A nurse who works at Mater Dei Hospital said she could not promise her ailing father that she would visit him in India before he dies because she has been waiting for a renewal of her work permit for months and cannot travel.

The woman is among 26 third-country national nurses who have been technically living and working in Malta illegally for the past months.

This is not through a fault of their own but because they found themselves helplessly trapped in a bureaucratic quandary as they wait for their employer and the authorities to renew their documents.

Third-country nationals – citizens from non-EU countries – can only live and work in Malta if they have a valid single work permit confirming they have employment. The moment the permit expires and is not renewed, they are automatically considered as having overstayed illegally and risk deportation by the police. If deported, they could also be banned from travelling back to Europe for up to five years.

The nurses would only speak to Times of Malta on condition of anonymity out of fear that the authorities would hunt them down. They are still working at Mater Dei, St Vincent de Paul and Sir Paul Boffa hospitals as the government grapples desperately with a nurse shortage, but they have been living in constant fear of deportation.

It is unclear who is responsible for the delays because their employer – a company called Healthmark – says it is doing all it can to process the applications as quickly as possible. Identity Malta said a permit renewal does not take more than eight weeks to be issued. But some nurses have been waiting for a year.

In replies to Times of Malta questions, the Health Ministry and the Active Ageing Ministry suggested they were not even aware they had undocumented migrants working for them because the nurses are not directly employed with the government but outsourced through Healthmark, which is a private company.

Meanwhile, some of the nurses have very sick and dying relatives in their home countries but cannot visit them because leaving Malta would alert the authorities to their irregular status.

“This last year I suffered a lot. My father is old and suffers from lung disease and his health is deteriorating,” one nurse said.

“And he keeps telling me, ‘When are you coming to visit me? Will you see me before I die?’ He thinks I don’t care about him and I don’t know how to explain to him that I can’t leave because I will lose everything, including my salary that I direly need to help him and the rest of the family back home.”

What is even worse is that despite working at the hospital, the nurses are refusing to seek medical help when they need it for themselves because that also risks alerting the authorities to their undocumented status.

“It is so strange that we work at the hospital every day to serve people, yet we are afraid to use the service ourselves,” another nurse lamented. 

“We are constantly exposed to illnesses and prone to falling sick, but if we do get sick we would rather not say anything.”

Some of the nurses formed part of the COVID team after they first landed in Malta in 2020. The pandemic had just hit and the government was fast-tracking applications from third-country national healthcare workers to keep up with the urgent demand.

“I remember seeing an advert in India saying that Malta urgently needs nurses to help with the pandemic,” another nurse said.

“When Malta needed us on the frontline of the pandemic crisis it was quick to process our documents, but now that we need it, it didn’t care about us.”

"It is so strange that we work at the hospital every day to serve people, yet we are afraid to use the service ourselves"

How did this happen?

EU member states, including Malta, are very strict on when and how to allow third-country nationals to live in their territory.

Third-country nationals cannot live in Malta unless they have a job and they can only get a job if they find an employer in Malta who has proven that he cannot find an EU national who is interested or qualified to do that job. Only then can an employer recruit a third-country national. 

That explains why Malta has seen an influx of third-country nationals – because they are either doing jobs that the Maltese people would rather not do or filling in gaps in the Maltese workforce where there is a growing demand for skilled labour that is not being sufficiently met by the local supply, such as in healthcare.

Third-country nationals live and work in Malta with an ID card known as the single work permit. It is usually valid for a year and must be renewed when it expires. 

The permit is tightly bound to their employment. It details who their employer is and what job they were hired for, and if they change jobs, get a promotion or get fired, they must apply for a new permit with the updated details, even if the permit has not expired yet. 

If they fail to get the renewed and updated permit or fail to find a new employer within 10 days, they automatically become illegal migrants and risk deportation.

Meanwhile, the growing demand for foreign workers in Malta has seen a mushrooming of outsourcing companies to recruit foreign workers. The government increasingly engages workers through outsourcing contracts with these companies.

Furthermore, when third-country national nurses land in Malta they are usually not immediately employed as nurses, but as carers, despite having graduated as nurses in their home country. Their employer later enrols them for an adaptation course to bump up their qualification, following which they get promoted to nurses within the national healthcare system.

The course is aimed at focusing on skills that are important in the Maltese context, like care for the elderly – a concept that is often unfamiliar in countries like India where culture dictates that the elderly are cared for at home, not in hospitals. So, while geriatric care is not too important to becoming a nurse in India, in Malta it is absolutely indispensable.

The biggest healthcare outsourcing company is Healthmark and it provides most of the third-country national nurses and carers working at Mater Dei and other state hospitals and care homes. But Healthmark employs a system whereby carers are employed with a company and nurses are employed with a different company, both run by Healthmark.

This means that when the Healthmark carers were promoted to nurses, they needed to change both their job designation and their company of employment on the single work permit. 

Despite having submitted all the necessary documents to their employer in time, this process was delayed and has left them waiting for a renewed permit for too long – in some cases even for a year. And whenever they chase their employer for answers, they are only told that the process is still ongoing.

The nurses who spoke to Times of Malta confirmed they have truly been promoted. They do a nurse’s job, they got a salary raise and their taxes and national insurance are being paid regularly. But they do not have documentation which allows them to live and work in Malta legally, causing them to live in constant fear of deportation for months.

The number of affected nurses stands at 26 but Times of Malta understands the number was greater until a few weeks ago, before some of the backlog was quickly eased when the media got wind of the story.

‘Final stages of approval’

In a reply to questions, Healthmark said the backlog was caused by the growing demand for healthcare workers and the processes required to upgrade carers to nurses and keep up with the national demand. The process slowed down when the carers were getting the promotion to nurses, it said.

“This change in role required a change in work permit and also to move them to a different company, and therefore required a change in employer. We needed to reapply for their work permits and start the original process from scratch with the authorities,” a spokesperson for the company said.

The bureaucratic process is just one of many issues facing third-country nationals and the companies that employ them, the spokesperson said.

“Over the past months we have been working closely with Identity Malta and other authorities involved in this process to achieve more efficiency from both sides, so as to solve this problem and give workers peace of mind that they can travel and not risk deportation.  

“In recent weeks we have found several ways of improving our processes. In fact, up until today, the issue currently affects 26 nurses who are third-country nationals. Their application is pending with the various authorities for approval, most of which are at the final stages since they have been approved by some of the authorities.”

"The ministry outsources additional nurses through a contract"

‘No more than six weeks’ 

Identity Malta would not comment on these particular cases but said permit renewals only take between four and six weeks to be issued. 

“In some cases, it may also take up to eight weeks if additional checks and verifications are required,” a spokesperson for the agency said.

“Both the employer and the applicant must ensure that the latter is in possession of a valid single permit which reflects the conditions on which the document was originally issued for.

“Applicants may continue to work and reside in Malta while their renewal application is being processed provided that their conditions of employment have not changed and a full application was submitted. A renewal application should be submitted in due time, before the document’s validity date lapses.”

‘No visibility’

In replies to Times of Malta, the health ministry and the active ageing ministry appeared to be unaware that a number of nurses are working in their hospitals and care homes without the necessary documentation.

They said that since the nurses are not employed directly with the public sector, the government has no way of knowing what their residency status is.

“The ministry outsources additional nurses through a contract awarded following an open call for tender. The Health Authorities are responsible for ensuring that each nurse provided by the private contractor is registered with the Nursing Council, however, we are not given visibility on the individual’s residency permit,” a spokesperson for the Health Ministry said.

The Active Ageing Ministry’s reply was identical.