Critical care

Godsfavor Okotie planned to spend her career working in Nigeria’s healthcare system. That all changed during one 12-hour shift early in October.

It started out like any other hectic day at the hospital. The 24-year-old nurse read through the handover notes from the previous shift, handed out medications, and attended to the flurry of patients and their family members who needed help.

Okotie had gotten used to working on a short-staffed team. Most days, she was one of two nurses caring for about 16 patients. But on that day, Okotie was the only nurse managing an entire ward of 10 critical patients.

“I was literally taking turns to cry, and going to attend to the patients with my red eyes,” she said.

The hospital was also running short on supplies. Okotie called it a “Do-It-Yourself” situation. In one case, she had to cautiously open transfusion fluid bags and puncture them at different points for a second use.

Nurses work in the pediatric ward of the MSF hospital in Rutshuru, Democratic Republic of Congo. André Quillien/Alamy

Her patients included an 8-year-old girl with sickle cell disease. Okotie scrambled to get the blood and other supplies the girl needed.

“There was a delay, and when we finally got it, it felt like nothing was working,” she recalled, tears choking her voice. The girl died later that night—and so did Okotie’s will to keep working in Nigeria. “I just could not take it anymore,” she said.

Nigerian nurses have long complained about their working conditions, but in the past three years, the growing frustration has prompted a mass exodus. Some 42,000 have left the country, leading the government to make it much harder for nurses to get the training verification document they need to apply for jobs abroad or to seek advanced degrees in other countries.

Nigeria’s measures are some of the most stringent in Africa as leaders continue to fight brain drain that is siphoning their best and brightest workers to the West. Healthcare leaders across Gambia, Zimbabwe, and other African countries also are grumbling over the loss of already limited healthcare workers.

Meanwhile, this loss appears to be the West’s gain. The African exodus is filling gaps across the United States, Canada, and in parts of Europe, where the COVID-19 pandemic exacerbated already dire healthcare shortages. The World Health Organization estimates a global shortage of 10 million healthcare workers by 2030, with the poorest nations hit hardest. That has left many questioning the most ethical approach to meet healthcare needs on both sides of the economic divide, while respecting people’s freedom to migrate legally.

Cynthia Okafor Adereyi, who runs a resource platform for her fellow Nigerian nurses, said leaving the country is not the first choice for many. Scores of nurses rush to apply for any Nigerian job she posts on her Telegram social platform within the first 24 hours. When she recently shared an online registration form for unemployed nurses, more than 2,000 responded.

Cynthia Okafor Adereyi Photo by Onize Oduah

Adereyi pointed to the working conditions that many nurses face, particularly in public hospitals, as driving the push to migrate. Pay is also a serious problem. Nurses in specialized private hospitals may earn as little as $100 monthly, less than a third of the monthly living costs for a single person in Nigeria. Some public healthcare nurses get paid far less—the $20 monthly minimum wage.

That makes life especially difficult as Nigeria suffers through a record economic crisis. Inflation topped 34 percent in June, and food costs have more than tripled in the past year. The struggles are fueling a larger exodus across many ­sectors that’s now popularly called japa—which means “to flee” in the Yoruba language.

Okotie’s final “breaking point” came when the hospital she worked for delayed her already minimal salary that month. Her parents took out loans to fund her education, and by that time, the repayments were long overdue. Her mother often had to field tense calls from creditors. Meanwhile, four of her younger siblings are still in school.

“There are days where I wake up, and then I’m just not motivated to even go to work,” Okotie said.

Nurses demonstrate outside the Nursing and Midwifery Council of Nigeria in Abuja. Photo by Onize Oduah

ON A CLOUDY morning in mid-February, Adereyi bustled between unloading the trunk of her blue Lexus and answering questions from nurses. Around her, a growing crowd in a rainbow array of scrubs gathered outside the head office of the Nursing and Midwifery Council of Nigeria (NMCN) in Abuja.

Adereyi handed out markers and blank paper for the nurses to make handmade banners. She also distributed printed placards with inscriptions like “Justice for Nurses” and “No to verification rules” in between fielding calls from other nurses asking for directions to the protest.

All around her, nurses traded stories about their work frustrations.

“I don’t have the intention of traveling out of this country, but there’s nothing in this country that encourages nurses to stay,” said Omotayo Adeiza, who has practiced in public and private hospitals for 12 years.

After sorting out their signs, the protesters presented a letter with a list of requests to Dr. Faruk Abubakar, the NMCN registrar, who met them outside the office. “Sir, when you first came on board, we were able to get our [training] verification in three weeks,” Adereyi told him.

The new NMCN regulations now extend the verification process to at least six months. Applicants also must submit a reference letter from their employers and must work for at least two years before their certificates can be verified.

Linda Isioma Alexander, a nurse with over 15 years’ experience who joined the protest in Abuja, called that requirement “obnoxious,” since the council already verified the nurses before issuing their practice licenses. “It’s just like after giving birth to a child, you’re telling another person to verify it’s your child,” she said.

But Abubakar sees the problem from a different perspective: “If we allow every Nigerian to leave as they graduate, who is going to handle our healthcare services?”

Nigeria ranks fifth in the world for the number of nurses applying for visa screening documents provided by the Commission on Graduates of Foreign Nursing Schools (CGFNS) International, a Philadelphia-based organization that assesses international nursing credentials. The Philippines ranks the highest.

Other African countries also are struggling to stop the healthcare exodus. More than 3,600 health workers left Ghana in the past three years, according to the country’s Health Service. In Cameroon, about a third of trained doctors who completed medical school last year left the country, according to its Ministry of Higher Education.

A student nurse exams a child at a pediatric hospital in Freetown, Sierra Leone. Matthew Oldfield Editorial Photography/Alamy

OKOTIE KNOWS leaving Nigeria won’t solve all her problems. She describes it as a “pick your poison” situation, since nursing is tasking anywhere in the world. But, she said, both the pay and the working conditions are better abroad.

Word about work opportunities overseas spread increasingly during the COVID-19 pandemic, when healthcare systems around the world struggled to cope and were willing to pay more. Before that, the lack of information initially “made nurses just remain where they are, thinking it is the same everywhere,” Adereyi said.

But since then, nurses who successfully relocated to the West have started posting their experiences on YouTube and other social media platforms. They share their legal migration stories, how they prepared for foreign examinations and visa interviews, and their more comfortable lifestyles.

Mukul Bakhshi is the chief global affairs officer at CGFNS International. In July 2023, he attended the International Council of Nurses Congress in Montreal, Canada. That’s where he met Faruk Abubakar, the Nigerian nursing council registrar.

“He was very clear that he felt that the world was taking Nigeria’s resources and that Nigeria had to protect its healthcare system,” Bakhshi recalled.

While sympathetic to Nigeria’s plight, Bakhshi calls its efforts to prevent migration “a very blunt tool to deal with a very nuanced problem.”

In 2010, the World Health Organization adopted a voluntary global code of practice to regulate international recruitment of health personnel and protect countries with the most pressing healthcare needs. A decade later, the WHO began publishing a list of countries most at risk. Last year’s report included 55 countries, more than half of them in Africa. But the regulations remain voluntary, and Western countries continue to recruit overseas.

Germany, for instance, has ramped up its foreign recruitment as health authorities project the country will need 150,000 more nurses by 2025. German authorities say it’s not all bad for the countries the workers leave, noting migrant remittances help support families back home. Last year, the U.K. Nursing and Midwifery Council reported registering just over 12,000 Nigerian-trained nurses in six months.

The United States also benefits from the influx of foreign medical workers. In its 2023 report, CGFNS International highlighted Texas, Illinois, Montana, Florida, and New Mexico as the top states attracting foreign-trained nurses. And the need shows no signs of abating: The U.S. Chamber of Commerce predicts an average of 193,100 annual job openings for registered nurses until 2032.

Ironically, many of the same factors that drive nurses out of developing countries are causing shortages in the West.

“There aren’t enough nurses who are willing to work under the conditions and wages that we provide them,” Bakhshi said. “I think all of that was exacerbated during the pandemic.”

While working conditions have eased back to pre-pandemic levels, the shortage projections remain. Bakhshi’s agency encourages recruiters not to woo workers under government contracts and to partner with hospitals in lower-income countries.

But he also urges countries to consider more sustainable solutions beyond recruiting from areas already combating similar shortages. One part of that is improving worker retention: “The real problem is not that we don’t train enough nurses, it’s that a significant minority are out within a couple of years because they’re burned out.”

More creative approaches could involve brainstorming how to do more with fewer nurses, Bakhshi said. Hospitals also could consider better ways to incorporate technology into treatment and involve more certified aides to allow nurses to focus on higher-level cases.

“I think there’s a lot of interesting nuance here when we’re thinking about not just the pandemic, which obviously highlighted the importance of nurses, but more generally, what does healthcare policy look like in 2030 and 2040 in a world where particularly the developing world is getting much older?”

STILL IN ABUJA, Okotie continues to follow the debate over the verification process. She joined other nurses at the National Assembly in May as lawmakers listened to their grievances. The hearing offered her hope that someone was listening.

By then, she’d started exploring job opportunities in the United States, but the process turned out to be too expensive. So she set her sights on Ireland—until Nigeria’s new restrictions put the brakes on those plans.

Despite the uncertainty, Okotie has continued to research her opportunities —and also to work at staying one step ahead of scammers. She recently came across a recruitment agency that claimed to help nurses like her get employment abroad without any verifications.

“I joined a group [on WhatsApp], and that was where they were saying it’s a scam and some other nurses had already fallen for it.”

Okotie is also exploring options beyond nursing. She’s considering starting a business, or taking advanced classes online to qualify for remote jobs.

“I’m still going to leave, and I’m still going to come back,” she said. “You can’t run away or leave forever. Our family members are still here.”