Plan the causeway crossing instead of pretending to stop it
A hospital group with wards on both sides of a large wage gap cannot stop nurses crossing it. It should run the crossing as a priced internal pathway with a route home, so the losing hospital is paid to train replacements and the nurses who leave have a reason to return.
I believe a hospital group that operates on both sides of a wage border should stop trying to prevent nurses from crossing it. A freeze on internal transfers does not keep nurses; it sends them to competitors. An open door lets the richer hospital empty the poorer one. The better course is a managed pathway inside the group, priced so that the receiving hospital pays to train replacements, limited by specialty, and paired with a right to return. I hold this view because I have watched the same border from three sides: as a nurse recruited into Singapore, as an HR manager losing nurses in Johor, and now as the executive responsible for hospitals on both sides.
Aravelle has three hospitals in Singapore and one in Johor Bahru, about thirty kilometres apart. Thousands of Malaysians cross the causeway to work in Singapore every morning, and nurses are among them. Some move to Singapore; many commute, leaving home before five and returning after dark. Every private and public employer in Singapore can recruit them, and many do.
A wage gap no allowance can close
A staff nurse in a Singapore hospital earns roughly three times what the same nurse earns in Johor, once the pay is converted into ringgit. No allowance a Malaysian hospital can afford will close that gap. When I ran HR for a Malaysian hospital group between 2009 and 2013, our Johor hospital lost a quarter of its nurses in some years. We raised pay, added allowances and ran recognition schemes. Group turnover fell; Johor's barely moved. I treated it as a pay problem, and it was not one I could solve with pay.
At Aravelle in 2022, our Johor hospital lost 31% of its registered nurses. About 150 left, 61 of them for jobs in Singapore, and 23 of those joined our own Singapore hospitals through ordinary external hiring. Our Singapore recruiters were doing their jobs. Our Johor managers were losing the nurses they had trained, and the group was paying recruitment costs on one side of the causeway to replace losses it was causing on the other. Johor closed 40 of its 310 beds.
The two obvious responses both failed on inspection. Johor's chief executive wanted a two-year freeze on internal transfers. It would have stopped our Singapore hospitals hiring Johor nurses and left every other Singapore employer free to do so, which meant the nurses would still leave and the group would lose them entirely. Our Singapore hospitals wanted no restriction at all. That would have continued the pattern in which the hospital with the higher wage simply absorbed the one with the lower wage.
Price the move inside the group
From January 2023 we ran the crossing as a pathway. A Johor nurse with two years' service can apply for a post in our Singapore hospitals through an internal route, up to an annual limit. The nurse keeps their seniority and benefits from a support package for registration with the Singapore nursing regulator. The receiving Singapore hospital pays S$14,000 into Johor's training budget for each nurse it takes.
The charge is the part people question. It is not a fee for the nurse, who pays nothing; it is the Singapore hospital paying for training it did not fund. Johor uses the money to take a larger cohort of newly qualified nurses each year and to pay for post-basic courses in intensive care, theatre and emergency nursing, alongside an allowance of RM 600 a month for nurses in those specialties. Without the charge, the pathway would have been the open door under another name. With it, the Singapore hospital has to decide whether an internal hire is worth more than an agency nurse, and Johor can plan its training around a flow it can predict.
I made a mistake in the first year. I set the annual limit by grade, not by specialty, and Johor's intensive care unit lost too many experienced nurses at once; its vacancy rate reached 30% by mid-2023 before we set specialty limits. I also failed to explain the charge to the nurses themselves. Several told their managers they felt they had been sold. When we showed them the trainees their transfer had funded, most saw it differently, but I should have started there.
A route home is worth more than a retention payment
The feature I would keep if I could keep only one is the right to return. Any nurse who moves to Singapore through the pathway may come back to Johor within three years at the same or a higher grade. Commuting across the causeway is hard, and family circumstances change. Before the pathway, a nurse who left for Singapore and wanted to come back faced a hospital that had replaced them and a grade that did not recognise what they had learnt.
Between 2023 and 2025, 151 nurses moved through the pathway and 27 returned, 19 of them as senior nurses or clinical educators. They bring practices from Singapore wards, and they make a convincing case to junior colleagues that a career in Johor need not end at the causeway. Johor's turnover fell to 16% by 2025, its vacancy rate to 8%, and 34 of the 40 closed beds reopened. Agency spending in our Singapore hospitals fell by S$5.8 million a year.
There are limits to the argument. The pathway does not stop other Singapore employers from recruiting Johor nurses, and some still go. It works because we own hospitals on both sides; a Malaysian hospital without a Singapore partner cannot copy it, though it could negotiate something similar with one. And it depends on a group finance function willing to let one hospital's budget pay another's.
The same pressures will reach our Indonesian hospitals more slowly, because registration and language form a higher barrier. I would rather design the route now than discover it later in the resignation figures. The question for any board of a group spanning a wage border is whether its hospitals are cooperating or competing for the same nurses, and who decided which.