Is Nigerian nurse emigration really a “win-win”? Critique of a CGD article

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 datathat 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)