Beyond Brexit: A Triple Win Nursing Partnership to Benefit the NHS and Low-Income Countries

December 08, 2016

After Brexit, can the UK pursue its own national interest while still benefiting global development? We think an innovative, practical plan leveraging skill creation and mobility will do just that—offering mutual benefits to all relevant parties.

In the UK, the need for healthcare services is growing rapidly. With an aging population, nearly 1 in 4 UK citizens will be over the age 65 by 2034. That means a slow-moving but unavoidable rise in the need for healthcare services.

This creates a problem for the UK’s already cash-strapped National Health Service (NHS). If demand rises without an increase in supply, then prices go up. This demographic and fiscal problem is particularly grave for nursing care. There are about eight nurses per 1,000 people in Britain—falling behind most other European countries and the OECD average overall. A recent stocktake of NHS England nursing supply showed there are currently over 21,000 full time positions unfilled. Nurses provide critical assistance to people with chronic needs, offering broader care for less money than doctors and medical specialists. Without more nurses, caring for Britons will be much more expensive, or more meanly rationed, or both.

Lilongwe, the capital of Malawi, is 8,000 kilometers from London as the crow flies. Malawi faces a very different challenge: providing healthcare to its much younger, lower-income population. With fewer than four nurses or midwives per 10,000 people, the country has less than a tenth the number of health care workers suggested by the WHO to achieve even rudimentary health standards. Despite its growing population, Malawi doesn’t have enough nurses to provide basic health coverage. It faces a “deficit” of almost 60,000 healthcare workers that’s expected to increase.

Global Skills Partnerships for a win-win-win

Malawi and the UK have very different problems in keeping people healthy—but they may also share a common solution. Our colleague Michael Clemens has proposed a simple mechanism to target the skills deficit in the UK, tackle a shortage of health workers in Malawi, and leave Malawians much better off in the bargain.

A Global Skills Partnership (GSP) is a bilateral arrangement linking skill creation and skill mobility. The two countries participating in a Partnership craft a pre-migration agreement: targeting a specific skills gap, deciding how to allocate and finance training for potential migrants, and agreeing on employment terms and conditions for participants. (Healthcare is an obvious example because the needs are so great, but this could apply to a long list of occupations.)

An implementation of such a Partnership would leverage the UK’s impressive aid budget to invest in training and education centres for health workers—particularly nurses—in Malawi. Some of those nurses could choose to work in the UK for reasonable, extended periods, perhaps three to five years.

That raises the number of trained nurses in Malawi, a country that badly needs more health workers. It creates an opportunity for nurses from a lower-income country to dramatically improve their incomes and augment their skills by working overseas, boosting Malawi’s economy. It enhances incentives and resources for better education outcomes in Malawi by raising returns to education by raising future earnings. And it would enable the NHS to meet urgent needs in the UK.

Without an explicit bilateral agreement, there’s a perceived risk that all the benefits of an increased training and supply of nurses go to the UK, leaving Malawi worse off. A Global Skills Partnership addresses this concern so that benefits accrue to both sides. Here’s a summary of a GSP’s benefits:

Who benefits?
How do they benefit?
The UK
  • Trained workers to fill nursing shortage
  • Lower public training expenses
  • Planned limits on migration
NHS Trusts
  • Custom-trained nurses
  • Reduced training expenses
  • Facilitated recruitment
Malawian nurses
  • Professional employment opportunities
  • International-quality training
  • Access for low-income students
  • Large rise in earnings
  • Subsidised training for nurses
  • Greater supply of trained nurses
  • No fiscal drain from graduates’ migration
  • Stronger in-country training institutions
  • Remittances from nurses who migrated


Costs of the programme could be covered by the foreign aid budget. There’s political interest in spending money in ways that—directly or indirectly—benefit the British taxpayer. A bachelor’s degree nurse training programme costs in total about $100,000 in the UK or $2,000 in Malawi. Starting wages for nurses in the UK are about $27,000 per year or less than $600 per year in Malawi. It doesn’t take fancy maths to see the cost savings from training nurses in a developing country while benefiting from wages in a wealthier country: this is astonishing value for money for UK aid to increase the supply of nurses in both the UK and Malawi.

A(nother) good reason to fix bad rules

Because the Global Skills Partnership enables labour mobility that benefits everyone involved, it would also give us a chance to revisit UK immigration regulations that currently aim to restrict foreign workers and leave us all worse off.

Pressures to reduce migration have caused the rules for recruiting nurses from outside the European Economic Area to be tightened further. New hurdles have been introduced, like increasing the minimum salary and adding a £1,000 per year fee for every year of an international health worker’s visa.

Nursing is on the UK’s Shortage Occupation List, but recruiting non-EEA workers requires a Resident Labour Market Test to prove that the skills can’t be sourced locally—even though these skills are in short supply by the government’s own definition. All this red tape gums up an already expensive, time-consuming, and opaque process. More than two-thirds of targeted recruitment campaigns in EEA countries (places where workers wouldn’t need visas) have failed to attract the number of nurses hoped for.

Britain’s reconsideration of its relationship with the EU may have many pitfalls. But it is also an opportunity to rethink how aid is invested, revisit and fix broken labour, and recruitment policies—and to invest in innovations like Global Skills Partnerships that generate wealth overseas while plugging critical skills gaps at home.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.