This hospital in Kelâat M'Gouna, Morocco, is only seven years old, but locals say people hardly ever set foot in it, patients or staff. When The Globe and Mail asked to speak to a doctor working there, it was told that there were none. Understaffing is a chronic problem at health centres in remote Moroccan communities.Photography by Jade Prévost-Manuel/The Globe and Mail
Manara Naji doesn’t know much about New Brunswick. Over coffee near a Casablanca train station in September, she studies a map to get a closer look at the place she’s trying to get to. “Is it a city?” she asks.
She’s talking about Edmundston, where – if all goes well at her interview with government recruiters – she might be working later this year, thanks to a program bringing Moroccan nurses to the Canadian province.
Ms. Naji, 34, has travelled 350 kilometres overnight from Tangier to attend the recruitment event. As an auxiliary nurse, she earns the equivalent of just a dollar an hour at a Moroccan hospital, and she knows she would get a much higher salary in New Brunswick, where long-term care workers – the position she’s interviewing for – make nearly 20 times as much. She wants to move to Canada for a “changement de vie” – a different life. “I’m very motivated to work there,” she told The Globe and Mail.
Auxiliary nurse Manara Naji holds her luggage at a Casablanca train station. She came overnight from Tangier to meet recruiters from New Brunswick.
Her feelings are common in Morocco’s health sector. Workers complain of unlivable salaries, poor working conditions and a lack of political will to improve the health care system, all of which are fuelling the exodus of nurses from Morocco to foreign countries like Canada.
But Canada’s efforts to recruit nurses from there is also worsening a severe staff shortage in Morocco, which is hemorrhaging nurses faster than it can produce them.
Officials say the country of 37 million people needs another 65,000 nurses to fix its care deficit, making its health care worker shortage among the worst in the Arab world. Canada scouting and scooping up their best talent, they say, isn’t helping.
According to the Moroccan Ministry of Health, Morocco lost some 400 nurses to Quebec in 2021. Local news outlet Raseef22 reported in August that during the previous year, one Casablanca hospital lost at least 14 nurses to Canada.
Volunteers line up in Marrakesh on Sept. 10 to donate blood for those injured in an earthquake that struck south of the city days earlier.
A banner from Immigration New Brunswick hangs at their kiosk at a Sept. 12 recruitment event in Casablanca.
The world caught a glimpse into just how fragile Morocco’s health care system is last month, when a 6.8 magnitude earthquake killed nearly 3,000 people. The disaster left hospitals and emergency clinics scrambling for medical staff and basic medical supplies, including suture kits.
Days later, Immigration New Brunswick held its recruitment event in Casablanca to bring Moroccan health care workers to its long-term care homes. The details of what New Brunswick’s pitch to foreign nurses looks like are unclear, because when The Globe and Mail showed up to the event, recruiters promptly slammed shut the doors to a room where employers were speaking to a crowd of about 50 nurses.
Signage outside the event indicated that one of those employers is Villa Providence Shediac, a nursing home in a coastal New Brunswick town of about 6,500 people. Last year, the provincial government announced it would spend $70-million over the next three to four years to turn it into a 190-bed facility, based on a facility assessment report. Last year, inspectors found the nursing home was non-compliant with provincial recommended patient-to-staff ratios and public health and coroner reporting plans.
For more than 50 years, Canada has relied on acquiring international nurses to help run its health care system. Last year, the federal government announced it would commit $115-million, with $30-million ongoing for five years, to help thousands of internally-educated health workers get their degrees recognized in Canada and find work in their fields.
But there’s a problem with the way that Canadian medical recruitment happens, say researchers like Margaret Walton-Roberts, a human geographer who studies the international migration of health workers at Wilfrid Laurier University. Peel back the layers of some of Canada’s provincial recruitment programs, she says, and what you’re left with is essentially health worker poaching – Canadian provinces using immigration as leverage to staff less-desirable posts, leaving countries scrambling to fill positions left behind.
“We’ve been here before. This is a pattern,” says Dr. Walton-Roberts of foreign recruitment. “And that’s part of the problem: it’s a pattern that becomes like a crutch. It’s that easy fix that we always turn to.”
At the Sept. 12 event in Casablanca, signs feature a New Brunswick long-term care home looking for Moroccan workers. The Globe could not get inside the event to hear what recruiters were saying.
New Brunswick and Quebec are two provinces turning to international recruitment to staff their health care institutions. Both need French-speaking health care workers to care for their large francophone communities, which together account for most of the more than seven million Canadians who predominantly speak French. Morocco has them – French is one of the country’s two official languages.
To understand how badly many Moroccan nurses want to come to Canada, one needs only to read the hundreds of Facebook posts asking for advice and support on how to make the move. Ahead of Immigration New Brunswick’s event, posts that linked to the event’s registration page were flooded with hundreds of comments. Ms. Naji is one of the fortunate few to have been invited to Casablanca for an interview.
Earlier this year, New Brunswick reduced the timeline for registering Morocco-trained nurses to work in the province from over a year to as little as two weeks. Recruiters with Immigration New Brunswick declined to answer The Globe’s questions about its foreign recruitment practices at the event.
Sean Hatchard, a representative from the Department of Health, confirmed in an e-mail that international recruitment helps fill labour gaps that New Brunswick cannot meet domestically.
But the countries they’re recruiting from are facing their own critical labour gaps. In fact, both Quebec and New Brunswick recruit from countries (Cameroon and Haiti for Quebec; Senegal and Ivory Coast for New Brunswick) on the WHO Safeguards List – a document, updated every three years, that identifies the countries facing the most severe health worker shortages globally. These are countries that the WHO discourages developed nations from recruiting in.
Back in early 2022, Quebec announced it would commit $65-million to recruit 1,000 nurses last year from francophone African countries, including Morocco, Tunisia, Algeria, Lebanon, Cameroon, and Haiti.
Around the same time that program was announced, Moroccan news outlets were reporting on the country’s acute shortage of health workers. Nationwide, nurses were planning a three-day strike to demand better pay, regulation of the profession, and improved working conditions.
Nurses in Morocco say they don’t have access to the proper medicines or equipment to properly care for patients. Some work in clinics that are dirty and lack clean water and electricity. When they must do the job of a doctor – which happens often, given the shortage of doctors in Morocco – they can face jail time if something goes wrong.
Days before the strike, the government had come to an agreement with health care unions to increase pay for doctors, pharmacists and dentists to incentivize them to stay following a nationwide strike. Nurses were left out of the agreement.
Fatima-Zahra Belline, a nurse in Rabat who protested nursing conditions last year and is heavily involved in the Independent Union for Nurses and Healthcare Technicians, says the state isn’t doing enough to address the demands from striking nurses. Leaders have been more focused on holding onto doctors, for whom they’ve cut down the number of years needed to study to practice medicine in Morocco. The state is also in talks to open Morocco’s borders to nurses from the Philippines, the world’s biggest supplier of nurses.
Ms. Belline believes there needs to be stronger incentives for people to stay, but it’s tough to stay hopeful.
“There isn’t political will here to change things,” she says.
Oumaima Misbah is a children's-hospital nurse in Morocco's capital, Rabat, and has considered seeking work abroad.
Many of the country’s young people, from all professions, want to emigrate – about 70 per cent of them, suggests a recent poll by Bayt, a recruitment agency based in Dubai. Given the opportunity, polyvalent nurse Oumaima Misbah would happily leave. She works at the Children’s Hospital in Rabat.
“Everyone wants to go away,” she tells The Globe as she prepares for her night shift.
A few years ago, she looked into emigrating to Germany, which recruits heavily from Morocco. But learning the language – Moroccan nurses must pass a German language test before they can emigrate – was a barrier. For French-speaking Moroccans, language isn’t a barrier to come to Canada.
A lot would need to change to make her and other nurses stay put in Morocco, she says. Better working conditions and opportunities for higher education in the field of nursing is part of that. So is the salary. Nurses in Morocco earn a fixed-rate salary, which means, among other things, that they aren’t paid extra to work nights.
“The salary, it’s not enough to live,” says Ms. Misbah. “It’s enough for us right now, we’re not married, we don’t have children. But it’s not going to be enough.”
In Kelâat M’Gouna, population 50,000, patients often have to travel great distances out of town when they need a doctor, even for simple maladies.
Finding local health care can be a hassle in Kelâat M'Gouna, says Hamza ait El Houssaine, who sells SIM cards at the town market.
Nowhere is the country’s health worker shortage more strongly felt than rural Morocco, where Ms. Misbah says the majority of health care centres do not have doctors on staff. In Kelâat M’Gouna, a remote city of less than 50,000 people in southeastern Morocco, people pray that they do not get sick. People who live here can try to see a doctor in Ouarzazate, a city an hour and a half away. But getting care in rural Morocco often means having to travel from hospital to hospital to find the right medicine, specialists, and infrastructure.
“If it’s something small, I’ll fix it myself,” says resident Hamza ait El Houssaine, who sells SIM cards at the city souk, or market. He told The Globe he once had to travel as far as Ouarzazate to treat a bad stomach bug.
Morocco has a highly centralized public health care system, with most of its health professionals working in big cities like Fes, Casablanca and Rabat. Rural Moroccans have the worst access to basic health care. People in Kelâat M’Gouna who need to see a doctor or get care beyond what the local facilities can provide – something as simple as getting an X-ray or a dose of anti-venom for a scorpion sting – have no choice but to leave town.
It is not uncommon in the desert towns a few hours outside of Kelâat M’Gouna, like Zagora, for example, for children to die from illnesses or injuries. They might have to get themselves to Marrakesh, more than a five-hour drive by car, to access basic public health care.
“People die on the way to Marrakesh,” says Kelâat M’Gouna resident Brahim, a former political activist who is only using his first name for fear of speaking out against the national health care system.
A weathered sign marks the entrance to Hôpital de Proximité Kelâat M'Gouna.
Part of Morocco’s plan to bolster its health care system is to build facilities in isolated areas. But there aren’t enough people to staff them. When The Globe visited the city’s newest hospital, Hôpital de Proximité Kelâat M’Gouna, there were only four people in the building – a human resources professional, a security guard, and two nurses on break by the gate. Upon asking for a doctor, The Globe was told that there aren’t any who work there.
Together with a public-health centre and a dialysis centre that opened in 2019, this hospital serves people living within a 200-kilometre radius of town. When it first opened seven years ago, there were doctors, nurses, and a handful of specialists, recalls Brahim. But within months, they had left. Today, it is virtually empty. There haven’t been any doctors for years, he says.
“When people asked the Ministry what happened, they said the doctors don’t want to stay here. They want to go to big cities,” says Brahim. “They said the conditions were bad.”
Kelâat M’Gouna is part of the Drâa-Tafilalet region, Morocco’s poorest. Left to serve its vulnerable population are people like Abdellah Mairouche, one of about two dozen nurses that serve Kelâat M’Gouna and its outer banks. Mr. Mairouche has worked at the Centre de santé urbain de Kelâat M’Gouna, a regional health clinic, for nine years. He stays, he says, because he doesn’t know what will happen to his patients if he leaves.
“Nurses, they’re the only people that can give care here,” says Mr. Mairouche. “Sometimes, we have to bring people more than 200 kilometres to get help.”
Fatima-Zahra Belline looks across the Corniche Bouregreg waterfront in Rabat, where she works as a nurse and advocates for better working conditions.
Ms. Belline also feels a responsibility to stay in Morocco, to try to better the system and improve the quality of care for those suffering the most from the health worker shortage.
“The day I’ll leave Morocco will be the day when I realize the profession isn’t going to change,” says Ms. Belline. She pauses, emotional over the thought of leaving her country. “I’ll leave if I see that my actions aren’t getting us anywhere.”
But she understands why nurses, like her twin sister who works in Sainte-Hyacinthe, Que., leave. Her sister earns more money and she’s part of a union that gives her workplace protection. She has tools she needs to do her job properly – a luxury for many Moroccan nurses.
While all that’s true, there are difficulties that immigrants face in Canada, too: the high cost of living, soaring rates of health worker burnout, and the fact that many immigrants are recruited to work in isolated, rural areas.
Experts say Canadian provinces should focus on retaining nurses before recruiting them. Burned-out nurses leaving acute care could be reintegrated into public health, says health care sociologist Ivy Bourgeault, where they would have more predictable hours. The next step is then creating the conditions that would bring staff who left back to hospital floors.
Historically, the ethical test for recruitment has been whether there are strong reciprocal benefits for the countries sending the workers. But the ideal recruitment program really should follow something called the triple-win model, says Dr. Walton-Roberts, whereby the sending country, the receiving country, and the immigrant all benefit.
She says that Saskatchewan, for example, had an agreement with the Philippines whereby they would recruit nurses to Canada and, in return, pay the country to help build skills. The U.K. has used an “earn, learn, return” model, which invites foreign health care workers to the U.K. on a three-year visa, in turn giving them the skills they need to be successful back home.
“Every province and territory across Canada at this time seems to have acute staffing issues,” says Dr. Walton-Roberts, adding that the solution always seems to rely on stealing from one system to feed another, as opposed to fixing the systems themselves. “Understanding what’s going wrong in your system, and figuring out how you can work in a sustainable long-term solution – that seems to be the last thing on people’s agendas.”
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