Our data analysis suggests that, when it comes to integration of IEHPs, there are a lot of similarities across the provinces studied. Despite some variations in procedures for the three professions, such issues as, lack of spots in bridging and integration programs (especially for IMGs); difficulties in navigating through the integration process, in obtaining information, and in finding an organization that can coordinate or consult about the process of integration; and finally, the time consuming and money draining nature of the process of integration, were raised by virtually all of the respondents.

At the same time, it should be noted that interprovincial differences exist across Canada and many IEHPs are well aware of that. As one of our ITM participants explained:

But, you know, as I say every province is so different that that's the same with Canada that I've learned since I've been here. Each province has its own way of doing things. It's not like a national, you know, it's not like a theme that runs through everything in Canada nationally. It seems to be each province is a rule unto themselves. So how effective that would be when things are so different in each province I'm not sure. I guess you'd have to kind of draw from each province on what their practice is and adapt once you know where the immigrants are going to, kind of be able to adapt that to the provincial culture rather than a national culture. [Manitoba ITM #1, practicing]

The majority of our respondents suggested that each province's culture is unique and that integration into Canada must be done by way of assimilation into a provincial culture.However, it is difficult to objectively qualify these cultural differences, and how they affect IEHP integration, particularly when the IEHPs in question have generally only applied to one province. We can, however, look at the effects of policy on the experiences of IEHPs in the four provinces. The most significant differences between the provinces under study were in the number of provincial programs that are available to IEHPS who wish to integrate and practice in their chosen profession. Whereas Ontario, for example, during the time of the interviews, reserved about 200 residency spots for IMGs, BC had only 18 residency positions available and other provinces had none. Ontario provides the greatest number of bridging opportunities for all IEHPs. However, IEHPs residing in Ontario did not feel that the provincial health authorities were willing to integrate them or that an effort was being made. This is probably due to large number of applicants and large numbers of IEHPs willing to attend those programs.

Many of the programs available in Ontario were not available in Manitoba. The small number of midwives residing and practicing in Manitoba, for example, means that there was insufficient demand to justify a program similar to IMMP for ITMs living in Manitoba. In addition, at the time of the interviews, there was no formal bridging program available for Manitoba IENs (this has more recently been resolved). Nevertheless, the openness with which regulators and health policy makers in Manitoba demonstrated in facilitating integration, was noted by many of the respondents. For instance, the Filipino Nurses Association worked with regulatory bodies to establish refresher courses and language courses for IENs and this initiative was met positively by the stakeholders. ITMs in Manitoba were also able to organize their efforts to push for a more unified assessment process and recieved a positive response from the authorities. They were not kept on the outside of the process, but participated in it, and were thus able to take credit for some of its success.

As mentioned above, shortages of health care personnel in all four provinces necessitate recruiting IEHPs from abroad. Respondents' experiences reflect the above policy findings that Manitoba appears to engage in recruitment more aggressively than the other provinces. Respondents in Manitoba note that the province not only invites IEHPs to practice their professions there, but also works hard to retain its own trained professionals and to recruit local nurses and physicians to work in rural and remote areas. Respondents generally believe that it is easier to immigrate to Manitoba than to Ontario and Manitoba IEHPs report making use of the Provincial Nominee Program. Moreover, respondents found that Manitoba has very welcoming websites and does direct recruitment for remote andrural areas. Although those same opportunities are available for people willing to move to Ontario, migration pathways are more clearly supported in Manitoba than elsewhere, and Manitoba was seen by our respondents as more welcoming than Ontario.

When comparing the situation for IEHPs in Québec to Manitoba and Ontario, the consensus among respondents from all three professions is that Québec is the least organized to welcome health professionals who are educated outside of Canada and had the least supportive integration initiatives when compared with the rest of the provinces under study. The support structure for these professionals simply does not exist, or is not readily available for those seeking licensing in Quebec. In general, the licensing processes for IMGs, IENs and ITMs is perceived as being longer, more stressful, and more costly in Quebec than elsewhere in Canada. Furthermore, there is far less assistance with exam preparation for IEHPs in any of the three professions in Quebec than in Ontario.

There was no consensus among our British Columbian respondents regarding the ease or rapidity of the immigration and licensing process there compared to the other Canadian provinces. Some argue that British Columbia is quite easy to migrate to, while others complain that it is more time-consuming to obtain a license there than elsewhere in Canada. For example, British Columbia was seen as welcoming to IENs and ITMs but less helpful in integration of IMGs. The opinions are reflective of initiatives set out by each profession individually, with midwifery and nursing being more organized to accept international professionals than medicine.

Finally, social networks and close proximity to ethnic and cultural communities also had a great impact on the process of integration. The support from social networks (or the lack of it) was perceived as crucial by the respondents. It was also often cited as the source for informal information from other IEHPs, which helped them to integrate more quickly and more successfully. Not surprisingly, the IEHPs who resided in the GTA and other Canadian metropolitan areas were more likely to receive such support than IEHPs who were living in more remote areas.

To summarize, British Columbia, Manitoba and Ontario had relatively similar requirements for obtaining licenses. However, IEHPs immigrating to each of these provinces had somewhat different integration experiences. The availability of bridging opportunities, the perceived willingness of health authorities to integrate IEHPs, and the availability of informal social networks made each province unique in its perceived willingness and readiness to accept IEHPs and integrate them into the local workforce. IEHPs both recognize and denounce some of these jurisdictional differences. They call for simpler, standardized and nationally based licensing requirements, so that they can share their precious skills and knowledge with the population, and so that they can choose where to live in Canada, based on factors other than whether or not they can work in their field of expertise in a particular province. Interestingly, the conference of Deputy Ministers of Health launched the Advisory Committee on Health delivery and Human Resources (ACHDHR) in 2002 began to address, among other issues, those of immigration and workforce needs. The ACHDHR came to the same conclusion as Canadian-based IEHPs and implemented the Pan-Canadian Health Human Resources planning initiative in an attempt to forward the notion of standardized and nationally based licensing requirements for internationally trained health workers; however their goals have yet to be realized. IEHPs still face great variance in licensing procedures and the existence of support structures established to assist them during their integration period. There appears to be no accountability either from province to province, or on a national level, giving IEHPs the impression that there are few structures in place to ensure fair treatment. If those provinces with successful integration programs could be held up as an example to those who lag behind in terms of established support structures for IEHPs, the lessons learned could be invaluable and have far reaching impacts for the health care system in Canada as a whole.