Before delving into the insights of respondents, it is helpful to look at a brief synopsis of what we know of the history and current situation of health professional migration in Canada and the key contextual issues that impact upon the integration of IEHPs in Canada. On the demand side, there has been a concern with shortages of health human resources presently and projected into the future. This is always acute in rural and remote locations and for some professions more than others (i.e., physicians and nurses). Added to this mix is the issue of interprovincial migration that causes the shortages to be felt more acutely in some provinces than in others. Certain sectors within nursing, for example, are also hard to fill. This has lead to an overall increase in demand on IEHPs, but more so in some jurisdictions and sectors than others. On the supply side, shifts in immigration policy have influenced the international make up of the health care workforce. This has become especially true most recently, with the use of the Provincial Nominee Program, a route by which many IEHPs are recruited to Canada, but this also affects those who come to Canada independently or to be reunited with family.

A Brief History of Migration & Health Human Resources in Canada

The ebb and flow of health professionals into Canada is a reflection of policy decisions and the broader policy context of health human resources. Prior to the 1970s, IEHPs were generally welcomed into Canada and made up a significant portion of the health workforce. Many nurses from Britain, particularly those with advanced training in midwifery, were recruited by Health Canada in the 1960s to serve in northern outposts (Mason 1988). Both tighter immigration policies and a change in Health and Welfare Canada policy in the early 1970s to one that required all pregnant women residing in isolated and under populated northern areas of Canada to travel to urban hospitals located in the south to deliver their babies, led to an overall reduction in the number of immigrant nurse-midwives practicing in rural and remote areas of Canada (Bourgeault & Benoit 2004). Unfortunately, unlike the case for medicine, we do not have demographic data readily available to describe these trends.

In the 1960s, there were more IMGs entering Canada than there were physicians being educated in Canada. While this influx dampened somewhat with the expansion of medical schools in the late 1960s and early 1970s, the downward trend in immigration of IMGs in the mid 1970s reflected projections of a surplus of physicians. The number of post-graduate training spaces was limited as a result, along with a number of other measures affecting Canada’s attractiveness to IMGs (CIHI 2003). For example, whereas prior to 1975, IMGs were granted the maximum 15 points for occupational demand, a change in policy that year meant that incoming physicians were assigned no points, virtually disqualifying an applicant who could not produce evidence of a concrete job offer (Roos et al. 1976). As a result, the number of immigrants claiming medicine as their intended occupation fell dramatically. These trends were consistent with the recommendations of the National Committee on Physician Manpower who wanted to focus on the goal of self-reliance for future physician needs (CMA 1999). The most significant measure to restrict IMGs was the reduction in the recruitment of visa trainees, which in Ontario dropped from 210 positions in 1990/1991 to 77 positions in 1993/1994 (Chan 2002). A retrenchment of numbers was paralleled by a narrowing of the definition of suitable source countries, as Grant (2004) states, “Since 1975, …admission …has been highly selective and largely restricted to the graduates of medical schools in former Commonwealth countries where academic standards are compatible with those in Canada. ” (p. 2)

Data compiled on nurses and IENs since 1980 reveals that the same decrease in numbers of IMGs in Canada can be observed for IENs from almost 10% in 1985 to 6.2% in 2000. Two main factors explain this decrease: 1) nursing, like medicine, was removed from the list which specified the employable trades and professions which were accepted into Canada; and 2) public health sector cutbacks during the 1990s had a significant effect on curbing the demand for nurses in general (Dumont et al. 2008). Indeed, many Canadian educated nurses migrated to the U.S. during this time period.

Health Workforce Shortage: the demand side

As fear of looming health workforce shortages began to take hold in the late 1990s the number of IEHPs licensed and practicing in Canada has been on the rise. Medical professional associations, working groups and others began to discuss a shortage of physicians. As Grant (2004) states, “After years of seeking to curtail the number of physicians, and foreign-trained physicians in particular, practicing in the country, there is growing support for the view of an impending shortage.” (p. 7). Similarly, the demographics of the Canadian nursing population indicate an increasing number eligible for retirement in 2006, which is further indication of the serious and impending nursing shortage in Canada (Shamian 2006). In 2005, the Canadian Association of Nursing (CAN) reported findings from a 2004 OECD study that showed that “Canada had the highest relative nursing shortage of the six countries examined, at 6.9 per cent of the present workforce.” (CNA 2005i:4). Various measures are being taken to counter the anticipated shortages of health care professionals in Canada.

Physicians:

There have been aggressive recruitment campaigns by educational facilities to enrol more medical students. Since 2003, British Columbia has doubled its enrolment into medical school from 128 to 256 in 2007. In Quebec, the rates rose from 450 in 1999 to 700 in 2007. In Ontario, they climbed from 532 in 1999 to 810 in 2007 (Dumont et al. 2008). Interprovincial differences in enrolment and graduation rates have had a direct impact on the number of IMGs licensed by that province. Interprovincial migration of health care workers tends to follow these trends: British Columbia continues to attract health care workers, as has Ontario, until most recently; Alberta has begun to benefit from interprovincial movement; while Manitoba is a net loser and Quebec tends to be relatively stable, largely because of the boundaries created by language (Dumont et al. 2008, p. 30).

Provinces that tend to lose more physicians through interprovincial migration tend to compensate by recruiting and licensing more IMGs (Ryan & Stuart 2007). For example, in 2008, Saskatchewan had the highest percentage of licensed IMGs in the country at 55%, and nearly 40% in Newfoundland and Labrador were trained abroad (see Figure 1). Rates in Ontario, Manitoba and B.C. all hover near the national average. In Quebec, only about 11% of physicians were internationally educated (CMA Masterfile 2008). Numerically, the majority of IMGs in Canada in 2008 worked in Ontario (5,904), followed by British Columbia (2,558), and Quebec (1,721); Manitoba had 687.

Figure 1: Percentage of IMGs by Province/Territory, Canada, 2008

*Note: Excludes residents and physicians over age 80; includes non-clinicians licensed to practice.
Source: CMA Masterfile, January 2008. Accessed at: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Statistics/09GradCountry.pdf

Another motivating factor for several provinces to recruit IMGs is the need to fill the dire shortages in their rural regions. Canadian trained physicians tend to remain in busier urban areas, and rural regions often have a difficult time attracting and retaining a sufficient health work force. CIHI statistics (2007) indicate that the highest provincial proportions of practicing IMGs are found in rural areas or very small urban regions. As an incentive for IMGs to live and work in these underserviced areas, some provinces provide an alternative, accelerated route to licensing for these professionals. This pathway is established under the guise of provisional licenses, whereby IMGs enter into an agreement to work in a “specific location for a fixed term” of between two and five years. The duration of the working term generally coincides with the time required in clinical practice before a physician qualifies for a permanent license. Once the term expires, IMGs are generally awarded full licensure and all restrictions on practice and location are then removed (Audas et al. 2005). Thus, the problem of under servicing is not resolved, but simply delayed (Dumont et al. 2008).

Provinces in Western Canada (British Columbia, Alberta, Manitoba and Saskatchewan) have implemented specific policies designed to attract and retain IMGs (as well as Canadian medical graduates) to small and rural communities, including specific financial incentives, thereby reducing turnover. In Saskatchewan and Manitoba, IMGs who move to rural regions are offered salaried employment, which is more suited to the type of practice found in those regions, rather than fee-for service payment. Manitoba also offers a 5%-10% higher pay scale for physicians working in rural and remote regions. A similar approach has been adopted in British Columbia for physicians working in specific northern and remote regions, but lump sum incentives are added to the increased pay scale (Fournier et al. 2004).

Nurses:

Studies have been conducted to assess the retention difficulties in nursing. The quality of work-life balance has been identified as a key issue. In 2001, absenteeism among RNs working full-time was 83% higher than in the general labour force (Dumont et al. 2008). Attempts are being made to address these issues, but in the meantime, there has been a heavy reliance on recruitment of IENs to fill in the nursing gaps in Canada. Recent demographic data on Canada’s nursing workforce confirms that Canada’s healthcare system reliance upon IENs has remained steady over the past twenty years and has increased slightly in recent years following the cutbacks of the mid 1990s (Figure 2).

Figure 2: Number of Internationally Educated RNs in Canada, 1980-2006

Source: CIHI. 2008. “Numbers of Internationally Trained Registered Nurses in Canada, 1980-2006.” excel file, edited by Lori Kirby. Ottawa: NDB/CIHI.

British Columbia has the highest proportion of IENs at 15% of all practicing nurses, followed by Ontario with 12%, and Manitoba with 7%. The proportions are only few percentage points lower in most other provinces but are below 1% in New Brunswick (Dumont et al. 2008).

Midwives:

The number of midwives remains small but is slowly increasing, and has actually doubled in the last decade. There were only 837 registered midwives in 2009, and only 744 of them were listed as practicing (CAM 2010). The proportion of registered midwives is unevenly distributed with 52% in Ontario (n=487), 20% in B.C. (n=184) and 15% in Quebec (n=139); there are about 44 practicing midwives in Manitoba (CAM 2010). This variation in distribution is due to several factors, including the timing of legislation, the funding of the profession and the number of training programs within each province (see Table 1).

Table 1: Status of Midwifery by Province/Territory (April 2010)

Source: CAM/ACSF (2010)

The entry-to-practice requirements for midwives across those provinces that regulate the practice are a direct-entry undergraduate degree or equivalent. This means that midwives need not have prior training in nursing to practice in Canada. The relatively recent integration of midwifery has also meant that there are only three relatively small university-based schools for midwives: one in Ontario, established in 1993, which graduates 30 to 40 midwives per year; one in Quebec, established in 1999, which graduated its first class of 12 in 2003, and one in B.C., established in 2001, which had its first graduating class of 10 in 2005.

While there are not yet enough midwives to fulfill the demand for their services in many provinces, there are more applicants to midwifery programs than can be accommodated by those programs. A case in point, in 2008-2009 the Ontario Consortium of Midwives received upwards of 650 applications for the 90 training spaces available (CAM 2009-b). To date, no recruitment efforts have been made internationally.

In sum, even though efforts to increase enrolment in health professional programs have been successful, there remains a lag in time before those professionals can practise, as well as uncertainty regarding whether or not the number of new graduates will be sufficient to fulfill the healthcare needs of the population. IEHPs can help to fill the gap more immediately. Most recently, the number and proportion of IENs working in Canada has risen by about 25% between 2002 and 2005. An increase in the number of IMGs admitted to residency positions has almost tripled from 369 in 2001-02 to 1065 in 2006-07 (CAPER 2007). International entrants to the midwifery profession have also been recently increasing. These professionals are recruited both the actively and passively.

Shifts in Immigration Policy: affecting the supply side

The change in Canadian immigration policy has impacted both the demographic and the professional make-up of newcomers (Kapur & McHale 2005). The demographics of Canadian immigrants have been slowly shifting from that of predominantly white Europeans to a greater multicultural mix. In the past decade, the vast majority of newcomers to Canada arrived from South Asia and the Pacific region (CIC 2008). In addition to this change, the introduction of the New Immigration and Refugee Protection Act in 2002 facilitated immigration of skilled professionals, allowing more internationally educated health professionals to enter Canada as immigrants (rather than on working visas) (Kapur & McHale 2005).

Federal, provincial, and territorial governments share responsibilities for immigration. This can pose organizational problems for provinces in need of certain professionals who do not have full responsibility for immigration policies. To gain some control over the recruitment of international workers, several provinces have implemented Provincial Nominee Programs (PNP): “The PNP gives provinces and territories the authority to nominate individuals as permanent residents, based on established criteria and assessment to fill regional or local economic needs.” (Dumont et al. 2008, p. 43). Several provinces (British Columbia, Saskatchewan, Manitoba, Ontario and Newfoundland and Labrador) target health care professionals via the PNPs. Alberta, through Citizenship and Immigration Canada (CIC), has implemented a pilot program to facilitate immigration for doctors and nurses currently awaiting admission into Canada. In fact, in June 2008, reforms were made at the federal level to the Immigration and Refugee Protection Act to accelerate the application process for skilled immigrants. These reforms include providing more detailed instructions to immigration officers about priority employment gaps to be filled by an immigrant workforce. (Dumont et al., 2008)

Another national level measure to address general worker shortages plays a role in the healthcare sector. The Temporary Foreign Worker Program (TFWP) is a tool which plays an increasingly significant role in filling the gaps in the health workforce. In 2006, Human Resources and Social Development Canada (HRSDC) added a Regional Occupations Under Pressure list to identify occupations that are facing labour market pressures.

For occupations found in these lists, employers are not required to undertake lengthy or comprehensive advertising efforts before being eligible to apply to hire foreign workers. Such lists have been established in Alberta, British Columbia, Manitoba, Nova Scotia, Ontario, Prince Edward Island and Quebec. All these regional lists have confirmed that there is a need for health professionals to address temporary labour and skill shortages. Specialist physicians and general practitioners are included in all of the lists and registered nurses are included in all but two (Nova Scotia and Prince Edward Island). (Dumont et al. 2008, p. 43-44)

Such targeted international recruitment, however, began to generate increasing controversy in the late 1990s spurred on in part by Nelson Mandela’s criticism of the U.K. for recruiting nurses from South Africa (Bach 2003), and of Canada by the South African Ambassador André Jaquet when he asked Canada's health ministers to stop the "targeted recruiting . . . that leaves us even less able to grapple with the serious HIV/AIDS pandemic." (Sullivan 2005). One example noted in the literature details how the recruitment of two South African anaesthetists by a Canadian hospital led to the closure of the Centre for Spinal Injuries in Boxburg, near Johannesburg, South Africa - a referral centre for the entire region (Martineau & Decker 2002). This did not go unnoticed by Canadian stakeholders. In the Final Report of the IMG Task Force (2004), it was noted:

It is wrong for Canada to actively recruit, or “poach” physicians from developing nations. Any active solicitation of physicians from countries that have a great need for physicians is troubling. Improving Canada’s lot, at the expense of healthcare delivery in countries who are less fortunate is not a Canadian healthcare policy goal (p. 4).

Similarly, while many nursing recruitment initiatives have existed in the various provinces across Canada for several years, the CNA recently made a policy statement on ethnical recruitment, emphasizing the need to make recruitment efforts in developed nations with sufficient health workforces and not actively recruit from developing nations who have health workforce shortages. The statement implies a move away from international recruitment and towards self-sufficiency:

CNA supports health human resources planning strategies that lead to self-sustainability in Canada. The active recruitment of IENs from developing countries is unethical, and CNA condemns this practice. CNA encourages governments, employers, recruiters and others to respect ethical recruitment practices (CNA 2009, p 2).

Thus, it is clear that Canadian HHR policy is intricately connected with the issue of the migration of health professionals, but these issues also have broader global implications.