfare. If an applicant lacks a medical or nursing diploma, they may request a background paper from the Swedish Council for Higher Education (Universitets- och högskolerådet, UHR), which evaluates their qualifications based on available evidence. Sweden – along with Canada, Denmark, Estonia, Italy, Norway and the Netherlands – offers a specialised refugee qualification assessment, as outlined in the Lisbon Recognition Convention and co‑ordinated through the ENIC-NARIC networks.
Once a complete application is sent, the National Board of Health and Welfare typically completes the assessment within three months. If the application is rejected, candidates may still qualify for a Swedish license by completing compensatory training or retraining through a Swedish medical or nursing degree. If approved, the candidate continues to the proficiency exam.
For physicians, the proficiency exam, administered by Umeå University, consists of theoretical and practical components in Swedish. The theoretical part is a 7.5‑hour written exam, offered four times per year, and must be passed before trying the practical part, which lasts two days, is held eight times per year. Candidates are allowed five attempts for the theoretical exam (within five years) and three attempts for the practical part. Physicians who pass the proficiency exam may apply for special authorisation to work temporarily as medical doctors.
For nurses, the proficiency exam, conducted by Gothenburg University, also consists of theoretical and practical components in Swedish. The theoretical part is a four‑hour written exam, offered six times per year (with a maximum of 60 candidates per session), and must be passed before taking the practical component, which lasts half a day. Candidates are allowed five attempts for the theoretical exam (within five years) and three attempts for the practical part.
After passing the proficiency exam, candidates must complete a course on Swedish laws and regulations, which may be taken full-time or part-time before, after, or during clinical training.
The clinical training period is six months for physicians and three months for nurses, completed at a single healthcare facility. Earlier professional experience is not considered. Candidates must secure employment themselves and obtain special authorisation to practice temporarily.
The compensatory training pathway for physicians consists of two to four semesters of full-time studies at five universities, conducted in Swedish, followed by an 18‑month full-time internship (or an optional 36‑month part-time internship). The curriculum is partially adapted to the candidate’s prior education, but study places are limited, and universities set their own admission requirements. Candidates are responsible for securing an internship employer.
For nurses, the compensatory training pathway consists of two to three semesters of full-time studies at three universities, also conducted in Swedish, but without an internship. Universities may request a qualification assessment from the National Board of Health and Welfare before enrolment.
Foreign-trained physicians may apply for specialist qualification recognition only after obtaining a Swedish medical license. To receive a recognition of a specialist qualification, candidates must have completed at least three years of specialist training abroad, have a total of five years of combined specialist training and work experience outside Sweden, and complete at least one year of specialist training in Sweden after obtaining their license to practice.
In the United Kingdom, foreign-trained physicians can obtain a licence to practise through several pathways, with the recognition process taking anywhere from three months to over a year, depending on the route. All applications are submitted online to the General Medical Council (GMC), and each stage, including final registration with a licence to practise, is subject to fees. Since January 2020, the United Kingdom is no longer part of the EU/EEA, yet automatic recognition of medical qualifications from EU/EEA/Switzerland has been maintained.
For most foreign-trained physicians, the process begins with an assessment of their primary medical qualification and postgraduate internship of at least 12 months, which is required for full registration regardless of the country of study.
Applications for medical and postgraduate internship assessment must be submitted to the GMC, along with copies of relevant documents. Before submission, candidates must complete Primary Source Verification through the Educational Commission for Foreign Medical Graduates (ECFMG), which verifies documents directly with the awarding institution, usually within 90 days. If documents are missing or destroyed, the GMC assesses qualifications using alternative evidence. Following verification, the GMC evaluates whether the applicant’s qualifications meet UK standards. If a qualification is not accepted, the decision cannot be appealed.
For postgraduate internships, 12 months of continuous medical practice in an approved public hospital training post is required. Alternatively, two years of supervised practice after graduation may be accepted. Candidates who have not completed an internship may apply for a Foundation Programme training post in the United Kingdom, which requires provisional registration, but this can only be granted after passing the PLAB test or an accepted overseas registration exam.
Physicians without specialist training must pass the Professional and Linguistic Assessments Board (PLAB) test to obtain full registration. The PLAB test consists of two parts. PLAB 1 is a multiple‑choice written exam available in several countries and in the United Kingdom, held four times per year, and can be attempted up to four times. PLAB 2 is a practical Objective Structured Clinical Examination (OSCE) held throughout the year at the GMC Clinical Assessment Centre in Manchester. Due to high demand, candidates may experience waiting times for a test date. Physicians who pass both PLAB 1 and PLAB 2 are eligible for full registration with a licence to practise. The PLAB test requirement is waived for those who have passed a licensing exam in Australia, Canada, or the United States.
An alternative to PLAB is the Sponsorship Pathway, which is available to physicians with at least three years of practice, including the most recent 12 months, and who have been selected for postgraduate training by a GMC-approved sponsor. There are more than 110 approved sponsors, each with varying admission requirements. The sponsoring organisation provides a Sponsorship Registration Certificate, which must be included in the GMC application for full registration. Initially, physicians using this route must work under supervision in an approved practice setting until revalidated.
For physicians with specialist training and experience, the Portfolio Pathway allows them to apply for specialist consultant or GP registration by submitting extensive evidence of their specialist training and recent practice. Gathering the required documentation is a significant undertaking, so applicants are given up to 24 months to complete and submit their application, which then typically takes three to six months to process. If rejected, applicants can appeal within 28 days or submit additional evidence within 12 months. The Portfolio Pathway covers 65 medical specialties and includes an option for non-standard specialities. Alongside the Primary Source Verification by the ECFMG, applicants must provide evidence verified by medical supervisors as well as detailed reports from referees.
Some medical qualifications from Australia, Bangladesh, Canada, Hong Kong, Malaysia, New Zealand, Singapore, South Africa, Sri Lanka, the United States, and the West Indies are automatically recognised, as they have been assessed to meet the same standards as UK postgraduate qualifications (GMC, n.d.[38]). The European Society of Intensive Care Medicine qualifications also receive automatic recognition. Under the Recognised Specialist Qualification procedure, automatic recognition applies to five specialties from Australia, Canada and New Zealand. If the qualification was awarded less than three years ago, only the diploma is required; otherwise, the candidate must also document recent medical practice.
Foreign-trained general nurses must validate their nursing diploma with the Nursing & Midwifery Council (NMC) and pass a Test of Competence to register and obtain the right to work in the United Kingdom. The United Kingdom still maintains automatic recognition of EU/EEA/Swiss nursing qualifications. The registration process consists of an eligibility and qualification application, a test of competence, and the final registration application. During the first stage, the NMC validates the candidate’s identity and education, verifies the authenticity of diplomas with the issuing institution, and confirms whether the qualification allows the applicant to work as a general nurse in the country where it was obtained. Refugees must follow the same process, though alternative evidence may be accepted if they cannot provide the required documentation.
With a positive result, candidates can proceed to the test of competence, which consists of a computer-based test and the OSCE, which may be taken in any order. The test assesses numeracy and clinical knowledge and is available through an international network of test centres in multiple countries. The OSCE is a practical exam conducted at five locations in the United Kingdom. After three failed attempts, the entire registration application is closed and must be reopened from the beginning, although there is an option to appeal.
Once the test of competence is successfully completed, nurses can apply for registration with the NMC to obtain the right to practise. In addition to passing the test, applicants must also submit evidence of health, character, and language proficiency.
In 2020, within NHS England, a new employment position, medical support worker, was created as part of the response to the COVID‑19 national emergency. The role enabled NHS facilities to employ foreign-trained physicians before completing or even starting the recognition process and registration with the GMC, if NHS employer standards were upheld. Physicians working as medical support workers were only permitted to practise under supervision. Employment was typically offered for six months, with the possibility of extension. The scheme aimed to help foreign-trained physicians return to medical practice while also supporting them in initiating and completing the recognition process, leading to full registration with a licence to practise as a physician in the United Kingdom.
Since 2022, the medical support worker role has been increasingly used to support refugee doctors, including those from Ukraine, as they seek recognition of their qualifications and await full GMC registration. Several organisations facilitate connections between refugee doctors and potential employers, who then assess candidates on an individual basis.
1. The data for the United States in the background box refers to foreign-born individuals, not necessarily foreign-trained professionals.
The recognition process for medical qualifications in the United States is complex, with licensing procedures governed by individual state laws and regulations. International medical graduates (IMGs) must obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG) before entering the US healthcare system. IMGs are those who earned their medical degrees outside the United States and Canada, but from 1 July 2025, graduates from Canadian medical schools will also be classified as IMGs in the context of entry to residency programmes accredited by the Accreditation Council for Graduate Medical Education (ACGME) due to changes in accreditation bodies (ECFMG, 2024[39]).
To be eligible for ECFMG certification, an IMG must meet several requirements. Their medical school must be listed in the World Directory of Medical Schools with an ECFMG note indicating that its students and graduates are eligible to apply for certification. If a school is not listed, its students are not eligible. IMGs must also pass the two first steps of the United States Medical Licensing Examination (USMLE), which assesses a physician’s ability to apply medical knowledge and clinical skills in patient care.
The USMLE consists of three steps and is mandatory for all doctors seeking a licence to practise in the United States, including domestic medical graduates. Step 1 is a multiple‑choice exam assessing fundamental medical sciences in clinical scenarios. Step 2 is divided into two parts: Clinical Knowledge (CK), a multiple‑choice test evaluating essential medical knowledge, and Clinical Skills (CS), a practical exam testing patient interaction, physical examination, and communication skills. Step 3, a multiple‑choice exam focussing on the independent practice of medicine with an emphasis on patient management in ambulatory settings, is taken last, as IMGs must be ECFMG-certified to be eligible.
Once certified, IMGs may apply for a hospital residency, which lasts between three and eight years depending on the specialty. Residency applications are highly competitive, as IMGs compete for the same positions as US medical graduates. Applications are submitted in the autumn of the year preceding the residency start date. There are over 8 000 residency programmes in the United States, and each programme director has sole discretion over selection, meaning there are no national admission standards.
All medical graduates, whether trained domestically or internationally, must apply for a state‑specific licence to practise. Though there are 50 states, there are approximately 70 licensing jurisdictions, as some states maintain separate licensing boards for MDs (Doctor of Medicine) and DOs (Doctor of Osteopathic Medicine), while others have a unified board. Each licensing board has their own requirements. In recent years, several states have been introducing new provisions to address licensing pathways for IMGs. As of early 2025, 11 states have enacted laws that don’t require IMGs to complete a US-based medical residency to gain a license to practice medicine (Box 5.15).
As with medical licenses, nursing licensure requirements in the United States vary by state, making the process complex for internationally trained nurses. Generally, obtaining a nursing licence involves multiple steps. The first step requires contacting an evaluation agency. The Commission on Graduates of Foreign Nursing Schools (CGFNS) is the primary provider of credential evaluation services for internationally trained nurses, with all states using at least one of its evaluation products. To expand options for applicants, some states have begun allowing alternative evaluation providers. In 2023, for example, Virginia required its nursing board to approve multiple credential evaluation entities. CGFNS or another evaluation body typically pre‑screens foreign-educated nurses by assessing their education, home‑country licensure, English language proficiency, and performance on a predictor exam that indicates their likelihood of passing the National Council Licensure Examination (NCLEX).
The second step involves meeting additional state‑specific requirements if relevant and taking the NCLEX, a nationally recognised examination required for licensure as a registered nurse (NCLEX-RN) or a licensed practical nurse (NCLEX-PN). The exam is developed and maintained by the National Council of State Boards of Nursing (NCSBN), and state nursing boards use NCLEX results to determine whether to grant or deny a nursing licence.
Several states have introduced reforms to facilitate licensure for foreign- trained nurses. In 2018, Georgia allowed its nursing board to approve foreign nursing education programmes as equivalent to US standards if deemed no less stringent. Alabama permits licensure if an independent credential review agency verifies the foreign education as comparable to a board-approved programme. In 2022, Kentucky introduced temporary work permits for internationally trained nurses pursuing licensure by endorsement, drawing from temporary measures implemented during the COVID‑19 pandemic. That same year, Hawaii adopted legislation allowing internationally trained nurses to obtain temporary licensure by endorsement if their education met Hawaii’s standards at the time of their graduation and they had secured employment with a Hawaii-based employer.
States have long provided alternative routes to medical licensure, such as academic licensing, faculty appointments, and exceptional service licensing. Recently, new pathways have emerged that allow IMGs to gain licensure through evaluation by approved medical employers. These reforms generally require candidates to have previously been licensed abroad, hold Educational Commission for Foreign Medical Graduates (ECFMG) certification, pass all steps of the United States Medical Licensing Examination (USMLE), and secure employment with an approved hiring entity where they are supervised and assessed to ensure clinical competence. Many states also require IMGs to work in rural or underserved areas for a fixed period following their assessment.
Washington was the first state to implement such a pathway with SB 1 129 in 2021. The law grants a limited two‑year licence, renewable once, to IMGs nominated by the chief medical officer of an approved medical practice. Candidates must have resided in Washington for at least one year, hold ECFMG certification, have passed the USMLE, undergo a background check, practise under a fully licensed physician, and file a practice agreement with their employer. Washington’s broad definition of approved medical practice includes hospitals, state departments, and multi-physician medical practices. However, this pathway does not currently lead to full, unrestricted licensure.
Colorado introduced a different approach in 2022 with HB 22‑1 050, allowing IMGs to obtain re‑entry licences if they hold a current or expired foreign medical licence and meet other board requirements. The legislation also authorised an assessment model to evaluate applicants’ skills and competencies, with criteria set by the medical board. Unlike Washington’s model, Colorado’s pathway provides full and permanent licensure without requiring a provisional period.
By the end of 2023, Tennessee, Illinois and Idaho had also introduced alternative licensure pathways, followed by Virginia, Wisconsin, Florida, Iowa, Louisiana and Massachusetts in 2024. These reforms aimed to create a fairer licensure process for IMGs and spurred a broader national discussion. More states are expected to introduce similar legislation in 2025.
In late 2023, the Federation of State Medical Boards (FSMB), Intealth and the Accreditation Council for Graduate Medical Education (ACGME) established an Advisory Commission on Additional Licensing Models. Meeting four times in 2024, the commission issued nine recommendations to standardise these alternative pathways while ensuring patient safety.
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The stock of foreign-trained health professionals reflects the current composition of the workforce and is the cumulative result of both inflows and outflows of domestic and foreign-trained workers. However, focussing specifically on the annual inflows of doctors and nurses allows for a more targeted analysis of recent migration trends. From 2010 to 2023, almost every country saw its doctor and nurse workforce expand in absolute terms, but the contribution of foreign-trained staff to that growth differed markedly (Annex Figure 5.A.1). Many health systems relied especially on foreign-trained doctors to bolster medical capacity: in five countries these professionals represented more than half of the growth in doctor numbers, whereas the same was true for nurses in only three countries.
Note: In Germany, data is based on nationality (not place of training). Numbers shown at the end of each bar indicate the overall change in the number of doctors or nurses during the period analysed. Data for doctors in the United States only goes up to 2016.
Source: OECD Data Explorer (DF_HEALTH_WFMI).
For a more detailed breakdown Annex Table 5.A.1 and Annex Table 5.A.2 compare inflows of foreign‑trained doctors and nurses to OECD countries in 2010 and 2023. In 2023, the 31 OECD countries with available data received more than 68 000 foreign-trained doctors – double the number recorded in 2010 (data available for 26 countries). The United Kingdom, the United States, Spain, Australia and Canada attracted the largest numbers, together accounting for over 70% of the total inflow.
Absolute figures, however, require context. Several indicators can help place inflows into perspective – such as population size, the size of the existing labour market for each occupation, or the stock of foreign-trained professionals already present. Another useful approach is to compare these inflows with the number of domestically trained professionals entering the labour market, namely recent graduates. This method more clearly illustrates a country’s reliance on foreign-trained professionals at a given point in time and allows for analysis of how this relationship has evolved over time.
In 2023, the United States admitted 33 foreign-trained doctors for every 100 new medical graduates, whereas the United Kingdom received 148. Other high ratios were observed in Norway (265), Israel (252), Switzerland (195) and Ireland (170). Between 2010 and 2023, this ratio doubled in both the United Kingdom and Ireland, indicating an increasing reliance on foreign-trained doctors. By contrast, the ratio declined in New Zealand, where more modest inflows coincided with significant growth in the number of domestic graduates – 74% (Annex Table 5.A.1).
Note: Data missing for Costa Rica, Mexico, Japan, Luxembourg, Portugal, the Slovak Republic and Türkiye.
1. The Foreign Trained Dependency Ratio expresses the number of foreign trained doctors entering practice for every 100 new domestically trained graduates.
Source: OECD Data Explorer (DF_HEALTH_WFMI and DF_GRAD).
Note: Data missing for Costa Rica, Canada, Greece, Mexico, Japan, Portugal, Luxembourg, Slovenia, the Slovak Republic and Türkiye.
1. The Foreign‑Trained Dependency Ratio expresses the number of foreign‑trained nurses entering practice for every 100 new domestically trained graduates.
Source: OECD Data Explorer (DF_HEALTH_WFMI and DF_GRAD).
In 2023, the 28 OECD countries with available data admitted more than 104 000 foreign‑trained nurses, well above the inflow of doctors and over four times the 2010 level (data available for 23 countries). The United Kingdom, the United States, Germany, Australia and Ireland received more than 85% of these nurses.
Reliance on international recruitment is lower for nurses than for doctors. Using the Foreign‑Trained Dependency Ratio, only Ireland and Austria exceeded parity: in 2023, Ireland registered 307 foreign‑trained nurses for every 100 new Irish nursing graduates, up from 13 per 100 in 2010. Over this period, the annual output of Irish nursing graduates stagnated at about 1 600, while the inflow of foreign‑trained nurses rose almost 20‑five‑fold, from roughly 200 to more than 5 000.
The next‑highest ratios were recorded in New Zealand and the United Kingdom – around 100 and 80 foreign‑trained nurses per 100 graduates, respectively. For the United Kingdom this represents a sharp increase from 18 in 2010. Norway moved in the opposite direction: by more than doubling its nursing graduate output over the 13‑year period, it cut its dependency ratio by half to 40 and reduced foreign‑trained inflows by roughly a quarter.
1. This designation is without prejudice to positions on status, and is in line with United Nations Security Council Resolution 1244/99 and the Advisory Opinion of the International Court of Justice on Kosovo’s declaration of independence.
← 1. OECD averages for foreign-born doctors and nurses in this chapter are calculated using the OECD Total* in each table, based on countries with consistent data available for 2000/01, 2010/11, and 2020/21.
← 2. Protokol o rovnocennosti dokumentů o vzdělání, vědeckých hodnostech a titulech, které jsou vydávány nebo udělovány v Československé socialistické republice a ve Svazu sovětských socialistických republik.