Gone are the days when Denmark was a model for the world in providing quality health services to all age groups. With life expectancy getting longer by the year, those days when senior citizens could look forward to a comfortable old age are under threat unless the Danish authorities dare to address xenophobic values that hamper innovative solutions.

Desperate need for health workers

In 2022, the Danish health service had 31 342 doctors, 57 694 nurses, 61 000 healthcare workers, and 53 301 assistant nurses. According to the FOA, healthcare workers with immigrant status account for around 38 %, while assistant nurses account for 25 %. In 2023, the Danish Medical Association estimated that 40 000 more healthcare professionals will be needed in 2030, while in 2045, 100 000 more healthcare professionals will be required, including specialist doctors, nurses, healthcare workers, and assistant nurses. University colleges estimate the need for nurses by 2030 at 8000 people.

FOA1, the union for service staff in the health sector, estimates that in less than three years there will be a shortage of 41 000 healthcare workers1 and assistant nurses2. Over the past few years, 5000 nurses have chosen to withdraw from the health sector due to unsatisfactory working conditions. Against this background, the government set up a task force to prepare proposals for solving human resources problems in the health sector.

Efforts to meet staffing needs

Denmark has just rounded the anniversary of adopting a so-called Voting Agreement to recruit foreign health professionals from third countries. The agreement identifies sixteen points of action on which the government and several parties in the Danish Parliament will vote together on future draft laws to implement the agreement's objectives. The agreement aims to ensure "a more flexible framework for recruiting foreign healthcare professionals from third countries."

The 24.1.2024 Voting Agreement is based on recommendations from an interministerial working group2, which identified the framework for rapid and effective integration of foreign healthcare professionals with demanded competencies. The demographic challenge threatens Denmark's welfare system. Fewer young people seek to educate themselves for work with the care and well-being of the elderly, children, and the very young. The health authorities assume that the quickest solution to the staffing problem is recruiting from third countries, mainly India and the Philippines.

Arguments

This paper argues for support of local solutions to the demographic challenge. One of the arguments is that the authorities must review and revise work responsibilities for staff of all categories. One of the objectives would be to avoid overlaps of human resources. The conclusion of a significant revision of the framework of tasks for health staff should aim to create a sufficiently large group from which to recruit Danish-trained assistant nurses to the nursing profession. With more extensive recruitment of nurses from this group, Denmark would not have to expose countries such as India and the Philippines to an additional burden on an already overcharged healthcare system.

Whether the government can find solutions to the demographic challenge of an uninterrupted provision of welfare services depends entirely on awareness and understanding of the interplay of ethnocentric xenophobic values. Politicians are not above ethnocentric barriers, which, in an unfortunate way, prevent the establishment of appropriate laws and procedures that enable a smooth and satisfactory solution to the shortage of staff in the health sector while at the same time ensuring opportunities for individual well-being and professional development.

This article asserts that the well-being of the Danes, particularly its senior citizens, cannot be guaranteed because a significant portion of responsible health staff live in precarious conditions. This applies particularly to healthcare workers and assistant nurses with foreign roots, who often spend years uncertain about their stay in Denmark and when they can obtain permanent residence permits.

Critical observations to the Voting Agreement

After over a year, there are clear signs that the agreement's expectations will never be met. The deal is more based on dreams than reality because the government does not want to consider the need to change the rules governing the short-term residence of foreigners and, in the longer term, their chance of obtaining permanent residence permits with subsequent nationality. It is possible that the initiative to the agreement is a political 'publicity stunt' to maintain the political support of the growing older generation.

The Aliens Act does not sufficiently differentiate between different employment categories for foreigners. Healthcare professionals with immigrant backgrounds are often affected by stressful situations created by the rules administered by the Danish Immigration Service and SIRI1. Job requirements for healthcare professionals in close contact with citizens differ from those for foreigners who arrive in Denmark to work in the agricultural sector or the hotel industry. However, the regulations are administered almost uniformly for all groups of foreigners.

The government and the supporting parties to the Voting Agreement have given scant attention to the long-term implications for immigrants. The long-awaited progress in recruitment from third countries is yet to be seen. Potential candidates are probably familiar with current conditions in Denmark and how it will affect them and their families when they consider applying for entry to Denmark. One gets the impression that politicians and their civil servants assume that potential immigrants cannot orient themselves about the conditions in Denmark.

To what extent could Danish-trained staff contribute to a complete or partial solution to the problem? The task force ignored that question. Several professional organisations received the Voting Agreement with critical comments. The Danish Medical Journal wrote that it is not "…decent to set up a scheme in which thousands of health professionals are lured to Denmark with little hope to get a job because the coordination between those who recruit and those who lay down the rules is not right. And those who must pay the necessary expenses are non-existent. The agreement thus puts the foreign applicants under great financial and general stress. Many will likely waste years of their lives, saved money, etc., on this hopeless scheme before leaving Denmark with unresolved cause."

The biggest obstacle for foreign staff is to obtain employment in an evaluation job. As a foreign nurse, you do not get an extended residence permit if you have not completed a six-month evaluation appointment. Against this background, several health system representatives propose that local solutions should be identified rather than recruiting from third countries. Another reason is that local solutions will satisfy language requirements and provide sufficient knowledge of Danish culture.

The Voting Agreement led to the adoption of the Danish immigration Act on 1.7.2024, which amended the authorisation and residence of health professionals who immigrated from third countries. By the beginning of 2025, however, the Act had not led to any significant changes in the composition of personnel in the health sector, although the government had added 1000 healthcare workers to the positive list.1 Only five members of this group have arrived in Denmark. The immigration authorities had previously refused four of them an extension of residence.

Unethical recruitment from third countries

Instead of identifying stable and lasting solutions to the staffing crisis, the government and the parties behind the Voting Agreement have taken the fast track by trying to fill the numerical gaps in staffing needs rather than assessing how better to use existing resources. Furthermore, recruiting from third nations, like India and the Philippines, results in deterioration and, at worst, a halt in the coverage of health services in the two countries. An exodus of health workers would harm the population's general health.

In both countries, there is less than one doctor for every 1000 people, four times less than in Denmark, and half as many health workers as in Denmark. Nevertheless, the Danish government does not hesitate to promote cooperation agreements with the two countries regarding the recruitment of nurses. It seems entirely justifiable when the Danish Council of Nurses chairperson describes the government's decision as unethical.

National contributions to address the shortage of staff

The Council believes that local solutions to the staff problem should be found. At the same time, the chairperson of the Danish Medical Association said, "Of course, one should try to attract and retain healthcare staff. However, as a community, we must prioritise how and when we use available resources. They must be used as wisely as possible."

In this context, assessing the relative importance of different staff groups in the health sector is essential to determine how best to use human resources. When reviewing the staff hierarchy with the general practitioner at the top, one is bound to conclude that nurses comprise the most critical group because revising their job descriptions may contribute to more flexibility for medical doctors. Accurately identifying how current health staff are used is crucial for satisfactory recruitment of nurses to the group of health personnel.

Suppose we want to wholly or partially overcome the staff shortage nationally. In that case, we must make national recruitment to the group of nurses more efficient and flexible by removing all barriers to continuing training for assistant nurses. Optimal use of health staff will have a better chance of success after an audit and adjustment of the responsibilities of healthcare workers and assistant nurses.

A prominent and significant task for FOA will be to take over the leadership from civil servants of the Ministry of Health, identifying obstacles that hinder assistant nurses from continuing training that will enable them to enter the profession of nurses. This proposal is because civil servants are more likely to implement an assignment following the political line and principles of the minister responsible. Whereas a union, such as FOA, will be obliged to give due consideration to the interests of its members.

More room for heart than control

The Prime Minister's New Year address in 2022 is far from being realised now—two years later. At that time, she said: “I do not believe that we can save on our budget while building better welfare for our senior citizens. Financial support will be granted to the growing population of children and senior citizens. This government will ensure that." It is doubtful how much confidence can be placed in these words today, while all the political parties want to ignore sound accountability principles for using scarce funds with priority to modernise the military. When referring to a welfare society with more room for the heart than control, the Prime Minister alluded to the necessity of immigrants' contributions to solving the challenges of the welfare state.

The highlighting of more room for heart and reason underlines the need to ensure the safety and well-being of senior citizens–not of immigrants! According to the Prime Minister, the welfare guarantee in Denmark should be enforced through controlled immigration under strict management. Foreigners must return to their countries of origin once the problem is resolved. Such language certainly does not ensure the well-being of foreign citizens responsible for maintaining Denmark's welfare society. However, the immigrant group lacks legal and democratic means to influence their welfare and well-being. Thus, the Prime Minister has nothing to worry about from the immigrants.

Citizens without democratic rights

The initiative for the Voting Agreement gives the impression of being guided by political motives. Its goal is to demonstrate to the population, especially its older members, that the most vulnerable people in society have not been forgotten. Meanwhile, vast resources are invested far from Denmark's borders. The agreement reflects the shared values of the coalition government and supporting parties regarding immigration and residency in Denmark. More and improved social services are priorities.

The government assumes that such priorities are achievable without changing the legislation on temporary and permanent residence for foreigners. Immigrants have a growing value in the sustenance and development of the welfare society. Qualified foreigners are invited to Denmark to help maintain the welfare of society. Still, it is difficult for them to navigate the labyrinth of regulations that facilitate their existence as permanent members of the health staff and the Danish population. Has it been considered to introduce different residency requirements for diverse groups of foreigners based on their place in the labour market and their chances of becoming citizens?

Lawmakers ignore the fact that many foreigners stay in Denmark because they consider it their home. It is worrying for the Danish democracy that approximately 430 000 adult foreigners, who on average have remained in Denmark for more than 10 years, do not yet have Danish citizenship and therefore cannot participate in elections to the legislative assembly. This group is a source of great fear for the political class. It poses a threat to the established parties. A fundamental change in the power structure of the legislative assembly could result from almost half a million citizens becoming eligible to vote.

Aliens Act hampers a national solution

Suppose foreign nurses and their families do not satisfy the Danish immigration service regulations. In that case, they cannot renew their residence permits. Approximately 40 foreign nurses who arrived in Denmark in 2021 did not have their stay extended and had to leave the country again with their families because they were unable to obtain the mandatory employment evaluation required by the Aliens Act so that the Authority for Patient Safety could approve their employment in the health system.

The history is not one-of-a-kind. The media mentioned Syrian refugees with basic Danish education and about to finish their training as healthcare workers. Still, their residence permits were withdrawn due to the possibility of peace in Syria. The Prime Minister justifies this by saying, “It is quite natural that people to whom we have given protection because of war in their homeland must return home when peace has come so that they can contribute to the reconstruction of their country.” It sounds beautiful and considerate but loses some credibility when the Danish state actively tries to recruit nurses from countries where they are needed to develop the health sector. Hypocrisy at the highest level is what this is about.

Because of the requirements for obtaining permanent residence, qualified assistant nurses of foreign origin can't continue their training after completing their education. Most prioritise residence permits and citizenship to ensure personal security and welfare for their families. This objective is incompatible with continuing nursing education because permanent residence requires full-time employment of not less than 30 hours per week for at least 3 years and 6 months before being granted permanent residence. Therefore, most assistant nurses postpone all further education until after having established security of their stay in Denmark.

It may take many years to achieve this goal, and it will often be too late to start further education in the health sector. FOA has brought attention to this unfavourable situation and argued that appropriate training should replace the requirement of permanent work. It doesn't seem like the parties to the agreement have taken the time to assess these conditions. The government has put the issue on hold. Why, when the welfare society depends on an increase of the workforce? The answer to this must be sought in the values that Danes share.

Cultural racism uniting the country

The culture that defines the social structure incorporates these values. Cultural racism would be a suitable way to describe these values. Since racism is forbidden by law, no one tacitly agrees to be classified as a racist, even though it describes somebody who, most often unconsciously, acts on several ethnocentric values that are so integrated into the social structure that only Greenlanders and immigrants notice them. Emotions and irrationality govern these ethnocentric values. That is why political decisions regarding immigrant groups are most often taken on an instinctive and emotional basis.

Those who come here must adapt and preferably assimilate themselves to the Danish monoculture. The Voting Agreement must be understood in this context. The agreement carries the message to the voting part of the Danish population that the government will do everything to preserve the benefits of the welfare society, even if it means neglecting the well-being and security of 15% of citizens of foreign origin. That group must continue accepting an existence as second-class citizens, without the same democratic rights as blue-eyed Danes and with limited opportunity to influence their everyday lives.

The lack of interest in improving the living conditions of ethnic minorities in Denmark, apart from prohibiting racist behaviour towards these groups, is mainly due to an unconscious fear that treating these minorities too humanely will result in concessions that could have unforeseen consequences for future immigration to Denmark. It is worth noting that the Aliens Act was tightened up immediately after the large influx of refugees to Denmark in 2015 and the terrorist attacks in Paris and Copenhagen. Denmark's mindset is characterised by the connection between terror, Islam, and a multi-cultural society.

The Danes and the others

Most politicians who love their livelihoods only reluctantly enter debates on improved living conditions for immigrant health workers through amendment of legislation on residence, especially permanent residence, and citizenship. Politicians risk losing votes and support from the electorate if perceived as too friendly to immigrants. 52 percent of Danes fully agree with the statement: "Immigration poses a serious threat to Danish culture."1 Politicians therefore adhere to values that emphasise and promote Danishness and its monoculture. It is better to avoid whether assistant nurses of foreign origin should have a real opportunity to develop their professional competence by continuing with training as nurses.

It is very possible that the task force behind the Voting Agreement did not examine the extent to which assistant nurses can contribute to solutions to the demographic challenge due to underlying cultural values of a profound ethnocentric character. These values have emerged over time and have become part of the justification for Denmark’s involvement in the slave trade. After all, the African slave was viewed as a being inferior to his Danish slave master. These values persist today and have assumed an irrational fear towards strangers.

The behaviour of Danes has become xenophobic towards immigrants, especially those with origins in third countries. Extreme ethnocentrism to the degree of xenophobia renders it impossible for even immigration experts to identify areas of significant concern and importance for immigrants. These problems will not be resolved until Danes dare to confront their ethnocentricity and learn to see them as an existential component of Danish society, often impeding positive and harmonious relations with citizens of foreign origin with essential contributions to the Danish welfare system.

The political class may resort to other solutions when it is firmly established that the Voting Agreement with the subsequent revision of the Aliens Act does not lead to the desired expansion of human resources of health staff. One should perhaps also consider whether the lack of reaction from third-world healthcare workers to apply to Denmark according to the group's position on the positive list should be interpreted as a growing insight and understanding of the xenophobic conditions that foreigners risk meeting in Denmark. Perhaps sooner than expected, Denmark will be known for its xenophobia rather than the Little Mermaid.