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

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.

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

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.

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.

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.

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. 

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.

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.

This is totally separate from your main line of argument, but it does seem plausible that, ex post, Nigrerian nurse emigration might actually significantly undermine AI Xrisk mitigation efforts:

• The UK government accepted a lot of Nigerian immigration (and from other countries) in an attempt to address NHS labour shortages.
• Elevated levels of immigration are very unpopular, and one of the main reasons for the unpopularity of the prime minister Rishi Sunak.
• Rishi Sunak also seems to be, completely unrelated to the above, the world leader most concerned about AI Xrisk. His rival, Kier Starmer, who will probably replace him in the General Election, has given few signs of interest in the topic.

To be clear I don't think this was particularly forseeable in advance, and it's not a general problem with nurse emigration. It's just that in this one specific case it seems to have happened to had a very bad effect.