Nursing Students Must Work 140 Days to Pay for a SINGLE Digital Textbook


A Case for Accessible Textbooks

 Textbooks are prohibitively expensive for students in developing countries. Here is one example: using a commonly purchased nursing text from a large textbook publisher and data from the World Bank, a Burundian student would have to work 140 days to earn enough money to purchase one digital textbook. American nursing students often work as Nursing assistants and are paid about $12 per hour. A US student would need to work 8 hours and 20 minutes to pay for the same book.

Using the same World Bank data, the cost of a digital textbook (the digital book used in the example was $100 USD on Amazon) in the USA is 0.17% of the average yearly US income. The same textbook would cost a Burundian 38.5% of the average yearly income of $260 USD

A Solution

After initial production costs, what is the cost to the publisher to reproduce a digital textbook? Almost nothing. Since the cost to reproduce digital goods is negligible, there is a business opportunity for publishers who make textbooks accessible to students in low-resource countries. When businesses intentionally price their products for the world’s poorest people it is called marketing to the Bottom of the Pyramid. The poorest in the world make up the greatest segment of the population and therefore need a great number of healthcare providers; many textbooks are needed to educate these nurses, more, in fact, than will ever be used in developed countries. Since so many books are needed and the cost to reproduce them is negligible a sliding scale pricing model based on each country’s GNI per capita makes sound business sense. Nursing students in resource-poor countries represent an untapped market for textbook publishers.

Even the poorest people in the world often have access to cheap cell phones on which digital books can be accessed. Per the World Bank, the world’s poorest people are more likely to have a cell phone than a toilet. It’s reasonable to expect nursing students to have access to a device on which to view a digital book.


There are a few reasons that publishers may be concerned about offering sliding scale pricing to low-resource countries. Publishers may be concerned about piracy when making their digital works available for reduced costs in undeveloped countries. Piracy is already happening. The textbook used in our example along with the corresponding workbook was easily available in pdf format with a quick google search. Software is available that protects digital content.

The music industry suffered a tremendous loss of revenue due to piracy but has recently seen the first rebound in years now that music is affordable and the barriers to purchase have been removed. What could the textbook publishing industry learn from the music industry?

Publishers may be concerned that textbooks in English are not desired, but we have found that many programs prefer that students be taught in English. Of course, translations into a student’s primary language are preferred, but it is necessary to take this one step at a time.

Finally, there may be a concern related to distribution and marketing. I have found that there is a tremendous demand for affordable nursing textbooks in developing parts of the world. Any offering would likely be quickly and widely accepted especially because many western nurse educators are actively helping in various nursing programs around the world. 

It makes the educators job much easier if he or she can simply use the same book they use when teaching their nursing students at their workplaces and then contextualize it when teaching internationally. Since one faculty member may choose a book for hundreds of students, marketing is targeted and efficient.

The Need for Commercial Textbooks

 The value of a solid textbook cannot be overstated. As I type this, I have within my field of vision my outdated textbooks from nursing school. Nurses often keep their textbooks, like old friends, with them for an entire career. Textbooks combine thousands of research studies, years of practice, and in most cases, the collaboration of many expert minds to produce condensed, reliable, and organized information for learners.

 Healthcare in developed countries like the US and the UK is often described to be in a state of crises. Imagine the state of healthcare in undeveloped countries. In some countries, healthcare providers are forced to use medicines that we only use in veterinary practice in the United States. If people cannot afford healthcare, they are literally kept prisoner in the hospital until the bill is paid. In one country where Nurses International partners, nurses receive a mere two weeks of training and are then labeled a nurse. In one country, where a contact was teaching, eighty students were given two biology texts to share. They were told, “We were unable to find an instructor for this course. Read the textbook, and we will be back in six weeks to administer the exam.” There is a major crisis and part of that crisis is a lack of education and education resources for nurses. How can nurses in under-resourced countries practice effectively with limited or no access to solid textbooks?

 In the USA and Canada, nurses and nurse practitioners are providing part of the answer to the healthcare crises. Multiple studies have shown that nurse practitioners are safe and effective in providing primary care. Well-educated nurses provide excellent healthcare. Building nursing capacity through providing educational resources and Technology-Enhanced Classrooms to nurses around the world is one way to address the healthcare crises and prevent needless suffering, but a major obstacle remains – lack of access to affordable textbooks for students in low-resource countries.

Why not find a free solution?

Textbooks for healthcare programs need frequent revision based on the newest science. It wouldn’t be best practice to create a nursing textbook once and use it forever. Therefore, a free version of a nursing textbook while desirable may not be sustainable without major funding for the initial creation and regular updates. Sometimes the best solution is not a free solution that will soon be outdated.

Materials Currently Available

Besides the latest works from major publishers, other sources for textbooks and teaching materials include the resources created and stored by the Carter Center and books from OpenStax. Old edition hard copies of texts can be purchased at a reduced cost, but they are expensive to ship and can be difficult to obtain in sufficient quantity. The HINARI website, an absolute goldmine of access to research, is available to students enrolled in approved nursing programs in low-resource countries, but volunteer faculty not residing in those countries often cannot obtain access to the same resources, creating yet another barrier. Articles and studies from open access sites across the internet such as the National Institutes of Health, Pub Med, and the World Health Organization round out the offerings commonly available to most faculty and students in low resource countries – that is when the internet is working.

Generous publishers have donated copies of digital books for some of the courses offered in Nurses International’s pilot project taking place in Burundi, Africa. Nurses International is incredibly grateful for these donations. In fact, members of the faculty always shed happy tears when they are gifted access to another book for our small cohort of 25 students who will make up our pilot program.

 As the CEO of Nurses International, I network with many different people doing international work. These nurse educators and their students are nothing less than heroic, accomplishing so much with so little. Nurse educators often teach without a textbook pulling directly from available research. Some of them have received the support of textbook publishers and some have not. One nursing program director in the Democratic Republic of the Congo makes do with textbooks from the 1970s and 1980s.

Who wants to be part of the solution?

Nurses International, a 501c3 organization, is developing a technology-enhanced classroom to be used by nursing programs in developing countries around the world. One of the biggest barriers to curriculum development is a lack of affordable textbooks and other educational resources for teachers and students. Nurses International cordially invites a discussion with publishers and other stakeholders regarding a long-term, sustainable solution to the lack of access to nursing textbooks. Nurses International believes that long-term solutions are based on sound business strategies that provide a great value to students in low-resource countries and opens new markets for publishers.

Nurses International has more than forty-five faculty members who are looking for affordable textbooks for the pilot project of our Technology-Enhanced Classroom in Burundi and later around the world. Do you want to partner with us?

Learn more about Nurses International: http://www.nursesinternational.org/

Donate: https://nursesinternational.nationbuilder.com/donate

Contact: miriamchickering@nursesinternational.org

CEO, Nurses International


Miriam Chickering






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