Canada has both historically encouraged, and more recently relied on, internationally educated health professionals (IEHPs) to address shortages in rural and remote locations and hard to fill positions within its health care system. This has been true for medical and nursing labour, and only more recently, for midwives, due largely to our unique historical exclusion of midwifery from our formal health care division of labour. Throughout the 1970s, roughly a third of the physicians practicing in our health care system were international medical graduates (IMGs). Although this has dropped to 23% more recently, we still have a dependence on other countries to train the physicians that work here (Canadian Institute for Health Information, 2003). Canada relies on a smaller percentage of internationally educated nurses (IENs). Six to eight percent of all Registered Nurses in Canada are IENs. However, their numbers are sizeable, at over 22,000 in 2008, compared to nearly 16,000 IMGs. Due to the relatively recent integration of midwifery into various provincial health care systems (i.e., only since 1994), many practicing midwives are internationally educated, though the exact percentage of internationally trained midwives (ITMs) is unknown.

The profile of IEHPs coming to Canada has shifted over time. In the 1970s, the majority of IMGs came from English-speaking countries, such as Ireland or the United Kingdom. For example, in 1985, 35% of IMGs who entered Canada came from UK and Ireland, but this proportion has fallen to just over 5% in 2000. Now the primary source of IMGs is South Africa. South African IMGs accounted for 24% of those who entered Canada in 2000, up from 9% in 1985 (CIHI 2001). Similar educational systems and proficiency in English made the process of integration of these IMGs relatively simple: their credentials and training could be assessed according to Canadian standards and most were often fast-tracked. Nurses from the Philippines have been one of the primary sources of IENs in Canada, but nurses from the U.K. represent a close second (29 and 21% respectively) (Little 2005), with nurses from the U.S. (7%) and Hong Kong (6%) representing smaller groups. ITMs have been educated in a range of countries, but come to Canada from the U.K. and the U.S. in particular. Due the lack, until most recently, of local educational programs, many of these ITMs are Canadian citizens who have gone elsewhere for at least part of their training with the intention of coming back home to practice.

These numbers only reveal part of the story for IEHPs in Canada: the story of those who have successfully integrated into their profession. Increasingly, we hear of numerous accounts of IEHPs not being able to practice their profession. The barriers to practice for IEHPs – what some have labelled the 'brain waste' problem – have recently become a salient topic in the Canadian public arena. Nearly every month the print, radio or television media release a new story about IMGs who, instead of practicing in their field, are delivering pizzas or driving taxis. We even have television commercials that highlight this issue. What these stories typically ask is, 'why are highly skilled health professionals not being integrated at the same time as Canada seems to be experiencing a shortage of health personnel?' Media concerns have, however, become mirrored by policy makers at the federal and provincial levels and several initiatives to facilitate the process of integration of IEHPs have been developed (RCPSC 2006; Task Force 2005). These initiatives include: information portals available on the Internet for skilled immigrants to Canada, bridging programs run by the provincial governments, expansion of the number of residency positions accepting IMGs, and other programs designed to facilitate the integration of IEHPs (Bourgeault 2006).

Some researchers have identified one of the causes of this problem as the fact that there are "[c]omplex and interdependent actors in multiple jurisdictions with unaligned accountabilities. Governments do one thing, educational institutions do another, and regulatory authorities do a third" (Fooks 2004). As a result, we have not had (until recently) any nationally or provincially coordinated policy to address the integration of IEHPs. Others highlight how IEHPs are coming from a wider variety of nations making English language proficiency and credential equivalency key issues for health professional regulators tasked with the maintenance of high professional standards and the protection of the public. The absence of coordinated policy and programs in Canada to address the shifting demographic features of IEHPs is notable in light of the associated problems of lost labour and potential solutions to human resource crises, and also because of the increasingly salient ethical issues associated with the international migration or brain drain of highly skilled health workers (Buchan & Sochalski 2004; Mullan 2005; WHO 2005). Indeed, the ethical issues raised by the increasing migration of health care providers, particularly from developing countries, have moved to the forefront of not just health policy but also foreign policy agendas (Bach 2003).

This study was designed to fill some of the gaps in our knowledge by examining:

• the experiences of internationally educated physicians, nurses and midwives who were pursuing professional integration, who have achieved it and who have decided to redirect their efforts; and
• the barriers and facilitators they experienced along the way that they feel influenced their relative success at becoming integrated into provincial health care systems in Canada.

From the outset we decided to gather the perspectives of the IEHPs themselves. This was intended to supplement the policy recommendations that have been made through various stakeholder consultations. To date, there has been a great deal of media attention paid to the plight of IEHPs coming to Canada – and IMGs in particular (i.e., through newscasts and documentaries like The Big Wait (Osborne & Jackson 2010)). The issues that have come to the attention of various Canadian stakeholders may or may not be a true reflection of the IEHPs experiences of policy and programmatic disconnects. We borrow insights from the IEHPs lived experiences to offer another perspective on a) what the key problems are, and b) how to address these problems. This is not to say that recent policy changes have not been appropriately matched to the challenges faced. Indeed, in this report we highlight some of the most promising practices in this regard. We provide additional support for these practices and, through the words of our participants, we urge expansion of these initiatives.

The analysis took a comparative approach between professions. We found that although there is a growing mass of literature devoted to the migration of physicians and nurses, very little explicitly compares the situation across these two professions and even fewer look at the migration experiences of other health professionals, such as midwives. Comparative research of this nature allows us to contrast the process and outcomes of various models created to assist with immigration and integration across professions, and also helps identify key factors, such as gender, that influence the migration process.