Hide table of contents

I write to raise what I think is a fundamental flaw in a Center for Global Development (CGD) article about immigration.[1] I posted here only after receiving what I considered inadequate feedback from the authors over the last 3 months.[2]

The major argument of the article “UK recruitment of nurses can be a win-win” is that the current situation where Nigeria exports an ever-increasing number of nurses to the UK could be good for both countries. For Nigeria, the benefits come through both the classic economic benefits of remittances, and stimulating increased nurse training in Nigeria to compensate for the losses of nurses.


A Misleading Datapoint

The central datapoint on which their argument rests seems misleading. The authors cite the number of nurses who leave Nigeria each year for the UK alone and claim that increased nurse training in Nigeria is enough to replace these nurses. “Between late 2021 and 2022, the number of successful national nursing exam candidates increased by 2,982—that is, more than enough to replace those who had left for the UK.”  Technically, they are correct that the number trained replaces those who leave only for the UK, but they don’t consider the majority of nurses who left to other countries.
 

Emigration to the UK  constitutes under 25% of the total nurse emigration from Nigeria. A more meaningful data point would have been the total number of nurses that leave Nigeria for all countries. Based on this Guardian article (and others), about 29,000 new nurses were registered in Nigeria over the last 3 years, while 42,000 left. The total number of nurses in Nigeria is reducing, not increasing as they claim.

To express this situation graphically, the best graph to illustrate whether or not nurse Migration is a "Win-Win" for both Nigeria and England might have looked more like this (forgive the poor formatting!)



 

Over the last 3 years Nigeria has lost a net 13,500 nurses. This is a loss of about 1% of their nurse workforce a year, while Nigeria needs an increase of around 2.5% nurses yearly just to keep up with population growth. This assumes that no nurses left or joined the Nigerian workforce for other reasons. Nurses may leave the Nigerian workforce due to retirement or for other work, while nurses could also be entering Nigeria from other countries to work - I doubt these adjustments would make a big difference to the overall analysis.

Based on this data, it looks like England will win and Nigeria will lose. My main claim is that it is incorrect to claim a win-win scenario for two countries when emigration from Nigeria includes a majority of nurses leaving for many other countries – not just the UK. I’m very happy to be shown where I’ve gone wrong here and welcome any comments!
 

An Author's response

Privately, one of the authors briefly responded that their argument is based on the change in trainees and migrants over time. This still avoided my concern: you cannot look at migration outflows and inflows between two countries in a vacuum. The author also noted WHO data that shows a flat trend in the number of nurses per 1,000 people. I agree that tracking “nurses per capita” over time would be the best way to measure whether the nurse situation in Nigeria is improving or deteriorating. However the world bank data appears grossly inaccurate. Their “nurses per 1,000 population” number fluctuates implausibly between 1.75 per 1,000 in 2016, to almost half that 0.9 per 1,000 in 2018 then back up 1.5 per 1,000 the next year. Unless 100,000 nurses left Nigeria over 2 years then flooded back in the next year (not the case), the data is absurd and not to be trusted. The most proximate data we have to understand trends in nursing numbers is probably the data above - total number of nurses trained each year vs, those leaving he country (as displayed above). I don't think we have a reliable data source for nurses per capita in Nigeria.
 

                                               An Implausible WHO Data Set


 

Also, (a side point) the authors' argument that Nigerian nursing institutions could be increasing their trainee numbers as a direct response to the UK policy doesn’t make much sense either. There would be a long lag time (3-5 years of training) before we would see any response to a new policy which took in more nurses from another country. Instead nurse training increases rapidly 1-2 years after UK immigration increases. I think you could make a decent argument that Nigeria is increasing nursing training in response to a general overall trend in nurse emigration, but not just from the UK policy.

In summary looking at trends and number of nurse emigration (what I think the article tries to do), the data appears to show net harm to the Nigerian Health System, not a “win-win” at all. 

If I’m right, then I think the premise for the article is invalid – i t should probably be retracted or rewritten. I don’t love being that guy who brings the criticism and would rather have resolved this without posting here, but I think truth-seeking is  important, especially when addressing Open Philanthropy funded think tanks. I also think when you chase a potential inaccuracy in good faith, it's usually best to continue until the loop is closed. 

I recognize there’s more than a chance I’m wrong here, so I’m very open to being rebuffed in part or in full. I'll edit or retract the post based on convincing responses. I would especially appreciate a response from CGD authors or staff.
 

  1. ^

    I don’t have a strong opinion either way on the merits of high-skilled immigration. Part of what prompted me to look into this issue more is that I had a vague idea of starting a nursing school in Uganda, in partnership with the UK (or other) government, which could supply both our organisation OneDay Health and  a high income country with nurses.

  2. ^

    Before writing this I tried multiple times to get an adequate response from the authors.

    1) Contacted CGD by e-mail 3 months ago (response “your response was fed back to the authors for their consideration” only)

    2) Contacted the individual authors via e-mail 1 month ago (no response)

    3) Posted something similar to this on the EA Global Health and Development Slack (received a short response from one author, discussed here)

133

5
4
2

Reactions

5
4
2

More posts like this

Comments28
Sorted by Click to highlight new comments since:

TLDR:  The immediate drop in Nigerian nursing workforce isn't indicative of the long-run effect of rich country nursing visas. Prior evidence suggests that the increasing in nursing supply will be lagged, but big enough swamp the effect of outmigration.

Hi Nick, thanks for this! Point well taken on the misleading numbers in the CGDev article. I share your skepticism that the UK policy could have caused an uptick in the Nigerian nurse population within 2 years of its introduction. In the first couple of years of the policy, the outmigration is plausibly a net-loss for Nigeria before we consider the effects of remittances.

That said, the crux of the cost-benefit calculation (bracketing remittances for now) is the effect of UK nurse recruitment on the Nigerian nurse workforce over the longer run. In particular, we have evidence (open access) from the Philippines[1] showing that expansions in US nursing visas caused an additonal 9 non-migrant nurses to be licensed for each  nurse who migrated to the US. We can think of the big surge in nursing supply as being driven by the hopes of winning the "migration lottery" to the US, with most lottery entrants losing.

 Crucially, the increase in nurse licensing only showed up after at least a 4-year lag (the time it took to complete a nursing degree). This increase involved both increasing enrollment at existing institutions, but also an increase in the number of nurse-training programs, which would show up with even further lags. If the Nigerian case mirrors that of the Philippines, we wouldn't have expected the increase to be visible yet. I think you made a similar point when you said :

There would be a long lag time (3-5 years of training) before we would see any response to a new policy which took in more nurses from another country.

The Philippines nursing example is the closest analog we have in the research, but we see a similar mechanism at work in the boom in engineering/CS skills in India in response to changes in the US H1-B cap (Khanna and Morales, 2021).[2]

Now, there may be institutional differences between the Filipino/Indian and Nigerian cases that cause there not to be similar effects. For example, there could be bottlenecks to expanding existing nursing colleges or setting up new ones. Alternatively, all the increase in nursing supply could be absorbed by other countries.  I'm not familiar enough with the country to have a view on this, so I'd be curious if you think the Nigeria is particularly well or badly suited to expand nursing supply.

  1. ^

    The CGDev authors cite this research, and I'm guessing this drives their views more than the spotty WB/WHO data.

  2. ^

    And here's another paper with similar findings in the context of Fiji.

Nice one lots of important points there thank you.

First I want to stress I'm not an expert or even that well versed in this area, I just saw an article that I thought was deeply flawed and tried to correct the situation (still waiting for CGD response). Its great that this has triggered good commentary about the actual issue though and I'll engage as best I can, I find it fascinating and I think its an important issue.

My take is that the Phillipines situation seems so different from the situation here in Sub-Sarahan African that it has limited applicability here. Even just  looking at the "Brain drain vs brain gain" simplistic framing (bracketing remittances and other benefits/harms), the Phillipines situation mostly doesn't translate. Like you say we will see over the next few years whether increased nurse training will soon compensate for both those that leave every year and the deficit of tens of thousands which has already happened but I'm skeptical. My very low confidence take would be that within 2-3 years based on current trends the yearly no. trained might creep just past the number who leave, but will not replace the current deficit, nor keep up with the still rapidly increasing population.

To state the obvious, the current Nigeria situation provides evidence in the opposite direction the Phillipines article

"Our research provides evidence against the idea that skilled migration necessarily depletes origin countries of health professionals or college graduates more broadly."

So far from the limited data we have (See Nigeria above, and other West African countries like Ghana and Liberia are similar), skilled migration is depleting some origin countries of health workers. 

Looking more deeply though, I think the "brain-gain vs brain drain" framing isn't super useful as there are so many other factors at play. Rather the EA style framing of "overall net positive vs. net negative" is better as we can include a range of factors in our analysis, even if they are hard to quantify. Just looking at the Phillipines situation, here's a top-of-the mind list of i potential positives and negatives from the Phillipines mass training/migrations. Far from exhaustive

Potential Positives
- Remittances from the nurses that managed to emigrate (Massive in this case)
- Increase in overall skilled worker training
- No shortage of trained nurses in Phillipines 

Potential Negatives  (often harder to quantify)
- Dissatisfaction within the Phillipines Health system. How can nurses be satisfied with a local wage in the Phillipines, when so many of their colleagues have orders of magnitude higher wages abroad? This is a neglected downside in these mass migration situations. In the Phillipines there are so many registered nurses now unwilling to work there that the government is changing the rules so that they can employ unregistered nurses who haven't yet passed the board exam...

https://newsinfo.inquirer.net/1912359/nurses-group-hits-band-aid-solution-to-shortage-problem
 
- Gutting of senior staff/talent/leaders - senior and better nurses emigrate easier, leaving more junion/less talented nurses at home
- "Brain drain" from other skilled work The article points out that most of the new nursing stock was people who would have done another post-grad qualification if not nursing. This means other fields which needed workers (engineering,  law etc.) may have suffered some brain drain. Important to note though that  overall skillled graduation increased.
- The training glut left thousands of trainees without a meaningful qualification. Only 38% percent of the new glut of nurses passed the registration exam vs. 58% before. So on finishing training almost 2 out of 3 nurses wasn't able to work at all. 

I would lean towards the overall situation in the Phillipines being net positive, but I'm not sure its a complete slam-dunk.

To follow up on your Nigerian Question, as we can see from the increasing number of graduates in the CGD article, Nigeria is already doing a pretty good job at expanding nursing supply. Based on current evidence though, I doubt they can do it quick enough to keep up with emigration. I don't know the Nigerian situation, but here in Uganda most private nursing schools have spare capacity. Once that has filled though it will become a lot harder to open new schools.

Like the Phillipines article said "Such a response may not be possible in all contexts, for example in sub-Saharan Africa, where the postsecondary education system may not expand as readily in response to increased demand"

Agreed that we should consider the broader set of costs/benefits you list! The top talent loss cost could be an especially a big deal in Nigeria, where I'd expect a weaker "bench" of substitute human capital than the Philippines (both for new potential nurses and for those who would train the new nurses/found new private colleges).

My (unquantified) view is that the CBA still looks pretty one-sided in the Philippines context, but I'd love to see what a formal modeling exercise produces (and if the conclusions are different for Nigeria or other Sub Saharan African countries).

 I think there's strong evidence that there is  in fact a far weaker "bench" of substitute capital in the Phillipines. Pre nurse-glut, 58% of nurses passed the registration exam, whereas post nurse-glut that dropped to 38%. 

I agree that top talent loss is likely far less of a big deal in the Phillipines but for very different reasons - mainly because only 1 in 8 (or similar) new staff left, which should mean enough strong staff remain, even with the clear drop in average nurse quality.

Phillipines and Nigerian CBAs are likely be wildly different, even just based off the one datapoint that Nigeria has lost tens of thousands of net nurses through emigration while Phillipines gained.

 I think there's strong evidence that there is  in fact a far weaker "bench" of substitute capital in the Phillipines. Pre nurse-glut, 58% of nurses passed the registration exam, whereas post nurse-glut that dropped to 38%. 

I agree that top talent loss is likely far less of a big deal in the Phillipines but for very different reasons - mainly because only 1 in 8 (or similar) new staff left, which should mean enough strong staff remain, even with the clear drop in average nurse quality.

Not sure if we disagree here. Of course I'd expect the average nurse quality to go down as the workforce increases by 9x. Rather, the claim about weaker substitutes in Nigeria was about explaining why Philippines nursing supply might be more price elastic than Nigerian supply. Specifically, since literacy, numeracy and high school graduation rates are likely significantly higher in Philippines than Nigeria, there's a larger share of the population that could plausibly respond to the migration demand shock by acquiring the relevant training.[1]

Phillipines and Nigerian CBAs are likely be wildly different, even just based off the one datapoint that Nigeria has lost tens of thousands of net nurses through emigration while Phillipines gained.

Agreed if we conducted the CBA today. However, as stated in the original comment, we want to be careful about lags here. Even in the Philippines, the migration increase started in 2000 when the US policy changed (Figure 3) and peaked in ~2006.  While the enrollment rate in nursing programs did start increasing in 2000 itself (Figure 4, Panel A), the increase in the nurse graduation rate (i.e., the trained workforce) only started in 2004 (Figure 4, Panel B), and only hit it's peak in 2010, 10 years after the migration began. If we were looking at the change in  Philippines' nurse workforce from 2000-2004, I think we might've concluded that they'd lost nurses  and that the migration was a net-loss for them. Now, as we've discussed, there are reasons to believe that Nigerian nursing supply may not be as elastic as Philippines nursing supply, but I just wanted to emphasize that the current net-loss of nurses in Nigeria doesn't yet give us strong evidence that the CBAs will be wildly different.

  1. ^

    Implicit here is that basic numeracy, literacy and high school graduation are pre-requisites for acquiring nurse training.

Yep agree with all of that. Nigeria has been losing quite a large number of nurses for 5 years now, but maybe the compensation will happen like in the Philippines like you say

Shall we check in here again in 5 years and see what happens ;).

One of the authors of the original CGD blog here.

Hi Nick, 

Thanks again for engaging. I don’t think your criticism is correct and I’ll try again to explain why here in more detail.

Our blog argued that after a UK visa policy change in 2020, there was a change in the trend or growth rate in both nurse migrants to the UK and new nurse trainees. To show this we present data from both before and after the policy change in 2020. The data you present from only post-2021 can't therefore refute our argument. We’re arguing that the situation could have been worse in the absence of the policy change, with even fewer new nurses being accredited in Nigeria.

Between 2018 and 2020 there was increasing migration to the UK, before the visa change, but the rate of increase dramatically accelerated following the visa change. In our previous blog we left implicit the idea of the counterfactual - that absent the policy change in 2020, trends would have continued as they had previously.

What about other countries?

You’re right to point out our lack of data for other destination countries. If our theory is correct (and it is only really a theory), we should expect to see a spike in nurse migration to the UK after 2020, and no change in nurse migration to other destination countries. The best data on this would probably be going through each destination country's records, but as a short-cut I took a look at the OECD data on annual flows of Nigerian-trained nurses to OECD countries. This data is I’m sure flawed, but it is entirely consistent with our argument. The OECD suggests that in the most recent year for which data is available the UK is by far the largest recipient of nurse migrants from Nigeria, with a flow of 1,709 in the latest available year, followed by the United States (87), Ireland (82), Canada (36), New Zealand (24), Germany (9), and Italy (1). Furthermore, the trends fit our theory entirely. Unfortunately, there is no data for the United States after 2015, but for Ireland, Canada, New Zealand, Germany, and Italy, there is no change in annual flows after 2021, whilst there is a huge spike for the UK.

Is this really plausible? It probably shouldn’t be that surprising that the largest flows from anglophone Nigeria are to other anglophone countries, with a particularly high demand for jobs in the UK given historical links and the fact that it is geographically closer to Nigeria than the other anglophone countries and in a closer time zone. For another source, a recent survey of Nigerian nurses found that the UK was the most preferred migration destination (Badru et al 2024, Investigating the emigration intention of health care workers: A cross‐sectional study). 

What about the short time lag between the visa policy change and nurse training?

Is it implausible that nurse graduate numbers would increase so quickly in response to visa opportunities, given that training takes 3-5 years? This is a fair concern. If there was a steady pipeline of trainees progressing smoothly through the 3-5 year training course and all trainees then taking the professional exam at the end of their training period, then yes it would be impossible to see such a sudden increase. If however on the other hand there are significant numbers of trainees who have been enrolled on and off for a cumulative period of 3-5 years but had not previously sat the professional exam, for instance due to a lack of available job opportunities, then the emergence of new job opportunities could easily lead to the observed rapid bump in exam candidates.    

Is migration reducing the availability of health care in Nigeria?

For this to be true, you would have to assume that all trained health care workers are able to find jobs in Nigeria in healthcare, which doesn’t seem likely to be true to me. You dismiss the World Health Organisation workforce data on nurses per capita because it is noisy, and argue we should instead rely on the data from the Nursing and Midwifery Council of Nigeria, a government agency. I have bad news for you, because the WHO gets its data mostly from government agencies. WHO supplements government data where it can with more reliable census or survey data, but its unlikely to be significantly less reliable than the official government data. Official data from low- and middle-income countries is often noisy, but what does seem apparent to me from the long time period available in the WHO data is that there is no ongoing downward trend in the availability of nurses in Nigeria. An alternative data source are the Demographic and Health Surveys, which show the share of births attended by a skilled provider. This is relatively flat over time from 1990 to 2021.

Ultimately our blog was speculative - we have a clear theory that training should respond to job opportunities, which seems to be consistent with the data we presented. As we wrote in the blog, this data is not definitive and doesn't prove our argument. But the data you have presented doesn’t contradict our argument either, and neither do any of the other new data sources I have consulted, whether from the OECD, WHO, or DHS. None of this data is perfect and we might be wrong, but I don’t think you’ve made that case yet. 

Thanks, 

Lee

I've appreciated this response.

The biggest discrepancy seems to be around the number of nurses:

  • Lee writes that 1,709 nurses emigrated from Nigeria to the UK in a year, and that the UK takes ~85% of the total.
  • Nick cites a Guardian article claiming that 15,000 nurses emigrate per year, and says that less than 25% go to the UK

Any insight on these large differences?

Thanks yes I would agree the article might hold water if UK Nurses made up over perhaps 60 percent of emigration

Even on a sanity check there's no chance only 2000ish nurses leave Nigeria every year. It's way too low to even be plausible. I think there's a major issue here (which is common and somewhat understandable) with giving credence to sources because they are perceived to be "trustworthy' even when their numbers are obviously meaningless. The WHO and OECD data cited should be dismissed out of hand for absurdity, but I think Lee gives it credence because it is seen as an official source.

The nurses council in Nigeria has come out publication multiple times saying that at 45,000 nurses have left over the last 3 years and 16,000 last year. Noone has refuted them even though it would probably be in the interest of the Nigerian government and Western countries for PR reason to do so. These numbers may well be exaggerated a little sure (we can't know) , but this is the most direct, proximal data we have and has been cited on news articles for months now. I don't see a good reason to take other secondary data sources seriously that fail a sanity check.

You didn't factor in the response of the Nigerian Government in mitigating the loss suffered by such emigration There is a new policy in the pipeline If it has not been implemented, though The policy is to the effect that some number of years must be spent in Nigeria before some relevant training and professional certificates will be released to you These certificates are relevant for employment By the time it is released to the nurses, another cycle is repeated for the new new batch nurses This enables the Nigerian public to enjoy the services of the nurses before they emigrate. When they travel out, another corp comes in and compulsorily serves the public before emigration.

Thanks so much yes you are right that the Nigerian Government planned to bond nurses for a couple of years to stay in the country, but it looks like it may not happen. I didn't discuss it in the post here, as I was primarily intending to correct the CGD article rather than debate in detail the situation in Nigeria - which I'm glad has happened in the comments!

https://punchng.com/nurses-plan-showdown-as-fg-moves-to-slow-down-process/ 

I love your comment here "This enables the Nigerian public to enjoy the services of the nurses before they emigrate. When they travel out, another corp comes in and compulsorily serves the public before emigration."

I think you're right its very reasonable (especially when people are trained in subsidised government institutions) to bond people to work in-country for 2-5 years. I think this can help buffer a country's nursing resources, and allow training institutions time to ramp up their training. When considering opening a nursing school here in Uganda, perhaps in connection with a foreign government I thought a system like bonding some students for 3-5 years in Uganda before we connect them to opportunities abroad might be a decent way to operate.

 

This is a good point about the CGD paper I believe, though to some extent it's based on whether to look at overall flows rather than flows specifically to the UK. I think you make a strong case that it's best to look at overall flows, and show issues with the WHO per capita data. However, I don't think this gets anywhere near actually solving whether or not this can be a "win-win" for both countries. It is easily possible that nurse emigration, despite lowering the supply of nurses in Nigeria, can still be a win-win due to remittances. There is abundant evidence that remittances promote financial development and long-term economic growth. In order to determine whether or not this emmigration is a net benefit for both countries, one would have to take into account:

  1. The benefit that the nurse gives in Nigeria.
  2. The benefit the nurse gives in the UK.
  3. The benefit to Nigeria from remittances the nurse sends back.
  4. Any long-term effects that might come from having talented Nigerians leave for the 
    UK, and long-term effects a nurse shortage could have in Nigeria. 

To me, this seems like a complicated question that would take many hours of research to reach a  satisfactory conclusion to.

Thanks those are  good points and I agree a deeper analysis would be needed to see if the emigration was "overall" a win-win. My intuition though is that the effect of the huge nurse deficit on Nigerian healthcare though would likleyly take a LOT of remittance benefit to overcome the kind of problems we are seeing in Nigerian hospitals, and stalled improvement in Nigerian Healthcare. Also I think your second criteria "The benefit the nurse gives in the UK" would be so small as to be almost negligible compared to the remittance benefits and the nurse leaving harms

https://www.theguardian.com/global-development/2023/aug/14/africa-health-worker-brain-drain-acc

I also think with this high-skill emigration in these kind of analysis, some negative factors aren't often considered, which kind of fall under your "no.4" criteria.

1. Leadership and expertise vacuums when there is mass emigration. Often the best and most enterprising people leave both because they are most enterprising and more likely to apply to leave and because they are more likely to be accepted because of their ability/grades. This can leave leadership gaps which have more profound (and harder to measure) effects than just one nurse leaving.

2. Potential drops in population Wellbeing for remaining Nigerians due to "remainer dissatisfaction." Talking to some West Africans I have felt this deep dissatisfaction whern they know friends who have left and done better, while they still remain. This can feel quite unpleasant. In Uganda where I live, mass emigration is not yet a reality so there's little of that kind of dissatisfaction. Note I think this is just a theory of mine/others without real evidence so take with a grain of salt.

Specifically here though I'm taking the paper on its own terms. Its criteria for the "win-win" from a Nigerian perspective seems to involve Nigerian nurse numbers not reducing, so I don't explore the issue more.

Absolutely agreed that factor 2 that I mentioned might be insubstantial, but I felt the need to mention it just in case it ended up being greater than I expected. My intuition on this issue is somewhat different than yours, and my guess is that the two largest factors (remittances and direct effects on Nigeria through less nurses) are going to roughly balance out, and that it's going to depend on the other issues which I placed under factor 4. 

You mention two of the indirect (factor 4) impacts I was thinking of, but there's definitely a lot of that kind of impact which is difficult to measure.

On its own terms as you discuss it, I absolutely agree that the original article is flawed. It's certainly the case that the issue nowhere near as straightforward as the paper's authors would have you believe. However, the question of the overall cost-benefit is also an important one, and also worth examining. I'm going to start working on a basic model, and I'll post here (and maybe in a separate post as well) once I've completed it to a level I'm content with. The overall issue at work here, of brain drain vs. remittances appears to me to be a very important issue in  global development, with this being an example where the costs of brain drain appears higher than usual. If the effect of remittances is powerful enough to outweigh brain drain even in this case, it could have broader impacts in terms of immigration as a net QALY increase. 

There already does appear to be some evidence towards an effect of "brain gain" where even medical immigration appears to improve net wellbeing through remittances, as seen in the example of the Philippines here, but it's a complex issue, and the medical situation in the Philippines is different from the situation in Nigeria.

Love this, and super keen to see your model! Some of these things might be nigh on impossible to quantify, but its more than worth a go. I wonder if anyone has tried already (Openphil / CE / RP?) I think a separate post would be a great idea for that, as this is quite an important issue and if you've gone through the effort to make a model like that I think there's easily enough importance/interest there for a fresh post.

Just adding that I would also be keen to see this model. At AIM, we haven't done any detailed modeling of skilled migration, but if/when we do look into it, quantifying these sorts of tradeoffs will be one of our key considerations.

I think it's valuable to ask the question of whether this shift is net positive or negative for Nigeria overall, and your basic criticism of the article seems correct to me.

Though, in a global political context that is often hostile to immigration, I often find myself wanting discussion of the harms of emigration to acknowledge the harms to the potential migrants of preventing it. Even if we conclude this situation is overall net harmful for Nigeria, it feels unfair to tell potential migrants that they may not (or even should not) pursue a better quality of life that would otherwise be available to them, that this problem is their responsibility to endure sacrifice to solve.

Thanks so much for raising this, I sometimes get a bit overwhelmed by guilt thinking how unfairly amazing my life has been, I won the life lottery in so many ways

I think there are so many layers of unfairness here that it can be hard to factor it into decision making . Like you say it’s horribly unfair that these nurses can’t migrate for far better jobs when many high income nurses freely move around the world for marginally better working conditions.

But It’s at least as unfair that millions of poor subsistence farmer patients are now more likely to suffer and die because of the worse medical care caused by the exodus of their more well off nurse compatriots, who had the opportunity to leave for greener pastures.

And It’s horribly unfair that most Nigerians didn’t have the opportunity that these nurses had to study and get a decent job in their own country. Millions would even have got good enough grades but at some point didn’t have yet money to continue. just by becoming a nurse you are always in the luckiest few percent of Nigerians.

Its also unfair that many Nigerian lower skilled workers who are more badly off than Nigerian nurses as can’t migrate to countries that could benefit hugely from their labor.

It’s unfair for most Nigerians that they were born there and not in England in the first place. Terrible luck but we don’t usually try and remedy that in any way unless we are Give Directly or similar.

Thinking about fairness/unfairness really makes my head spin and I would be interested if anyone had a way of thinking about this that could help guide this kind of decision. I find it hard to sort through so usually revert back to benefits and harms frameworks.

For me it helps to swap nationalities around.

It seems to me that if there are not enough nurses in Nigeria, and too many in the UK, then the problem is as much due to a failure of people from the UK to move to Nigeria and work as nurses there as it is due to the movement of people from Nigeria to the UK to work as nurses there. Forcing people who happen to be Nigerian to work in Nigeria for low wages (indirectly, through migration laws) is as bad as forcing people who happen to be from the UK to work in Nigeria for low wages. 

Paraphrasing Bryan Caplan:  Imagine that a nurse from the UK goes to Nigeria for a holiday. Then, when they try to get on the plane back to the UK, they're told that because of concern about the nursing shortage in Nigeria, the British government has stripped them of their right to live and work in the UK; however, they're free to live and work as a nurse in Nigeria.

I don't think we should treat UK nurses like that, and I don't think we should treat people differently just because they happen to have been born in a different place (possibly especially when that different place is much poorer anyway), so that tells me that we shouldn't treat Nigerian nurses like that either. 

This is possibly a little provocative, but I'd be interested to know whether people who support removing migration options for Nigerian nurses in order to "encourage" them to work as nurses in Nigeria would also support forcing nurses from the UK to work as nurses in Nigeria (and to earn a Nigerian nurse's wage and live a Nigerian nurse's lifestyle). If it's not ok to force UK nurses to live like that, what makes it ok to force Nigerian nurses to live like that?

(I'm not sure how that comment comes across. I get very emotional when I talk about this topic.)

Another consideration: you have to be careful using the country as a unit of analysis when international migration is involved. For example, if someone with an income of $10 a day in Nigeria moves from Nigeria to the UK, finds a job, and ends up with an income of $40 a day, then the average income in Nigeria has decreased and the average income in the UK has decreased. But the average income of the whole group of people - both people from Nigeria and people from the UK, considered together and regardless of which of the two countries they currently live in - has increased. (You could also just think about the average income of Nigerians, as opposed to the average income of Nigeria. This is the concept of income per natural, as developed by Michael Clemens and Lant Pritchett. See here.)

I love that you wrote this. 

I am so sick of seeing countries praised for having "enlightened" immigration policies when what they actually do is accept the migrants they need for their economy and reject the rest. 

They always justify this on the basis of the rights of individual migrants, but the net outcome is that some rich country has avoided the cost of educating and training a person with valuable skills, while some poor country has been deprived of the services of someone whom they paid to educate and train - but also, potentially, of one of the people who would have added a lot of value to their country. 

It's difficult to see this in most typical jobs (doctors, engineers, nurses, ...), but anyone who follows football (i.e. soccer) will understand how this works. The best soccer players from Africa and South America play in Europe. If we focus on their individual rights, then it feels unfair to deny them the chance to emigrate. But if we focus on the rights of people in their home countries, this is daylight robbery - countries which produce some of the best players in the world have mediocre leagues, while rich countries have high quality leagues, often mostly with foreign players. 

Obviously, in the case of football, it's not such a big deal. And, with football, at least they can still watch on tv, and the players will still (mostly) be available for the national team. 

With other jobs, the person is just lost to the country, and the result will be an inferior quality of life for those who remain. 

If we accept that the individual's rights to emigrate trump those of their country of origin, at minimum we need some form of compensation which is appropriate to the scale of the problem. 

I don't have a solution - but sometimes I worry that we're very quick to jump to the conclusion that the individual's freedom is more important than everything else, especially when it's convenient. The countries who use this argument don't hesitate to deny the same freedom to immigrate to people who do not have useful skills, and they don't seem to lose too much sleep over it. 

Executive summary: The article argues that a CGD article's claim that Nigerian nurse emigration to the UK is a "win-win" for both countries is flawed due to misleading data and failure to account for total nurse emigration from Nigeria.

Key points:

  1. The CGD article's central datapoint, comparing nurses leaving Nigeria for the UK to the increase in nurse training in Nigeria, is misleading as it ignores the majority of nurses leaving Nigeria for other countries.
  2. Over the last 3 years, Nigeria has lost a net 13,500 nurses, a loss of about 1% of their nurse workforce per year, while needing a 2.5% yearly increase to keep up with population growth.
  3. The author argues that it is incorrect to claim a "win-win" scenario when considering total nurse emigration from Nigeria, not just to the UK.
  4. WHO data on nurses per capita in Nigeria appears to be unreliable and fluctuates implausibly.
  5. The premise of the CGD article is invalid, and it should be retracted or rewritten.

 

 

This comment was auto-generated by the EA Forum Team. Feel free to point out issues with this summary by replying to the comment, and contact us if you have feedback.

Wow impressive why did I even bother to write this piece myself :D...

You should have just waited for the summary and then expanded that into a full article.

I believe there’s an underlying assumption in both the article and the comments generally that the nurses who remain in Nigeria will be employed and thus benefit the local population. However, in many LMICs, it is common to find qualified doctors and nurses who have not been employed for years post-qualification. The key question, therefore, is whether it is preferable for a qualified nurse to remain unemployed in Nigeria for an extended period or to be actively saving lives elsewhere.

This is a critical point

Curated and popular this week
Relevant opportunities