Skills Research Initiative Initiative de recherche sur les compétences

Skills Research Initiative Initiative de recherche sur les compétences
Skills Research Initiative
Initiative de recherche sur les compétences
On the Move: The Migration of
Health Care Providers in Canada
Ivy Lynn Bourgeault (McMaster University)
Working Paper 2006 D-08
Human Resources and Social Development Canada/Ressources humaines et Développement social Canada
Industry Canada/Industrie Canada
Social Sciences and Humanities Research Council/Conseil de recherches en sciences humaines du Canada
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Acknowledgements
The author would like to acknowledge the assistance of Kim Matthews, Michelle Homer and
Judi Winkup on this research project.
1
Abstract
A key sector to examine the mobility of highly skilled workers is within the domain of health
care. The purpose of this pilot study/environmental scan was to: 1) examine the demographic
and policy contexts around the migration of physicians, nurses, midwives and psychologists into
and out of Canada using the provinces of Ontario, Manitoba and Quebec as referents; and 2)
begin to identify the gaps that exist between the policies of various institutions and regulatory
bodies to best match the supply and demand of skills and resources needed in our evolving
health care system. The methodological approach employed in this study involved first
examining the flow of physicians, nurses, midwives and psychologists into and out of Canada
through available datasets and published documents; and second linking these flows to the
policies of professional regulatory bodies and government departments (i.e., immigration, health,
human resources) at the national and provincial/state level through the analysis of key policy
documents and key informant interviews. Our findings highlight how the key health care
migration issue before us is not so much the emigration of health care providers which was
salient in the late 1990s, but the effective and efficient integration of the internationally educated
into the health care system. Indeed, we have better data on the inflow of some health care
providers into Canada than we do of the outflow. We also found that the ebb and flow of health
care providers into and out of Canada is due in large part to policy decisions and the broader
policy context of health human resources. Many of the most recent policies attempt to address
the key barriers experienced by internationally educated health care providers. Some of the key
partnerships that have emerged in the new programs to reduce barriers has been between the
various organizations involved - both government and professional - at the national and
provincial level. A key ethical debate that has emerged is whether we should be viewing
immigration as a solution to our skilled worker shortages or whether we should be attempting to
achieve self-sufficiency insofar as the number of health care providers in the country are
concerned. Because of Canada’s unique position of being both an importer as well as an
exporter of health care providers, it is imperative upon us to use this position to become a world
leader in ways in which to attend to the issues that both draw health care providers to our
country and away from it.
Résumé
L’un des secteurs clés où il convient d’examiner la question de la mobilité de la main-d’œuvre
hautement qualifiée est celui des soins de santé. Cette étude pilote ou analyse de
l’environnement avait pour but : 1) d’examiner les contextes démographique et politique
entourant la migration des médecins, des infirmières, des sages-femmes et des psychologues qui
entrent au Canada ou qui en sortent en utilisant les provinces de l’Ontario, du Manitoba et du
Québec comme références; 2) de commencer à cerner les écarts entre les politiques des divers
établissements et organismes de réglementation de manière à mieux jumeler l’offre et la
demande de main-d’œuvre spécialisée et de ressources nécessaires à notre système de soins de
santé en évolution. La méthodologie utilisée consistait tout d’abord à examiner les flux de
médecins, d’infirmières, de sages-femmes et de psychologues qui entrent au Canada ou qui en
sortent à partir des ensembles de données existants et des documents publiés; ensuite, nous avons
2
lié ces flux aux politiques des ordres professionnels et des ministères (p. ex. l’immigration, la
santé, les ressources humaines) à l’échelle de la nation, de la province ou de l’État grâce à
l’analyse d’importants documents stratégiques et d’entrevues auprès de personnes clés. Les
résultats de notre étude montrent que la question de la migration des soins de santé qui nous
préoccupe ne concerne pas tant l’émigration des fournisseurs de soins de santé, qui était
importante vers la fin des années 1990, mais l’intégration efficace et efficiente des personnes
instruites à l’étranger dans le système de soins de santé. Or, nous disposons de meilleures
données sur l’entrée de certains fournisseurs de soins de santé au Canada que sur leur sortie.
Nous avons aussi constaté que le flux et le reflux des fournisseurs de soins de santé à destination
et en provenance du Canada est, en grande partie, attribuable aux décisions stratégiques et au
contexte global des politiques en matière de ressources humaines de la santé. Bon nombre de
politiques récentes visent à lever les principaux obstacles auxquels sont confrontés les
fournisseurs de soins de santé instruits à l’étranger. Dans le cadre des nouveaux programmes
destinés à abolir ces obstacles, des partenariats ont été formés principalement entre les divers
organismes intéressés, gouvernementaux ou professionnels, à l’échelle nationale et provinciale.
Une question éthique se pose : devrait-on envisager l’immigration comme une solution à notre
pénurie de main-d’œuvre spécialisée ou devrait-on essayer d’atteindre l’autosuffisance en ce qui
a trait au nombre de fournisseurs de soins de santé au pays. Étant donné la position particulière
du Canada en tant qu’importateur et exportateur de fournisseurs de soins de santé, il importe au
plus haut point que nous profitions de cette position pour devenir un chef de file dans la manière
d’aborder les questions qui attirent au Canada les fournisseurs de soins de santé et celles qui les
en éloignent.
Table of Contents:
Page
Executive Summary
3
Abbreviations
5
1. Introduction
1.1
Research Objectives
1.2
Conceptual Framework
7
7
8
2. Methods
2.1
2.2
2.3
2.4
Selection of Provincial Cases
Documentary Data Collection
Interviews with Key Informants
Data Analysis
9
9
9
9
11
3. Key Findings
3. 1 The Demographic Context of Health Labour Immigration in Canada
Internationally Trained Physicians
Internationally Trained Nurses & Midwives
Internationally Trained Psychologists
3. 2 The Policy Context of Health Labour Immigration in Canada
The Process of Getting In
Barriers to Entry
Programs to Reduce Barriers
Underserved Areas
Ethical Considerations
3. 3
The Demographic Context of Health Labour Emigration in Canada
Physicians
Nurses
Midwives & Psychologists
3. 4 The Policy Context of Health Labour Immigration in Canada
Wages and Working Conditions
Trade Agreements
Return Migration
13
13
13
17
20
22
22
29
34
47
49
52
52
54
55
56
56
57
58
4. Concluding Comments
60
5. Future Research Directions
62
Appendices
64
Endnotes
74
3
Executive Summary
A key sector to examine the mobility of highly skilled workers is within the domain of health care.
While health-care workers have long been nationally and internationally mobile, there has been little
study of the policy or institutional response to their migration patterns particularly from a
comparative perspective. The purpose of this pilot study/environmental scan was to:
•
examine the demographic and policy contexts around the migration of physicians, nurses,
midwives and psychologists into and out of Canada using the provinces of Ontario,
Manitoba and Quebec as referents; and
•
begin to identify the gaps that exist between the policies of various institutions and
regulatory bodies to best match the supply and demand of skills and resources needed in our
evolving health care system.
The methodological approach employed in this study involved:
•
examining the flow of physicians, nurses, midwives and psychologists into and out of
Canada through available datasets and published documents; and
•
linking these flows to the policies of professional regulatory bodies and government
departments (i.e., immigration, health, human resources) at the national and provincial/state
level through the analysis of key policy documents and key informant interviews.
The Demographic & Policy Context of Health Labour Immigration to Canada
Internationally educated physicians, nurses, midwives and psychologists are a crucial component
of health human resources in Canada. For example, immigrant doctors account for roughly one
quarter of all physicians practicing in Canada and similarly, six percent of all nurses have been
trained in other jurisdictions. The source countries for internationally educated physicians, nurses,
midwives and psychologists differ across these cases and have also shifted over time. For example,
whereas physicians used to come from the U.K., the more likely source has recently been South
Africa. Internationally educated nurses largely come from the Phillipines but also from the U.K.
The demographic data available on midwives and psychologists is more variable making sound
comparisons with these groups difficult.
The ebb and flow of health care providers into and out of Canada is due in large part to policy
decisions and the broader policy context of health human resources. Many of the most recent
policies attempt to address the key barriers experienced by internationally educated health care
providers. Several barriers to internationally trained health care provider integration have been
noted in the literature, including:
•
Poor information available to prospective immigrants overseas;
•
Difficulty in having educational credentials recognized;
•
Navigating through the policies, practices and procedures for registration; and
•
The time and costs associated with being assessed.
An overarching criticism has been the many layers of organizations involved in the integration
process and the lack of communication across these stakeholders. In response to these concerns, one
of the key partnerships that has emerged in the new programs to reduce barriers has been between
4
these various organizations - both government and professional bodies both at the national and
provincial level. For example, the integration processes for medicine, nursing and midwifery have
with federal funds all moved towards a national based system of information and coordination.
The Demographic & Policy Context of Health Labour Emigration from Canada
Canada is both an importer as well as an exporter of health labour. Just as we have found
fluctuations in the volume and demographics of health care providers who migrate to Canada, we
find similar fluctuations in the number of providers leaving the country. We do, however, have
better data on the inflow of health care providers into Canada than we do of the outflow. Generally
speaking, across all professions the primary destination for those who leave is the United States largely for better pay and working conditions.
Similar to the case for immigration, what is also clear from these demographic trends is that various
health care and health human resource policy have an important influence. For example, many have
linked anger over health care cuts to the emigration of physicians and nurses in the mid 1990s.
Indeed, we know that the reasons cited by health care émigrés from Canada were primarily jobrelated, including job availability and satisfaction, and the amount of resources devoted to the health
care system. Trade agreements may help ease the flow but generally have not had as great an impact
as some would have thought. Very little is know about the factors affecting return migration of
health care providers who leave Canada though there are a few dedicated provincial ‘repatriation’
programs.
To summarize, the key health care migration issue before us is not so much the emigration of health
care providers which was salient in the late 1990s, but the effective and efficient integration of the
internationally educated into the health care system - that is a ‘brain waste’ rather than a ‘brain
drain’ issue. A related ethical issue of increasing international significance is whether we should
be viewing immigration as a solution to our skilled worker shortages or whether we should be
attempting to achieve self-sufficiency insofar as the number of health care providers in the country
are concerned. Moreover, if we direct our attention and our policies towards international migration
- as it seems to be we are determined to do - a related concern is regarding whether we should
actively recruit internationally trained health care providers (as has been the case) or simply focus
on better integrating those providers who are already here. This latter group is “a source of untapped
skilled workers and if not integrated into the Canadian labour force, represents a loss of human
capital” both to Canada and the country from which the provider came. Because of Canada’s unique
position of being both an importer as well as an exporter of health care providers, it is imperative
upon us to use this position to become a world leader in ways in which to attend to the issues that
both draw health care providers to our country and away from it. In both cases, a strong argument
can be made for better recruitment and retention strategies within Canada to stem the tide of those
leaving the health professions - not just for other countries, but altogether - and reducing the
necessity for us to go outside our borders to recruit.
5
Abbreviations
ACHDHR
AIPSO
APT
CAM
CaRMS
CAPE
CARE
CFNU
CFPC
CIC
CICIMG
CMA
CMM
CMO
CMQ
CMRC
CNA
CNO
COFM
CPA
CPO
CRNE
CRNM
CPSM
CPSO
DLI
EPPP
FCR
FMRAC
FTNs
GoFMS
HRSDC
IENs
IEN-DP
IMGs
IMPP
ITWI
LMCC
LPN
MAFTD
MCC
Advisory Committee on Health Delivery and Human Resources
Association of International Physicians & Surgeons of Ontario
Access to Professions and Trades (Ontario)
Canadian Association of Midwives
Canadian Resident Matching Service
Clinicians Assessment and Professional Enhancement (Manitoba)
Creating Access to Regulated Employment (Nurses, Ontario)
Canadian Federation of Nurses Unions
College of Family Physicians of Canada
Citizenship and Immigration Canada
Canadian Information Centre for International Medical Graduates
Canadian Medical Association
College of Midwives of Manitoba
College of Midwives of Ontario
Collège des médecins du Québec
Canadian Midwifery Regulator’s Consortium
Canadian Nurses Association
College of Nurses of Ontario
Council of Ontario Faculties of Medicine
Canadian Psychology Association
College of Psychologists of Ontario
Canadian Registered Nurse Examination
College of Registered Nurses of Manitoba
College of Physicians and Surgeons of Manitoba
College of Physicians and Surgeons of Ontario
Department of Labour and Immigration (Manitoba)
Examination for Professional Practice in Psychology
Foreign Credential Recognition program (HRSDC)
Federation of Medical Regulatory Authorities of Canada
Foreign Trained Nurses
Graduates of Foreign Medical Schools
Human Resources and Skills Development Canada
International Educated Nurses
Diagnostic Project for International Educated Nurses
International Medical Graduates
International Midwifery Pre-registration Program (Ontario)
Internationally Trained Workers Initiative (HRSDC)
Licentiate of the Medical Council of Canada
Licensed Practical Nurse
Manitoba Association of Foreign Trained Doctors
Medical Council of Canada
6
MCCEE
MCCQEI
MCCQEII
MICC
MLI
MLPIMG
MMH
MRCI
MSSS
NAS
OACCPP
OIIQ
OIMGP
OMCI
OMHLTC
OPAS
OPQ
ORA
OSCE
OSFQ
PAM
PLA
PLAR
PLEA
RCPSC
RM
RN
RPN
RSQ
SAEE
Medical Council of Canada Evaluating Exam
Medical Council of Canada Qualifying Exam I
Medical Council of Canada Qualifying Exam II
Ministère de l'Immigration et des Communautés Culturelles (Quebec)
Manitoba Labour and Immigration
Medical Licensure Program for International Medical Graduates (Manitoba)
Manitoba Ministry of Health
Ministère des Relations avec les citoyens et de l'Immigration (Québec)
Ministère de la Santé et des Services Sociaux (Québec)
National Assessment Strategy (Midwifery)
Ontario Association of Consultants, Counsellors, Psychometrists and
Psychotherapists
Ordre des infirmieres et infirmiers du Québec
Ontario International Medical Graduate Program
Ontario Ministry of Citzenship and Immigration
Ontario Ministry of Health and Long Term Care
Office for Partnerships for Advanced Skills (Ontario)
Ordre des psychologues du Québec
Ontario Regulators for Access
Objective Structured Clinical Exam
Ordre des sages femmes du Québec
Psychological Association of Manitoba
Prior Learning Assessment
Prior Learning Assessment and Recognition program (HRSDC)
Prior Learning and Experience Assessment
Royal College of Physicians and Surgeons of Canada
Registered Midwife
Registered Nurse
Registered Psychiatric Nurse
Recrutement Santé Québec
Self Assessment Evaluating Examination (MCC)
7
1. Introduction
A key sector to examine the mobility of highly skilled workers is within the domain of health care.
While health-care workers have long been nationally and internationally mobile, there has been little
study of the policy or institutional response to their migration patterns particularly from a
comparative perspective. An examination of the process and impact of current health care migration
trends is of critical importance because labour markets are becoming international in scope and
labour mobility under international trade agreements is often a requirement.1 This has increased
both the size and velocity of migration internationally. Moreover, concerns about the international
migration of health care providers have become a more prominent and controversial feature of health
sector analysis in recent years in light of severe staff and skill shortages in health systems of many
countries.2
While some have lamented about Canada’s health care “brain drain” 3 4 it is important to note that
we are not just an exporter of health labour, but a significant importer as well. For example,
immigrant doctors account for roughly one quarter of all physicians practicing in Canada and
similarly, six percent of all nurses have been trained in other jurisdictions.5 6 But although many
internationally educated health care providers get in, many do not. Some have claimed that this is
because immigration and professional regulatory policies have become more complex and with
greater disconnect between these institutions leaving a gap in matching available skills to
requirements. As one health care commentator has pointed out, 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.”7 This lack of
coordinated policy for health labour immigration (until most recently) has become much more
salient in the political landscape across Canada.
Further, although there is a growing literature devoted to the migration of nurses and physicians 8
very little compares the situation of these two professional groups. Doing so would better
enable analysts to tease apart the influences of various institutional forces – such as hospital
employment versus private practice – as well as gender influences on migration. Bringing into focus
the migration of other health care provider groups, such as midwives and psychologists,14 15 rarely
addressed in policy or in the literature could help expand the lens of comparison along gender and
institutional lines while at the same time addressing issues related to the prevailing human resource
crises in maternity and mental health care.16 Comparative research of this nature would also allow
us to contrast the process and outcomes of the various models created across professions to deal with
the issue of migration.
9 10 11 12 13
1.1
Research Objectives
The goals of this study was to:
•
examine the demographic and policy contexts around the migration of physicians, nurses,
midwives and psychologists into and out of Canada using the provinces of Ontario,
Manitoba and Quebec as referents; and
•
identify the gaps that exist between the endeavours of various institutions and regulatory
bodies to best match the supply and demand of skills and resources needed in our evolving
health care system.
8
1.2
Conceptual Framework
The analysis of the relationship between state policies and professional regulation of health care
immigration and emigration brings together two key levels of analysis – the meso (institutional) and
the macro (contextual):
•
We began our analysis at the MESO LEVEL, examining the strategies and policies of
professional associations and colleges, government departments (i.e., immigration, health,
human resources), professional regulatory bodies and recruitment agencies at the national
and provincial/state level through a combination of document analysis and key informant
interviews;
•
We then link this level of analysis to the MACRO LEVEL, examining the impact on health
labour migration of national and multinational trade agreements, immigration policy and the
health and social service needs in Canada. This was accomplished through a subsequent
search and analysis of contextual documents and interviews with relevant key informants to
help better situate the policies in the three provinces in a political, social, economic and
geographic context.
Both of these levels of analysis informed the other to ensure the most accurate understanding of the
interconnectedness of policies and the broader contexts under question. A visual depiction of this
conceptual framework of the policy influences on the migration of health care providers is provided
in Figure 1.1 (below).
Figure 1.1
Conceptual Framework of the Policy Influences on the Migration of Health
Care Providers
9
2. Methods
An exploratory, largely qualitative approach was employed in this environmental scan involving the
collection of documents and conduct of interviews with key informants influential in the policy and
regulatory decision-making process around the migration of health care providers into and out of
Canada.
2.1
Selection of Provincial Cases
Given that professional regulation in Canada is a provincial jurisdiction, it is important to have more
than one province from which to gather data with some variability in migration policy, practices and
experiences. The provinces of Ontario, Quebec and Manitoba were chosen as the provincial
referents for the comparative analysis in Canada because they represent variability as well as
comparability. There is variability in the policies around the integration of internationally educated
health care providers, variability with respect to immigration context, and comparability in terms
of all provinces having regulation for all four provider groups.
For each of the three provinces, data were collected through: 1) the acquisition of key policy
documents, position statements and commentaries from the various provider/stakeholder groups
(e.g., professional associations and colleges, government departments (i.e.., immigration), regulatory
bodies and recruitment agencies); and 2) interviews conducted with 31 key informants involved in
the health care migration policy decision-making community. Many of the documents and several
of the interviews focused on the national level and the relationship between the national and
provincial jurisdictions.
2.2
Documentary Data Collection
The data collection process began first with the collection of background documents and material
publicly available on various stakeholder websites (see Table 2.1 for target institutions and
organizations and Appendix 1 for list of relevant websites searched). These include publicly
available reports, proceedings from committee and task force meeting, memos and correspondence
between various stakeholder groups involved in the migration of health care providers. Information
garnered from the documents and websites helped to sketch out the context and dynamics within
Canada and within each province which were further fleshed out in the interview process. The
documents and website materials were also a critical source of information for the identification of
the most important key informants to be interviewed.
2.3
Interviews with Key Informants
Interviews were conducted with representatives from the various stakeholder groups in each of the
three provinces and federal/national key informants (see Table 2.1). Two additional interviews were
conducted with the director of a midwifery bridging program in Ontario and a representative of the
Association of International Physicians and Surgeons of Ontario. In selecting informants, care was
taken to ensure that a variety of perspectives are represented in the interview as well as the
documentary data. Interviews lasted on average 30 to 45 minutes and were with one exception taperecorded for subsequent transcription.
10
Table 2.1
Key Stakeholder Groups Identified for Documentary Data & Contacted for Interviews
Level
Organization/Agency
Federal Government
Agencies
•
•
•
Provincial Government
Agencies
Ontario
•
Ontario Ministry of Citzenship and Immigration (unable to set up interview)
•
Ontario Ministry of Health and Long Term Care (unable to set up interview)
Citizenship and Immigration Canada (unable to set up interview)
Human Resources and Skills Development Canada (n=2)
Health Canada (n=2)
Quebec
•
Ministère de l'Immigration et des Communautés Culturelles (n= 3)
•
Ministère de la Santé et des Services Sociaux (n= 1)
Manitoba
•
Manitoba Labour and Immigration (Referred to Ministry of Health)
•
Manitoba Ministry of Health (n= 4)
National Professional
Organizations
•
•
•
•
•
Medical Council of Canada (n= 1)
Royal College of Physicians and Surgeons of Canada (n= 1)
Canadian Nurses Association (n= 1)
Canadian Midwifery Regulators Consortium (n= 1)
Canadian Psychological Association (n=1)
Provincial Professional
Organizations
Ontario
•
•
•
•
College of Physicians and Surgeons of Ontario (n= 2)
College of Nurses of Ontario (n= 1)
College of Midwives of Ontario (n= 1)
College of Psychologists of Ontario (n= 1)
Quebec
•
•
•
•
Collège des médecins du Québec (n= 1)
Ordre des infirmieres et infirmiers du Quebec (n= 1)
Ordre des sages femmes du Quebec (n= 1)
Ordre des psychologues du Québec (n= 1)
Manitoba
•
College of Physicians and Surgeons of Manitoba (n= 1)
•
College of Registered Nurses of Manitoba (n= 1)
•
College of Midwives of Manitoba (n= 1)
•
The Psychological Association of Manitoba (declined)
The content of the interviews differed for each participant so that we could tap into their specific
area of knowledge and expertise and help fill the gaps left by the documentary analysis. Therefore,
the interview guides were more fully developed throughout the research and interview process but
a draft received full ethics approval with the McMaster Research Ethics Board (see Appendix 2 and
3 for Letter of Information and Consent forms). The interviews followed a loosely structured guide
to ensure that key issues were addressed but at the same time included several open-ended questions
that allowed for unanticipated information of critical importance to the research questions at hand
(see Appendix 4).I
I
The Letter of Information, Consent Form and the Semi-Structured Interview Guide were all translated into
French for the Quebec interviews.
11
Structured questions addressed the following key issues:
•
a description of the role of the key informant’s agency, institution or organization in this
process;
•
a description of the present state of affairs in terms of the migration of physicians, nurses,
midwives and psychologists (depending on the informant’s background);
•
a description of the various policies or other contextual influences;
•
the identification and description of the position of various stakeholder groups; and
•
identification of critical debates and disjunctures of policy.
These structured questions were modified depending on the feedback of participants throughout the
interviewing process. Unstructured questions (i.e., probes) were used to help obtain further depth
and completeness to participants' responses and to help identify relationships between responses.
2.4
Data Analysis
Data collected through the documents and the key informant interviews were analyzed
simultaneously via systematic, documented procedures of thematic and constant comparative
analysis. This involves a constant iterative process of going back and forth between documents and
interviews in producing a multifaceted description of the demographic and policy contexts in each
of the three cases. It began with the analysis of the documentary data collected to help frame the
context and to begin to identify the views of key stakeholders. Key segments from the documents
were excerpted and organized according to common themes that began to emerge from the data –
e.g., relationship between federal immigration policy and provincial health professional regulatory
policy, ethical issues arising from health care migration, etc. A preliminary coding scheme was
developed and subsequently applied to the remaining data gathered - interviews and subsequent
documents. Running lists of what is known and not known from the documentary analysis were
developed for each province and federally which informed the selection of key informants and the
questions they were asked. These draft descriptions of key policies, processes and perspectives were
then fleshed out with the key informant interview data.
Each taped interview with the exception of one was transcribed verbatim and prepared for analysis
using QSR-NUD*IST, a software program that assists in the management of the analysis of
qualitative data. Using this software program, codes from the preliminary scheme were applied to
segments of the interviews and analysed across the cases to assess the range of responses that exist
on particular issues. Some of the key themes that have emerged from the documentary analysis and
the interviews that we will be exploring further include the following:
•
regarding immigration to Canada
•
the issue of competency and equivalency with Canadian standards;
•
barriers to the process of gaining entry
•
discrepancies between policies at the national and provincial levels and
between government and professional bodies
•
programs to help streamline this process;
•
the relationship between immigration and the crisis of underserved areas
•
the ethical issues involved in the migration of health care providers to Canada.
12
•
regarding emigration away from Canada
•
the impact of local remuneration and working conditions;
•
trade agreements (e.g., NAFTA)
•
factors affecting return migration.
Relationships between themes and between the responses of different participants were then
identified. Key segments of the interviews were excerpted and merged into the draft documentary
analysis to both address existing gaps in what is known or to provide more clarification on existing
themes.
We begin our presentation of our preliminary findings first with a description of the demographic
context of health care provider immigration to Canada focusing on physicians, nurses, midwives and
psychologists followed by the policy context that exists federally and within each of our provincial
case studies. Our findings on the issue of health care providers emigration from Canada and that
policy context follows.
13
3. Key Findings
3.1
The Demographic Context of Health Labour Immigration in Canada
Canadian provinces have to a varying degree relied historically on foreign health labour to help
solve shortages in underserviced areas and in particular specialties.17 18 19 This has been true for
medical and nursing labour and to a lesser extent for the need for midwives (due largely to our
unique historical exclusion of midwifery from our formal health care division of labour). Little is
known of the historical impact of the immigration of clinical psychologists in helping to meet the
mental health care needs of Canadians. Similar to the case of midwives, this may be due to the lack
of direct funding for psychologists (i.e., in private practice) and thus their defacto exclusion from
the public health care division of labour (unless located in hospitals).
Internationally Trained Physicians in the Canadian Health Care System
Foreign medical labour is often referred to in the policy literature as international medical graduates
(IMGs). Though often considered a homogeneous group, IMGs are a varied group which include:
1) Canadians who pursue training elsewhere; 2) visa physicians who are recruited into Canada to
meet particular needs; 3) graduates who enter Canada as refugees or who otherwise meet
immigration requirements; and 4) visa trainees who enter Canada through postgraduate training
positions.20 The probability of achieving full registration status with a provincial licensing authority
varies dramatically across these categories and across provinces and territories (see Figure 3.1). For
example, the province of Quebec has the lowest percentage of IMGs whereas Saskatchewan has the
highest.21 Manitoba, for example, as well as Saskatchewan and Newfoundland have recruited
extensively in South Africa to meet the needs of their rural communities (Grant 2004).
Source: Derived from the CIHI (2002) Supply, Distribution and Migration of Canadian Physicians, 2002.
Throughout most of the 1970s, roughly one third of our physicians were IMGs but this has most
recently dropped to 23%.22 (see Figure 3.2). This downward trend reflect limits on the number of
post-graduate training spaces available as well as a number of other factors.23 For example, whereas
prior to 1975 physicians were granted the maximum 15 points for occupational demand, in 1975
incoming physicians were assigned no points virtually disqualifying an applicant who could not
produce evidence of a concrete job offer (Roos et al 1976). Indeed, as Grant (2004) states,
14
“Since 1975, Canadian immigration policy has been generally hostile to an inflow of physicians,
largely because additional physicians were seen as the major cause of the rapid increase in the cost
of maintaining Canada’s publicly funded health care system. Their admission, therefore, 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)24
As a result, the number of immigrants claiming medicine as their intended occupation fell
dramatically subsequent to these decisions in 1975. 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.25
Figure 3.2 IMGs as a Percentage of Active Canadian Physicians, 1969 to 1999
More recently, according to the CMA (2001), the number of IMGs recruited has increased quite
dramatically in recent years from 388 in 1993 to 790 in 1997.26 As Grant (2004) states,
“Part of the explanation for the recent increase in migration also rests with changes in Canada’s supply
of physician services. After years of seeking to curtail the number of physicians, and foreign-trained
physicians in particular, practising in the country, there is growing support for the view of an
impending shortage. Despite a relatively high and stable physician/population ratio ... , with an aging
population increasing the demand for medical services, and demographic changes in the physician
workforce (both in terms of aging and gender) resulting in a decline in the average hours worked by
physicians, talk of a “crisis” in Canada’s health care system is more frequent. ” (p. 7)27
The proliferation of temporary medical licenses to IMGs is just one indication, as argued by CMA
representatives, of the physician shortage in both family medicine and in particular specialties.28
15
Where are they coming from?
In terms of the source of immigrant physicians who end up working within the health care system,
they used to be mainly graduates of medical schools in the U.K. or Ireland. Specifically, in 1985
they were 35% of those who entered but this has fallen to just over 5% in 2000. Now the primary
source of IMGs who are working within the health care system are from South Africa and India,
with India being a notable source of specialists, and South Africa, of general/family practitioners
(many of whom are recruited into rural/remote areas) though this differs across provinces.29 For
example, South African physicians account for 24% of those who entered in 2000, up from under
9% in 1985.30 Interestingly, in 1998 only 3.3% of Canadian IMG physicians in active practice had
been trained in the United States, of which one-quarter had been trained in California or New York.
The relative importance of Eastern Europe as a source of IMGs has declined over this period, as
Western European countries have become a more significant source.31 Demographically, IMGs tend
to be older than Canadian-educated physicians (47 percent are age 55 or older, compared with 29
percent of all physicians) and a smaller proportion are female (22 percent versus 30 percent).32
16
Table 3.1 Immigrant Physicians to Canada & Destined for the Labour Force by Year of Arrival, 1986 to 2000
Destined for the Labour Force
All Immigrant Physicians
Year of
Arrival
From all
countries
From
S. Africa
% from
S. Africa
From all
countries
From
S. Africa
8
% from
S. Africa
1986
419
31
7.4
119
1990
450
38
8.4
163
28
17.2
1994
361
71
19.7
185
66
35.7
1998
306
39
12.7
186
38
20.4
2000
348
66
19.0
196
61
31.1
5781
817
14.1
2917
711
24.4
1986–2000
6.7
Source: Grant, H. From the Transvaal to the Prairies: the migration of South African physicians to Canada - Data Derived
from Citizenship and Immigration Canada (2001)
It is important to make some distinctions in the statistics presented here. First, there is a difference
between the proportion of IMGs in the country (depicted in Figures 3.3a & b) and those entering the
country (partially depicted in Table 3.1). Thus even the number of physicians emigrating to Canada
from the U.K. is in decline, they nevertheless still represent a sizeable proportion of IMGs in the
country. Moreover, it is important to emphasize that it is not necessarily the case that those entering
the country enter the health care system. Indeed, this difference is what has been highlighted by
many as one of the key policy problems in this sectors (see detailed discussion below). In terms of
the availability of demographic data, the latter number is tracked by CIHI therefore easier to find,
whereas the former is much more difficult to ascertain. The Association of International Physicians
and Surgeons of Ontario (AIPSO), for example, present the following statistics (see Figure 3.4)
based on their membership. These differs substantially from the data presented in Figure 3.3a & b
above.
Figure 3.4 Top Ten Countries of Origin of IMGs Wishing to Practice in Canada
17
To sum up thus far, there are clearly some dramatic changes occurring to the number and source of
IMGs immigrating to Canada. These fluctuations are due in large part to the changing policy
context, discussed more fully below, and the fluctuations in the supply and demand on physician
human resources in general (including our domestic training capacity). Similarly, changes have
occurred to the migration of nurses and midwives to Canada to which we now turn.
Internationally Trained Nurses & Midwives in the Canadian Health Care System
Many nurses from Britain, particularly those with advanced training in midwifery, were recruited
by Health Canada in the 1950s and 1960s to serve in northern outposts.33 Both tighter immigration
policies and a change in Health and Welfare Canada policy in the late 1960s and early 1970s
requiring all pregnant women residing in isolated and underpopulated northern areas of Canada
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.34
Unfortunately, unlike the case for medicine, we do not have readily available demographic data to
describe these trends.
More recently, the overall percentage of internationally educated nurses (IENs) has remained
relatively steady over the last five to ten years (see Table 3.2). Specifically, in 2003, 7.3% of all
nurses working in Canada were internationally trained up from 6.8% in 1999.35 There has, however,
been a slight increase in the recruitment of foreign trained nurses in some provinces and
territories—notably British Columbia (15.0%), Ontario (11.4%), Saskatchewan and the Northwest
Territories — in the face of impending shortages (see Table 3.3).
Table 3.2 Number and Percentage of IENs in Canada, 1990 to 2003
Year
# of IENs in Canada
% of RN population
1990
19,144
8.6%
1999
15,564
6.8%
2000
14,177
6.1%
2001
15,659
6.8%
2002
15,847
6.9%
17,633
7.3%
2003
(Sources: Little, 200536 and CIHI, 2000)
Where are they coming from?
Nurses from the Philippines have been one of the primary sources of immigrant nursing labour in
Canada (up to 26% of all IENs in 2003 from 23.5% in 1999) as it is elsewhere,37 but nurses from the
U.K. represent an equal proportion (albeit down to 26% in 2003 from 30.5% in 1999), with nurses
from the U.S. (7% in 2003 down from 9.4% in 1999), Hong Kong (6% in both 2003 and 1999) and
India (4.7% in 2003 and 4.3% in 1999) representing smaller groups (see Figure 3.5). In 2003,
nurses from the Phillipines, the U.K., and the U.S. represented 2.1%, 1.7%, and 0.5% of all RNs
employed in nursing in Canada.38
18
Table 3.3 RN Workforce by Location of Graduation and Province/Territory of Registration, Canada, 2003
Canadian-trained
Retained Graduates
N.L.
P.E.I.
N.S.
N.B.
Que.
Ont.
Man. Sask.
(percentage distribution)
97,8
97,9
97,7
98,8
97,5
88,5
94,1
Alta.
B.C.
Y.T.
N.W.T.
95,5
88,9
84,5
93,1
89,1
Nun.
85,7
Canada
91,8
93,0
69,0
77,6
85,9
95,7
80,8
83,8
81,4
61,6
55,6
0,0
11,1
0
80
Interprovincial Graduates
4,9
28,9
20,1
12,9
1,9
7,7
10,4
14,1
27,3
28,9
93,1
78,0
85,7
11,9
Canadian-trained (location
unknown)
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0,0
0
0
1,7
1,8
2,3
1,2
2,5
11,4
5,9
3,1
3,9
15,0
6,9
10,4
13,6
7,3
Philippines
0,3
0,0
0,2
*
0,6
2,9
2,6
0,6
1,9
4,7
*
2,2
*
2,0
United Kingdom
1,0
**
0,9
**
0,3
2,8
1,1
0,7
0,3
4,1
2,1
5,8
5,4
1,7
United States
0,2
1,0
0,6
0,5
0,1
0,9
0,7
0,5
0,0
0,7
*
*
*
0,5
Foreign-trained
India
*
0,0
*
0,0
<0.1
0,7
0,1
**
0,4
0,4
0,0
0,0
0
0,3
Hong Kong
0,0
0,0
*
0,0
<0.1
0,6
**
*
<0.1
1,5
0,0
0,0
0
0,4
Poland
0,0
0,0
0,0
0,0
<0.1
0,5
**
0,0
0,1
0,2
*
0,0
0
0,2
*
0,0
0,1
*
<0.1
0,1
0,1
0,2
0,3
0,6
1,7
*
3,1
0,2
0,2
*
0,5
0,2
1,4
2,9
0,9
1,1
0,8
2,8
*
*
3,5
1,9
Australia
Other Foreign
Not Stated
Total RN Workforce
Notes
0,5
0,3
0,0
<0.1
<0.1
0,1
0,0
1,3
7,2
0,5
0,0
0,5
0,8
0,9
100,0
100,0
100,0
100,0
100,0
100,0
100,0
100,0
100,0
100,0
100,
0
100,0
100
100,0
* Value suppressed in accordance with CIHI privacy policy; cell value is from 1 to 4
** Value suppressed to ensure confidentiality; cell value is 5 or greater
<0.1 Value is less than 0.05%; value is replaced to prevent displaying cells of 0.0 that are not true zero values
In addition to being disproportionately distributed across provinces, IENs from particular
jurisdictions also tend to “cluster” in one province or region of the country. This is likely to also be
the case for physicians. For example, as it was stated in the CIHI (2004) report,
“virtually all graduates from France that are now in Canada are located in Quebec, while Hong Kong
graduates locate primarily in Ontario or British Columbia, and virtually all graduates from Jamaica
are located in Ontario.” (p. 31)
In the case of Québec, for example, immigration had a barrier in place to prevent the entrance of
nurses until 2000 when this was lifted. Now, the provincial government agency, Recrutement Santé
Québec (RSQ - see discussion below) specifically goes to Switzerland, France and Belgium to entice
Québec nurses to return home.39
Figure 3.5 Percentage of IENs by Country of Graduation, Canada, 2003
19
Further, similar to what we found in the case of physicians, the percentage of IENs as per the
population of active nurses may mask some of the recent changes that are best captured by statistics
on new entrants. For example, in Ontario, we find that from 1999 to 2003, the number of IENs have
been on average 34% of the new registrants (see Figure 3.6). How long these new foreign trained
applicants stay in the country is difficult to track. Indeed, many key informants noted how Canada
may act as a sort of ‘weigh-station’ with the ultimate destination being the U.S. This has also been
noted to be the case for physicians, but again this is a trend that is difficult to track statistically.
Demographically, it has been found that IENs in the current workforce are, on average, more than
five years older than Canadian-trained nurses (49.4 years to 44.1 years in 2003).40 We also know that
immigrant nurses, particularly those of colour, occupy the lowest echelons of the profession if they
do manage to make it in.41 Indeed, it is common to find deskilling occurring simultaneously with
immigration and this trend is not unique to Canada (see more detailed discussion below).42
Although initially the migration of midwives was bound up with the migration of nurses - because
prior to the 1980s midwives were considered by many to be a specialty of nursing- their recent
integration into some provincial health care systems has taken a direct-entry approach. That is,
midwives need not have prior training in nursing in order to practice in Canada. Further, the
relatively recent integration of midwifery has also meant that there are only three small universitybased 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 200543). The newness of
these programs has dictated that almost all of the midwives practising in Canada prior to legislation
have been trained outside of the country. Others were trained informally which adds another layer
of complexity to the assessment of equivalency. This situation has also meant that there are few
practitioners from which statistics can be gathered and reported in a confidential fashion (There are
approximately 550 midwives across Canada (see Figure 3.7) but an estimated 50 to 60 are not in
active practice). Therefore, good demographic data of the nature available for medicine and nurses
20
As a case study, however, midwifery is important to examine in large part because of its newness,
its strong linkages to foreign training, its internationally unique baccalaureate entry to practice
requirement (in most countries, midwives are trained in vocational institutions or at the equivalent
of community college level), and its recent HRSDC-funded study to streamline the integration
process for foreign-trained midwives across the provinces where it is presently regulated (see
discussion below).
Internationally Trained Clinical Psychologists in the Canadian Health Care System
As noted at the outset, less is known about the immigration of other health care providers and this
is particularly the case for the clinical psychology profession. For example, data regarding foreign
versus Canadian training are not readily available through the CIHI databases. We do have data on
the number of psychologists by province (see Tables 3.4) and by population. We do not, however,
know is how many of these are practising clinical psychologists in the health care field.
Upon special request, the College of Psychologists of Ontario (CPO) prepared the following table
outlining the statistics of their members by the location of their graduate training (see Table 3.5).
Table 3.4 Number of Active Registered Psychologists by Province/Territory, 1993-2002
Source: CIHI (2004) Health Personnel Trends, 1993-2002. (p. 186)
21
From these data we can see that internationally educated psychologists (i.e., doctoral level) (18%)
and psychological associates (Master’s level) (14%) make up a sizeable proportion of the College
register of which U.S. training predominated (particularly for psychologists). These data, however,
do not indicate how many of these psychologists are Canadian or foreign-born. It is very likely that
students will seek training in the U.S. where there are a greater number of clinical psychology
programs.
Table 3.5 Statistics of Members of the College of Psychologists of Ontario by Graduate Training Institution
Location as of: October 12, 2005
Other
Ontario
Canadian
USA
Other
Total
C.Psych. AP*
1623
275
336
72
2306
C.Psych. (Sup)†
95
16
25
7
143
C.Psych. (Cand)‡
14
8
10
5
37
Total Psychologist
1732
299
371
84
2486
C.Psych. Assoc. AP
352
39
28
25
444
C.Psych. Assoc. (Sup)
21
5
3
7
36
C.Psych. Assoc. (Cand)
25
4
5
4
38
Total Psychological Associate
398
48
36
36
518
*
†
‡
Autonomous practice means registered for independent practice.
Supervised practice means members who have an acceptable degree in psychology, have been issued a certificate of
registration authorizing supervised practice and are completing the supervision and other requirements for registration
for autonomous practice.
Candidate means that the person has submitted an application but has not yet progressed any further in the registration
process.
Summary
In sum, what is clear in undertaking this comparative analysis of the demographic context of the
migration of internationally educated physicians, nurses, midwives and psychologists into Canada
is:
•
Internationally educated health care providers are a crucial component of these health human
resources. IMGs account for roughly one quarter of all physicians practicing in Canada and
similarly, six percent of all nurses have been trained in other jurisdictions.
•
The source countries for internationally educated physicians, nurses, midwives and
psychologists differ across cases and have also shifted over time. For example, the U.S. is
a prime source of internationally educated psychologists (as least as far as Ontario is
concerned) and is likely also the main source for Canadian midwives (though this is
anecdotal data at best) but not so for internationally educated nurses and physicians.
Moreover, whereas physicians used to come from the U.K., the more likely source has
recently been South Africa. IENs largely come from the Phillipines but also from the U.K.
•
There are clear differences in the availability of data on internationally educated physicians,
nurses, midwives and psychologists making sound comparisons difficult.
•
These demographic trends are influenced by various immigration and health human resource
policy. Less is known, however about how these trends and the policy influences compare
across professions. Recent policy changes remain to be fully examined in the case of
midwives and psychologists and greater attention to the collection of basic demographic
data.
22
3.2
The Policy Context of Health Labour Immigration in Canada
The ebb and flow of health care providers into and - as we shall see - out of Canada is due in large
part to policy decisions and the broader policy context of health human resources. In this section
we begin to map out the policy context in Canada regarding the following key immigration issues:
•
the process of gaining entry and the barriers to experienced by internationally educated
health care providers
•
the programs developed to reduce unnecessary barriers and to help streamline the
integration process;
•
the relationship between immigration and the crisis of underserved areas
•
the ethical issues involved in the migration of health care providers to Canada.
The Process of Getting In
The first step for most providers is the national system of immigration though for some this is the
next step following recruitment. Citizenship and Immigration Canada (CIC) officials assess
applicants using a point system. These points are awarded according to a social capital model that
includes the applicant’s age, language ability, whether prospective immigrants have arranged
employment in Canada, the type of work they intend to do here and their skills, qualifications and
experience in that area, and whether their occupation is in demand in the Canadian labour market.44
As noted above, physicians used to be penalized in the ‘points system’ but as of 2002 this situation
has changed.45 Presently, all four health care providers we studied are on the list of sought after
skilled professionals. This is, however, but one step in the integration process and one which often
sends mixed messages to applicants. For example, as Brouwer (1999) states,
Unless informed otherwise by a visa officer, many immigrants who are accepted as skilled workers
understandably mistake the federal government’s granting of ‘points’ for their occupation, education
and training as recognition and approval of their qualifications. These immigrants assume that they
then will be able to practise their profession or trade in Canada. In fact, however, the number of points
granted by a visa officer and the Department of Citizenship and Immigration has no bearing on an
individual’s ability to practise an occupation in Canada.46
Some of our key informants mentioned cases of health care providers ‘just showing up at the door’
of a provincial regulatory body without preparatory knowledge of the system of integration but these
cases are the exception. In the case of Quebec, Immigration Québec insists that immigrants who
work in regulated professions sign a document (two in the case of physicians) prior to immigrating
to Québec. This amounts to informed consent as they outline the meaning of a regulated profession,
the steps (briefly) to be able to work in the field, and that being admitted into Québec does not mean
that they will necessarily find employment nor be registered in their profession. This is done so that
newcomers are clear on the fact that access to the regulated professions is difficult requiring
considerable effort. Doctors must sign a second document that lists some of the steps required to
practice the profession in Québec.
Each of the professions we investigated in each of the provinces has unique features through which
internationally trained providers must navigate.
Getting into Medicine
There are six key steps to gain licensure to practice as a physician in Canada. The first step is proof
of completing an undergraduate medical degree (M.D.) program in an approved university listed in
23
either the International Medical Education Directory or the World Health Organization World
Directory of Medical Schools. Prior to 1993, there were two categories of IMGs, depending on
where they went to medical school. Category I IMGs had studied in the United States, Great Britain,
Ireland, Australia, New Zealand or South Africa. IMGs from any other country were category II and
thus had to take additional training.47 Milne (2003) details how,
In a pivotal legal case, called Bitonti, physicians from Italy, Romania, the Philippines and Russia who
had been unable to secure employment as physicians in BC, argued they were discriminated against
be the College of Physicians and Surgeons of British Columbia. Category I and II distinctions were
abandoned in 1993 and now all applicants for full registration must complete two years of
postgraduate training in Canada.
Next, IMGs must pass the Medical Council of Canada Evaluating Exam (MCCEE) in order to
demonstrate equivalent general medical knowledge and demonstrate English/French
language/communications proficiency. The third step often requires taking two to six more years
of postgraduate medical training (2 for Family Medicine and 4-6 for certain Specialties), of which
the number of places in such assessment/postgraduate training programs are limited, particularly for
IMGs. For example, according to the Canadian Resident Matching Service (CaRMS),
approximately 10% match to a program in part because with the exception of Quebec, IMGs are
only eligible to do so on the second round (IMGs are not eligible at all in the Ontario portion of
CaRMS; there is a separate program for IMGs in Ontario discussed below) (see Table 3.6).48
Table 3.6 Percentage Match Result for IMGs in CaRMS, 1995 to 2005 49
Year
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
International Medical Graduate Participation¹
629
657
625
496
387
294
231
205
208
236
240
Match Results
80
87
67
83
60
39
35
19
16
11
23
Percentage
12.7
13.2
10.7
16.7
15.5
13.3
15.2
9.3
8.0
4.6
9.6
Following this step, IMGs must pass a certification exam in either Family Medicine (through the
College of Family Physicians of Canada (CFPC)) or a Specialty (through the Royal College of
Physicians and Surgeons of Canada (RCPSC)) in order to be fully licensed.50
Exceptions have been made to these rules, however, such as in the case of hiring needed specialists
from abroad for urban hospital placements and fast-tracking the licensure of foreign medical
graduates to meet the needs of underserved areas (often through temporary VISAs and work permits
- see Figure 3.8). In some cases, specialists are permitted to take the certification exams without
additional postgraduate training through special assessments of equivalency of training by the
RCPSC.51
24
Figure 3.8 Percentage of IMGs Practicing with Provisional and Full Licences by Province
(source: Audas et al., 2005, CMAJ, p. 1315)
The fifth step involves passing the two part Medical Council of Canada (MCC) qualifying exam in
order to obtain an independent license to practice medicine in Canada (known as the Licentiate of
the Medical Council of Canada (LMCC), which is recognized by the 12 medical licensing authorities
in Canada). Together these exams cost over $3000 to take not to mention the costs of residency
training which is largely unpaid .52 The final step is registration with a provincial regulatory body
(such as the College of Physicians and Surgeons of Ontario (CPSO)).53
It has been found that on an individual basis many IMGs do as well as Canadian graduates on
qualifying examinations but as a group they do not. For example, of a group of 100 hypothetical
IMGs challenging the examinations for the first time, approximately 21% will have passed the three
levels whereas the success rate for Canadian medical graduates is approximately 95%. According
to the CMA,
This may be due to several factors, including the age (time from medical school until they challenge
the exam), language and cultural issues, and differences in the quality of the medical school training.
... Canada and the United States have a joint demanding accreditation process for their medical
schools. Few other countries have such a demanding and uniformly high standard of accreditation.
Many medical schools listed in the World Health Organization list of medical schools do not have a
review of programs or any form of vigorous accreditation.54
Some provinces, such as Ontario, offer recently immigrated IMGs who have become legal
permanent residents of the province a special training program in preparation for working as a
medical resident - The International Medical Graduate Ontario (IMGO) program (see discussion
below).55 The content and length of these programs vary from province to province.
Getting into Nursing
The process of getting into nursing as a IEN involves fewer steps than it does in medicine, but as
we shall see, these steps can put up equally effective barriers to integration. We focus here
specifically on obtaining the designation of Registered Nurse (RN) though some IENs will attempt
25
to gain entry and experience first through Licensed Practical Nurse (LPN) status. First, candidates
must apply for registration with their provincial/territorial regulatory bodies (and the application
process differs across provinces see Table 3.7II), have their credentials assessed (and some contact
an credential evaluation service for advice), and then they must pass the Canadian Registered Nurse
Examination (CRNE) or for Québec, l’examen professionnel de l’Ordre des infirmières et infirmiers
du Québec.56 This examination must be written in Canada or Quebec respectively. Many nurses
make applications to more than one province making accurate statistics of the total number of IEN
applicants in Canada difficult to assess (see Figure 3.9). Across all provinces, however, there have
been in some cases rather dramatic increases in the number of applications. In Quebec, for example,
whereas the OIIQ screened 105 application in 1998, the number in 2003 was 348.57
Table 3.7 Documentation Required for IEN Applicaitons by Province, 2004
Beyond the basic RN, applicants can seek certification in 14 nursing specialties through the CNA
and specialist nursing associations.58 Similar to provisionally licensed IMGs, an IEN may also come
to Canada to work under a temporary work visa for a period of one year while making applications
for permanent residency and registration in some provinces with the support of an employer.59 This
is made particularly easy if the country of the IENs’ education is governed under an international
trade agreement with Canada (such as NAFTA).
II
For example, as of January 1, 2005 all newly registered nurses in Ontario must have completed a four-year
university degree which will greatly impact upon IENs who have a diploma instead of a degree.
26
Getting into Midwifery
Midwives educated in other jurisdictions who wish to become registered in those provinces where
midwifery is regulated - Ontario, Quebec, B.C., Manitoba, Alberta and soon in the NWT - are
required to undergo an assessment of their previous education and experience to determine the
equivalence of their credentials for practice. This was initiated in Ontario, the first province to
regulate midwifery. The CMRC summarized the Prior Learning and Experience Assessment
(PLEA) process there as follows:
[The] PLEA included portfolio assessment, written exams, and a series of OSCEs [Objectively
Structured Clinical Examinations]. All successful candidates had to have a period of supervised
practice under the supervision of an experienced midwife. This period of supervision allowed for
additional assessment of competencies and provided support for addressing competency-gaps
identified in a candidate’s portfolio or examinations. In 1997-98, the second cycle of the program, the
in-depth portfolio assessment was dropped, mainly due to the time intensive nature of the assessment.
... After the 2001 PLEA cycle, the College decided to stop offering this particular process [and] ...
chose instead to pursue public funding that became available for a bridging program that could address
the obvious need for upgrading and education that had been identified in the earlier cycles of the
CMO’s PLEA. (p. 14-15)
Similiar PLEA processes have occurred in Québec between 1992 and 2002 and in Manitoba
beginning in 2003. Thus, each of the provinces that regulate midwifery run a semi-regular
assessment process that involves written exams, OSCEs and portfolios to a certain extent. It is only
in Ontario, however, that an educational upgrade component has been added (see description of
International Midwifery Preregistration Program (IMPP) below).
Getting into Clinical Psychology
Unlike for physicians, nurses and midwives, there is wide variation in the registration requirements
for clinical psychologists across Canada increasing the complexity of entry for those who are trained
outside of Canada and the U.S. (See Table 3.8).
27
Table 3.8 Requirements for Registration as a Psychologist by Province, 2002
Academic Entry
Requirements
Supervised
Experience
Examinations
BC
*Doc. (Indep.)
*Masters (P.Assoc. Indep.)
*Doc. (1 year pre-doc.)
*Masters (1 year post-masters internship
and 3 years supervised practice)
*EPPP 70%
*Written jurisprudence
Alberta
Masters (Indep.)
1 year (1600 hrs.) post- Masters
*EPPP 70%
*Oral
Saskatchewan
Masters (Indep.)
1 year (1600 hrs.) post- Masters
*EPPP 70%
*Oral
Yukon
No legislation governing
practice of psychology
Manitoba
*Doc. (Indep.)
*Masters (P Assoc.
Supervised)
*Doc. (1 pre- and 1 post- year)
*Masters (2 years post)
*EPPP Doc. 70%
Masters 65%
*Oral (both)
Ontario
*Doc (Indep.)
*Masters (P.Assoc. Indep.)
*Doc. (1 pre- and 1 post- year)
*Masters (4years post plus 1 year on
supervision register)
*EPPP 70%
*Oral jurisprudence
Quebec
Masters (Indep.)
none
*no EPPP
*no oral *Ethics
Newfoundland
Masters (Indep.)
(until 2001)
*Doc. (1 pre- and 1 post-year)
*Masters (2 years post)
*EPPP (pass score not set),
*no oral
NWT
Masters Degree in
Psychology from a Canadian
University
1 year (1600 hours) while on an Intern’s
Registry. Previous supervised experience
from another jurisdiction may be
considered.
An exam "MAY" be required
Nova Scotia
Masters(Indep.)
*Doc. (1 pre- and 1 post- year)
*Masters (6 years post)
*EPPP 70%
*Oral
PEI
*Doc.(Indep.)
*Masters(indep. in
inst/agency only)
*Doc. (1 pre and 1 post year)
*Masters (2 years post)
*EPPP scaled score of 500
*Oral
*Doc. (1 pre and 1 post year)
*Masters (4years post )
*EPPP 65%
*Oral
New Brunswick Masters(Indep.)
Source: CPA website: http://www.cpa.ca/licensing.html#For%20assessments%20of%20foreign%20degrees
With respect to the three provinces under investigation here, both Ontario and Manitoba make a
distinction between doctorally and master’s trained psychologists, whereas Quebec does not
(although according to our key informants, it is in the process of altering this level of
qualification).60 Both of these provinces also require the writing of the Examination for Professional
Practice in Psychology (EPPP) and an oral exam. The current fee for the EPPP in Manitoba is $US
375.00 and $CDN 300.00 for the oral exam. Manitoba does not, however, have a regulatory body
separate from its association (the Psychological Assn. of Manitoba (PAM)) as does Ontario (the
College of Psychologists of Ontario (CPO)) and Québec (Ordre des psychologues du Québec
(OPQ)). Each of these and the other provinces/territories has, however, signed a Mutual
Recognition Agreement61 effective July 1, 2003 which “evaluate[s] applicants seeking entry to the
profession on the core competencies as identified and agreed upon by the Parties, and establish the
28
equivalence of means to assess the competencies” (p.5). Consistent with the MRA, each province
must inform the other provinces of any changes it plans to make to its requirements for registration.III
Similar to the case for physicians, clinical psychologists are automatically eligible for registration
if they have a graduate degree from a program recognized by the Canadian Psychology Association
(CPA), the American Psychology Association (APA), or in the case of Ontario, a program of study
that is listed in Doctoral Psychology Programs Meeting Designation Criteria (ASPPB/National
Register), will satisfy this requirement. International candidates with a degree(s) from an institution
outside Canada or the United States are encouraged to arrange to have it evaluated to determine if
it is comparable in level to a degree from a Canadian university through the Comparative Education
Service (CES) of the University of Toronto. The CPO further asserts that,
“A degree that is not accepted by the College as a doctoral degree from a program of study with
content that is primarily psychological in nature cannot be augmented by the candidate, after having
obtained the degree, into the equivalent of a degree acceptable to the College. Therefore, in order to
become eligible for registration as a psychologist, as applicant must complete another doctoral degree
that is primarily psychological in nature as required in the Guidelines published by the College.”62
The issue of doctoral or master’s training is contentious, however, and those provinces that requires
doctoral level training to be designated as a independently practising psychologist (and to use the
protected title psychologist), such as Ontario, Manitoba, British Columbia and to a lesser extent
P.E.I., have created some difficulty for master’s trained psychologists from other provinces and
other countries. In Ontario, the Ontario Association of Consultants, Counsellors, Psychometrists
and Psychotherapists (OACCPP) has advocated for ...
“use of the world-wide standard for psychological training -- graduate training at a masters level or
equivalent. We reject the current Ontario practice of denying full recognition in title and practice to
psychologists whose academic training does not include a Ph.D. ”63
It is not known to what extent this has created barriers for entry to practice for foreign-trained
applicants and if so, for which groups in particular. We do, however, know that there are time
limits for applications. In the case of Manitoba, for example,
Candidates are expected to complete the required period of post-degree supervision and the EPPP
examination within two years of receiving their doctoral degree (for psychologist candidates) or
within four years of receiving their master’s degree (for psychological associate candidates). 64
III
The CPO and the PAM are also members of the ASPPB (Association of State and Provincial Psychology
Boards) Agreement of Reciprocity. U.S. members include Iowa, Kentucky, Maine, Missouri, Nevada,
Oklahoma, and Texas.
29
Barriers to the Entry of Internationally Trained Health Care Providers
Several barriers to internationally trained health care provider integration have been noted in the
literature dating back in some cases 15 years. Some of the key barriers highlighted by the Canadian
Midwifery Regulators Consortium (CMRC)65 from their review of several reports66 include the
following:
•
•
•
•
•
•
•
•
Poor information available to prospective immigrants overseas, especially with regards to
what they must do in order to legally practice their profession in Canada.
Difficulty in having educational credentials recognized due to, for example, difficulties in
getting official transcripts sent by institutions outside of Canada.
Difficulty in having professional experience gained outside of Canada recognized.
Absence of sufficient upgrading/bridging programs to assist newcomers to fill gaps in
knowledge or experience vis á vis professional expectations in Canada.
Need for improved orientation to Canadian workplace culture.
Lack of occupation-specific language training, especially at high levels.
Absence of or difficulty in accessing appeal processes.
Direct and indirect costs of assessment processes can be prohibitive. (p. 10-11)
Specific barriers experienced by IMGs noted in several of the documents we reviewed include that:
While some lack the required preparation, knowledge and skill, others have been unable to confirm
or demonstrate their skill levels due to tight workforce policies, limited access to assessment and/or
training opportunities and lack of support to understand the licensure requirements in Canada. (Report
of the Canadian Task Force on Licensure of International Medical Graduates, 2004, p. 1)
One of the key barriers is the above noted limitation in the number of residency training positions.67
This is a direct result of policy decisions to curb what was at that time considered to be a
physician surplus:
68 69
During the 1980s and early 1990s, studies predicting an oversupply of physicians resulted in policy
development designed to limit the supply of physicians. In Ontario, the first direct response to these
reports was the recommendation of the Joint Working Group on Graduates of Foreign Medical
Schools in 1986 to limit access for international physicians. The outcome was the implementation of
a restricted program for the integration of international physicians.70 (p. 1)
Ultimately the limits on residency positions lie with the provincial governments and many
informants echoed the following sentiments:
Because all physicians or virtually all doctors are paid for in one way or another either by Ministries
of Health or regions and because all training posts are controlled by Ministries of the provinces ... [so]
post graduate training is not open. It’s closed and it’s controlled by the ministries as another way to
deal with resource planning. Medical Informant 1
Even prior to the bottleneck the limited residency positions create, the Association of International
Physicians & Surgeons of Ontario (AIPSO) (2000) highlighted several barriers - in terms of time
and money - that the various exams IMGs must take prior to gaining licensure in Canada. First, it
expressed the view that taking the MCCEE is both redundant with the MCCQE1, it is also much
more expensive and should be eliminated and IMGs allowed to take the QE1 directly. The MCC,
however, argues strongly that the two exams test two very different forms of knowledge. Similar
30
to the methods employed by midwives and clinical psychologists, the AIPSO also feel that the
assessment of IMGs should be more oriented to a competency based system:
The emphasis should not be on the route taken to acquire a particular set of skills, but rather an
evaluation of those skills. There is a need for regulatory and licensing bodies to remain open to new
and innovative methods of comparing courses and training within a comparable and equitable scale.
The examination and training requirements which Canadian medical graduates must undergo need not
necessarily be the same for international medical graduates because the latter have already gone
through these processes in other jurisdictions. Rather, their competencies should be assessed, and if
there are areas identified that require further training, bridging programmes to meet those needs can
be undertaken. All international physicians and surgeons should not be required to begin their
integration into the health care system at the same point as new Canadian graduates. Developing
methods that are comparable to the peer assessments and quality assurance programs of licensed
physicians in Ontario is a more equitable and economical approach.71 (p. 5)
Such an approach would be based on the premise that IMGs have practical experience and the
objective should be to establish equivalence to Canadian standards. AIPSO also recommended that
in line with this that the residency and pre-residency programs should be replaced with a
professional orientation and clinical evaluation process. This is similar to what exists with the IMPP
for midwifery in Ontario discussed below.
With respect to IENs, they have a higher failure rate on their licensing exams (see Figure 3.10)
again similar to what was found for physicians. In Ontario, for example, the failure rate was found
to be 66 percent. What was particularly frustrating with this statistic is that some argue perhaps as
high as 70 percent of those applicants are excellent candidates with good formal education and
experience.72 Estimates of the costs of integration for IENs are in the range of almost $4000 when
the assessment process (~$220), English tests (~$320 – $500), licensure exams (~$440), criminal
records check (~$25), refresher books (~$2500), and their annual licensing fee (~$200) are
included.73
In the recently released report, Navigating To Become A Nurse In Canada (2005), the barriers to
integration of IENs were summarized as follows:
The first barrier confronting the immigrating IEN is locating the required information from
government departments and regulatory bodies. The system is fragmented and there appears to be a
lack of communication among and between the various players. Some of these problems have been
described in other studies of internationally educated professionals (Canadian Council of Professional
Engineers, 2003). There needs to be a concerted effort by all governments to improve communication
and coordinate departments.
The next challenge for IENs is navigating through the policies, practices and procedures for
licensure/registration. Canada has 25 regulatory bodies for some 300,000 nurses. While each of these
bodies has a similar general approach to assessment, there are some discrepancies and their assessment
may differ. The assessment process can be protracted and take months, even years, to complete. ...
Moreover, IENs may apply to more than one jurisdiction and/or to more than one nursing regulatory
body, resulting in duplication of effort. ... The approach to the integration of IENs into the workforce
is haphazard and problematic. Some provinces offer specific bridging programs for IENs but they are
not all similar in content, length or cost and only some incorporate language and communication
training.
31
Figure 3.10 RN IEN Applicants vs. First Time Writers & Passees
(Source: Little, 2005)
6000
5000
a p p lic a n ts
4000
firs t tim e
e x a m w rite rs
firs t tim e
exam p assees
3000
2000
1000
2003
2002
2001
2000
1999
1998
0
Moreover, as noted by Lisa Little, Chair of the Steering Committee of the IEN-DP,
There is widespread recognition that correcting the problems confronting IENs will require the cooperation of governments at all levels, regulatory bodies, unions, employers, government and
community agencies and that addressing these particular issues must be part of an overall strategy.
It was anticipated that due to the unique entry to practice requirements for Canadian midwives - a
baccalaureate degree - that this may increase the burden on internationally trained midwives who
are not university-trained.74 But because the various PLEA processes that provincial midwifery
regulators have established are based on core competencies rather than credentials, this is avoided
to a certain extent. Specific barriers identified in a recently conducted review of entrance to the
midwifery profession in Canada undertaken through the Canadian Midwifery Regulator’s
Consortium (CMRC) National Assessment Strategy (NAS)include:
•
•
•
•
•
•
•
•
Incorrect information being provided to foreign-educated midwives prior to their arrival in
Canada (e.g. via government websites or uninformed contacts in Canada)
Insufficient resources to offer midwifery-specific language tests in every jurisdiction. ...
Insufficient English and French language programs relevant in both content and level for
midwifery candidates.
Insufficient programs or mentoring to assist candidates in understanding the practice of midwifery in
Canada ...
Insufficient preparatory support for candidates in the assessment process ...
Lack of adequate bridging programs which candidates may be referred to once gaps in
competencies or education are identified in assessments.
Insufficient clinical refresher programs to refer candidates to when it is clear that they require
more current experience.
Insufficient intercultural/diversity training (and insufficient diversity) of staff, assessors,
examiners, evaluators, and supervisors which can lead to misunderstanding and frustrations
of all involved. ...
32
Many of the above issues may not be particularly unique to midwifery but the following are:
•
•
•
•
•
•
Small numbers of midwives available to be assessors, evaluators, examiners, supervisors, and
preceptors to be able to sustain assessment and bridging programs.
Lack of human and financial resources to maintain and revise examination materials as often
as this should be carried out.
Lack of human and financial resources and lack of an adequate number of midwifery
applicants for registration to be able to offer assessment processes more often and in a more
streamlined fashion (a common complaint is the length of time an assessment takes).
Expense of offering assessment must be largely passed onto candidates since midwifery
colleges are small with correspondingly small budgets and no way to offer assessment
without fees. ...
Lack of funded midwifery in Alberta and the fact that funding for midwifery positions in
Manitoba, Ontario and Québec may not meet the needs of a potential applicant (or may not
even be available), as well as limited funding to support supervision and the integration of
new foreign-educated midwives in British Columbia. ...
Difficulty in obtaining sufficient information about midwifery in other parts of the world to
effectively evaluate an applicant’s qualifications and experience. (p. 17-18)
One of the key barriers, however, seems to be the primary care model of practice where midwives
are not supervised but rather are the most responsible provider. This is quite unlike the systems of
midwifery care in many countries so is an issue with which some internationally trained midwives
must come to terms:
In the rest of the world most midwifery systems do not have midwives providing primary care. And
that is the biggest challenge we’ve been able to hone in on ... the biggest need to assist foreign trained
midwives ... it’s a paradigm shift, it’s, I mean the way you think is going to be different when you’re
a primary care giver. Midwifery Informant 1
We know little about the barriers in the case of clinical psychology, but according to our informants
these seem to be more salient between provinces than with other jurisdictions:
It’s an issue actually more within Canada than from outside of Canada ... In the U.S. I think just about
all the States with the exception of one or two, you have to have a doctorate to become licensed as a
psychologist. In Canada there’s quite a bit of variability between province to province to territory
about whether you need a doctoral or Masters degree. So ... ironically if you’re just migrating from
the States for example, and you have a doctorate the likelihood of you getting registered is probably
somewhat easier than it is from within Canada if you practice in a Masters level jurisdiction.
However, that’s what the mutual recognition agreement was intended to resolve, was to allow for
mobility within the country Psychology Informant 2
To sum up thus far, the process of being integrated into the Canadian health care system if you are
trained internationally as a physician, a nurse, a midwife or a psychologist is clearly complex and
costly. First, with respect to its complexity, a useful visual depiction is that proposed by The Centre
for Research and Education in Human Services (see Figure 3.11). This ‘Web of Stakeholders’
situates the internationally trained professional at the centre of a web of visible and less visible
stakeholders.
33
Figure 3.11 Web of Stakeholders involved in the Recognition of Internationally Trained Professionals in
Ontario
(© 2000 Centre for Research and Education in Human Services)
In f lu e n t ia l B a c k g r o u n d
S t a k e h o ld e r s
B e h in d - t h e - S c e n e s
S t a k e h o ld e r s
N a tio n a l
P r o fe s s i o n a l
O r g a n iz a tio n s
G e n e ra l P u b lic
P r o fe s s io n a l
A s s o c ia ti o n s
A c c e s s to P r o fe s s i o n s a n d
T r a d e s U n it ( P ro v in c ia l
G o v e r n m e n t)
M in is tr y o f T r a in in g
C o ll e g e s a n d
U n iv e r s itie s
( P r o v i n c ia l
G o v e r n m e n t)
V is ib le
S t a k e h o ld e r s
F o r e ig n - T ra i n e d
p r o fe s s io n a l s
E d u c a tio n a l
In s ti tu ti o n s
O c c u p a tio n a l
R e g u la to r y
B o d ie s
R e g u la ti n g M in i s tri e s
( P r o v i n c ia l G o v e r n m e n t)
I
n
f
l
u
e
n
c
e
P o t e n t ia l R e s o u r c e s :
M u n ic ip a l G o v e r n m e n t
H u m a n R ig h ts C o m m is s i o n
C o u r ts
H u m a n R e s o u rce s
D e v e lo p m e n t C a n a d a
( F e d e r a l G o v e r n m e n t)
E m p lo y e r s
E m b a s s ie s /
C o n s u la te s /
I m m ig r a ti o n
C i ti z e n s h ip a n d
I m m ig r a ti o n C a n a d a
( F e d e ra l G o v e r n m e n t)
S e r v ic e P r o v id e r s
A c a d e m ic
C r e d e n tia l
A ssessm ent
S e rv ic e s
G r o u p s o f fo re ig n tr a in e d
tr a d e s p e o p l e
F u n d e r s ( P r iv a te
a n d p u b lic )
M e d ia
C o a liti o n
o r g a n i z a tio n s
O CASI and
O n ta ri o N e tw o r k
P o liti c ia n s (F e d e r a l ,
P r o v in c i a l, M u n i c ip a l)
What is lacking from this web, however, is an acknowledgement of the relative power and autonomy
of organizations and structured interests, their interrelations and the broader federal/provincial
relations through which internationally educated health professions must navigate in Canada. A
revised web which expands upon our initial conceptual framework that better captures some of the
key (though not all) broader political and economic context factors including the relations between
various professional organizations and government agencies which are critical to examine in the case
of the integration of health professionals trained is depicted in Figure 3.12 below.
The barriers to timely and effective integration of internationally educated health care providers in
Canada is also costly to all involved - candidates, regulatory agencies and the society at large. As
Brouwer (1999) has argued:
According to a Price Waterhouse report commissioned by the Ontario government, failing to recognize
foreign academic credentials alone (not to mention foreign work experience) results in losses to the
Ontario economy due to:
increased costs to the welfare system and social services
losses to employers who are unable to find employees with the skills and abilities they
desperately require
costs associated with unnecessary retraining for foreign-trained individuals
the loss of potential revenue from foreign trained individuals who are unable to work and
contribute to the tax base and other parts of the economy [1998;iii].75
It is not surprising, therefore, that several programs have recently been employed to attend to these
difficulties.
34
Figure 3.12 Revised Web of Federal and Provincial Government and Structured Interests involved in the
Recognition of Internationally Trained Health Care Providers
Programs to Reduce Barriers to Integration of Internationally Trained Health Care Providers
One of the key criticisms preventing efficient integration of internationally trained health care
providers has been the many layers of organizations involved in the integration process and how
there can sometimes be little communication across these key stakeholders.76 Unintentional barriers
are also a result of regulatory bodies’ lack of adequate financial and human resources to develop and
maintain equitable and time sensitive assessment processes.77 In response to these concerns, one of
the key partnerships that has emerged in the new programs to reduce barriers has been between
government and professional bodies both at the national (i.e., through Health Canada and HRSDC
in particular) and the provincial level. This has resulted in a flurry of committees, task forces and
pilot projects set up in the past few years.
Government-Profession Partnerships at the National Level
Advisory Committee on Health Delivery and Human Resources
The Advisory Committee on Health Delivery and Human Resources (ACHDHR) is
federal/provincial/territorial committee reporting to the Conference of Deputy Ministers of Health
(CDM). One of the initiatives undertaken by the ADHDHR with respect to the integration of
internationally educated health providers was to identify foreign credential recognition as a priority
and as an initial step, it established a task force in June of 2002 to address the integration of IMGs
into the Canadian health care system. This followed upon the heels of a National Symposium on
IMGs held in Calgary in April of 2002 which included representation from governments and key
35
stakeholders in the medical community (see Table 3.9 for timeline). The goals of the IMG Task
Force was to:
...develop strategies to aid in the integration of qualified internationally trained physicians to the
Canadian physician workforce. The Task Force was asked to submit recommendations to the Advisory
Committee by September 2003 with a goal of reporting the recommendations to the Conference of
Deputy Ministers of Health in December 2003. (p. 6)
April
Table 3.9 Timeline of Recent Policy, Programs and Inquiries into the Issue of IMGs in Canada
2002
National Symposium on IMGs held in Calgary
June
2002
The Task Force on Licensure of International Medical Graduates was established with the
mandate to aid in the integration of qualified internationally trained physicians into the
Canadian physician workforce.
September
2003
The Task Force presented six recommendations to achieve this goal to the Advisory
Committee on Health Delivery and Human Resources.
October
2003
Transition Committee Developed Implementation Plan
December
2003
Task Force Recommendations approved by the Conference of Deputy Ministers
February
2004
Final Report of the Task Force
Summer 2004
International Medical Graduate Implementation Steering Committee established
March
2005
$75 million in funding over six years to address the recognition of internationally trained
health care providers announced in Federal Budget to Health Canada
The key recommendations of the Task Force include:
1.
2.
3.
Increase the capacity to assess and prepare IMGs for licensure.
Work toward standardization of licensure requirements.
Expand or develop supports/programs to assist IMGs with the licensure process and
requirements in Canada.
4.
Develop orientation programs to support faculty and physicians working with IMGs.
5.
Develop capacity to track and recruit IMGs.
6.
Develop a national research agenda, including evaluation of the IMG strategy. It would
include the evaluation of the IMG licensure recommendations and the impact of the strategy
on physician supply.
(Report of the Canadian Task Force on Licensure of International Medical Graduates, 2004, p. 1-2)
Most of these are in the process of being addressed largely through the recently announced funds
to Health Canada. Moreover, the ACHDHR viewed the work of the Task Force as a “successful
template” that could be used to address the integration of other internationally trained health care
providers:
The ACHDHR is considering the establishment of a task force to examine other health professionals
who have current or projected shortages, access to practice challenges, and are identified as priority
by the provinces and territories.
(http://www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/recru/internat-graduates-diplomes_e.html)
36
For example, more recently the ACHDHR held an inaugural Taskforce meeting on the recognition
of IENs in February 2004. Similar to the case in medicine, this was in response to an environmental
scan of current practices and policies with respect to IENs undertaken by the Canadian Nurses
Association with funds from HRSDC (see below). Shortly thereafter, the ACHDHR asked in
September 2004 that HRSDC bring together the key health professions who were identified as being
in short supply in many provinces and territories to begin the process of examining the issues
pertaining to the integration and recognition of internationally educated providers.
Foreign Credential Recognition Program
The Foreign Credential Recognition (FCR) program was established in 2003 within the HRSDC
Ministry as one of the key components of the governments broader Internationally Trained Workers
Initiative (ITWI). Its mandate is to provide:
... an integrated, comprehensive strategy in which over 14 federal departments work together to
address the barriers to working in Canada that internationally trained workers face.
http://www.hrsdc.gc.ca/en/cs/comm/hrsd/news/2005/050425bb.shtml
And the barriers they intend to address are not individual but systemic:
The goal is to try to achieve systemic change in terms our how we assess and recognize the credentials
and competencies that internationally educated folks bring with them when they come. And we’re
looking really to achieve systemic change on a pan-Canadian or a national basis so that we have
processes and systems in Canada that function with a degree of consistency from coast to coast.
Government Informant 1
In 2003 and 2004, the federal government provided a total of $68 million over six years to
implement the FCR program and fund the key activities aimed at improving FCR in Canada. Some
of the health care provider initiatives funded are listed below.
Further, the 2005 budget earmarked $75 million (through Health Canada in follow up to the Health
Accord the previous fall) to be spent over the next five years to accelerate and expand the
assessment and integration of internationally trained health professionals. So far these groups
include Pharmacy, Physiotherapy, Occupational Therapy, Medical Laboratory Technology and
Medical Radiation Technology (in addition to Medicine and Nursing) which they believe should
receive priority actions. Midwives are in the process of finding a way to get on this list. A sizeable
proportion of these funds are to be distributed to the provinces for initiatives that are presently being
negotiated.
In concert with these efforts of the ACHDHR and the FCR, there were a series of programs and
projects announced in 2004 and 2005 by federal government agencies including HRSDC, CIC and
Health Canada to address IMGs, IENs and to a lesser extent internationally trained midwives. The
issue of the effective integration of internationally educated clinical psychologists has received little
attention to date.
Medicine
In March 2004, HRSDC announced funds in the order of $341,050 for the Medical Council of
Canada (MCC - which contributed matching funds) for the Self-Assessment Tool project. The goal
37
of this project was to “create a self-assessment examination and associated delivery system to be
made available to foreign-trained medical graduates wishing to come to Canada to train or practice
in the field of medicine.” This is further elaborated on the MCC website78:
The Self Assessment Evaluating Examination (SAEE) is a multiple-choice question practice
examination and is intended for graduates of international medical schools wishing to test their level
of preparedness for the Medical Council of Canada's Evaluating Examination (MCCEE.)
The (SAEE) does not cover all of the material that is covered in the (MCCEE) and therefore is not
meant to take the place of the MCCEE. It is provided solely as a sample of the type and style of
multiple-choice questions that may be found in the (MCCEE) and is intended to be a study aid to help
participants prepare themselves for the (MCCEE).
Through the MCC website, IMGs can register for the SAEE online with the following provisions:
People who take the (SAEE) will be allowed four hours across a seven day period to complete
the examination. For results to be of the most use, however, it is suggested that the examination be
completed within 2½ hours. Upon completion, feedback will be e-mailed to participants consisting
of the number of questions answered correctly and a comparison to other (MCCEE) participants.
The issue of effective integration of IMGs has remained high on the policy agenda with an
announcement by Health Canada and CIC a little over one year later of a $75-million plan
implemented across 5 years to integrate “up to 1000 physicians, 800 nurses and 500 other health care
professionals who want to practise in Canada.”79 IMGs into the Canadian workforce. As it was
announced in the Canadian Medical Association Journal,
A National Credential Verification Agency, run by the Medical Council of Canada, would create both
a one-stop process to assess credentials and a national registry of graduates. Another $1.3 million
would help convert the council's evaluation exam [MCCEE] into electronic form to make it more
accessible. The Association of Faculties of Medicine of Canada would also receive $830 000 to create
a database to track all such graduates. Health Minister Ujjal Dosanjh also unveiled a Web site
(www.IMG-Canada.ca) to help immigrants prepare for medical licensing before they come to
Canada.80
This website is presently hosted by the AIPSO. As for the database, one of the key reasons behind
it, as explained by Dale Dauphinee of the MCC and co-chair of the IMG Task Force, is that it is not
known how many uncredentialed IMGs live in Canada:
The estimates is that it's probably hundreds, not thousands and thousands, but we don't actually have
an accurate estimate," he said. "That's one of the reasons why some of the things we're suggesting are
so important, is to be able to identify who they are.81
The implementation of many elements of this announcement would be through the provinces, given
that they are the ones that handle the regulatory process. As Health Minister Ujjal Dosanjh said,
The provinces and territories will determine the number of training positions based on their needs.
They will get money based on the number of people they integrate into the workforce from amongst
the medical professions.82
Nursing
In March, 2004 HRSDC (and specifically its FCR Program) also announced funds in the order of
$545,145 for the Diagnostic for the National Assessment of International Nurse Applicants project
38
by the Canadian Nurses Association (CNA). This diagnostic project (IEN-DP) was aimed at
“identifying and assessing the current practices and policies with respect to the licensing of
international applicants for each of the three regulated nursing groups [Registered Nurses (RNs),
Registered Psychiatric Nurses (RPNs) and Licensed Practical Nurses(LPNs)] and providing draft
recommendations for further action.” This was seen as a critical first step in the process of
understanding where systemic changes needed to be made to better integrate IENs into the Canadian
health care system:
In order to have a really good understanding of what needs to be done you really need to understand
what the situation is in advance. In the case of the physicians they did that on their own without any
funding from anybody. So they already had their diagnostic in place. ... nurses didn’t have as
complete a picture of what the labour market is in Canada for nursing particularly as it relates to
internationally educated nurses, as is necessary in order to have a good understanding of where are
the challenges, what are some of the barriers that need to be removed, and then how to go about doing
that. Government Informant 1
The report of this project, Navigating to Become a Nurse in Canada was released May 12, 2005
which according to its press release, “paints a disquieting picture of the experience internationally
educated nurses (IENs) face in integrating into the Canadian health system. The report shows that
language and culture remain two of the largest issues for IENs and makes several recommendations
that will make the process more efficient, coordinated and responsive to today’s realities.” Some
of the key recommendations included in the IEN-DP report are:
•
•
•
•
The establishment of a national assessment service to create an evidence-based standardized
approach to the assessment of IENs ...
The establishment of nationally standardized and flexible bridging programs to ensure IENs
have the competencies required to meet Canadian nursing standards. ...
The development of strategies to address the financial challenges incurred by IENs who
enroll in bridging programs.
The development of a central source of information such as a Web site specific to IENs to
access complete, clear and easily understood information related to immigration and nursing
licensure/registration.
Midwifery
In 2003, HRSDC (through it Prior Learning and Assessment and Recognition (PLAR) program)
provided over $300,000 over three years to fund the National Midwifery Assessment Strategy
(NAS) project through the Canadian Midwifery Regulator’s Consortium (CMRC - who also
provided support in-kind). As described in its Research Plan, the Consortium is
“the umbrella group of regulatory organizations in the five provinces where midwifery is currently
regulated: Québec (L’Ordre des sages-femmes du Québec), Ontario (College of Midwives of Ontario),
Manitoba (College of Midwives of Manitoba), Alberta (Midwifery Health Disciplines Committee, AB
Health and Wellness) and British Columbia (College of Midwives of British Columbia). The College
of Midwives of British Columbia is coordinating the project with the assistance and support of a
Steering Committee comprised of provincial representatives.” (precis, p. 5)
The overall goal of the project is to “determine an efficient, effective, and fair pan-Canadian strategy
for assessing internationally-educated midwives (IEMs) who wish to register to practice in a
Canadian province or territory.” Its specific aims are to:
39
• increase access by internationally educated midwives to the profession;
• build on the high degree of similarity in professional requirements and standards across the country
to create an efficacious inter-jurisdictional process;
• honour the unique aspects of midwifery in each province and territory; and
• support each regulator in carrying out its legislated responsibility to protect the public. (Report on
Focus Group with Midwifery Supervisors, July 2005, p. 3)
The project involves three phases, the first of which was undertaken from April 1, 2004 – March 31,
2005, withe the following key objectives:
•
•
•
•
Determining what assessment processes are being used by Canadian midwifery regulators;
Researching the midwifery competencies for safe practice in the five regulated provinces and
considering the possibilities for creating a national competency document;
Researching and analyzing promising assessment models, approaches and tools;
Determining the constraints and issues that must be considered in developing a national
assessment strategy.(precis, p.1)
Thus far the CMRC has:
•
•
•
•
approved a document entitled, Competencies for Canadian Midwives
approved the development of a pan-Canadian website for internationally educated applicants
approved the development of pan-Canadian expertise and a credential evaluation database
approved the recommendation that certain policies, procedures, forms, and criteria related
to the “portfolio assessment” process (application process), be analysed for the purpose of
creating standardization wherever possible (precis, p.1)
Government-Professional Partnerships at the Provincial Level
In addition to partnerships between relevant government agencies and national consortia of
provincial regulators), specific provinces have also undertaken similar partnerships of their own.
Given the demographic situation presented in the first section that highlights the overwhelming
burden of the integration of internationally trained health care providers in Ontario, it is not
surprising, therefore, that many of the provincially-based programs are found in that province. We
briefly describe some of those recently announced or implemented programs there followed by
programs in Manitoba and Quebec.
Ontario - General
Ontario has introduced several programs both specific to health care and about the integration of
internationally trained professions in general. Many of these emanate from the review it undertook
in the late 1980s on access to the professions and trades culminating in ACCESS! - the report of the
Task Force on Access to Professions and Trades in Ontario (1990). Following on the
recommendations of this report, an Access to Professions and Trades (APT) unit was established in
1995 initially within the Ministry of Training, Colleges and Universities but it has moved this past
summer (2005) to the Ministry of Citizenship and Immigration. Its mandate is to “Promote fair and
merit-based registration and employment practices for foreign-trained professionals and trades
people to enhance their social and economic contribution to the province”.83
The APT unit operates similarly to the federal FCR program providing funds to projects that further
its mandate (a few profession specific examples are described below):
The Access to Professions and Trades Initiative is based on the understanding that systemic solutions
are required to address the systemic barriers facing the internationally trained.
40
They target funds specifically to the following barriers: assessment of academic credentials and
skills; licensure and certification testing; language testing and training; supplementary education and
training; and the review and appeal of licensure and certification decisions. With assistance from
the APT unit a consortium of professional regulators in the province (including the CNO and the
CPSO), called Ontario Regulators for Access (ORA) has also been established to “help Ontario
regulatory bodies improve access by international candidates to self-regulated professions in Ontario
while maintaining standards for public safety.”84 It serves as a “catalyst for regulators to work
collaboratively on practical, proactive approaches and to benefit from each other’s experiences.
ORA also helps to foster collaborative partnerships with regulators and other players such as
educators, community groups, employers, and governments.”
More recently in January 2005, the Office for Partnerships for Advanced Skills (OPAS) received
funding from the provincial government to lead a project addressing the barriers facing foreigntrained professionals who require university upgrading:85
Initially OPAS will work with an advisory committee of representatives from Ryerson University,
University of Toronto, University of Windsor and York University. Together, they will research and
identify barriers, and then develop a call for proposal submissions by universities to address these
barriers. It is expected that this will lead to new practices that will more effectively integrate foreigntrained professionals into the Ontario university system. The project will be ongoing until March 2007.
(p.3)
This may have prove to have wide reaching implications for internationally trained health care
providers.
Ontario - Medicine
In 2004/05 The Ministry of Health and Long Term Care launched a new program to integrate IMGs
in Ontario called IMG Ontario (IMGO):
The IMGO integrates Ontario's current IMG programs while creating many new opportunities for
qualified IMGs to become licensed in Ontario. The system is administered through the Council of
Ontario Faculties of Medicine (COFM) and is a co-operative endeavour of COFM, the College of
Physicians and Surgeons of Ontario (CPSO) and the Ministry of Health and Long Term Care
(MOHLTC).86
The specific ways in which IMGO intends to streamline the assessment process for IMGs by
offering: 1) “an integrated, co-ordinated system for information, support, assessment, and training”
meaning that “IMG physicians now only need to apply to one office to access all of Ontario's IMG
opportunities, thereby reducing duplication of the application process to various programs;” and 2)
the opportunity for “IMG physicians who do not need full postgraduate training are able to access
advanced-level training positions, bringing them to practice in the shortest time possible.” It
provides approximately $26 million to expand the number of training and assessment positions from
65 to over 200 annually.87 As stated on the IMGO website,
By providing this significant financial support, the MOHLTC wants to ensure that a large percentage
of these IMGs are fully utilised in our healthcare system, especially in underserviced communities
where they are most needed.88
41
Included in this new package are also five-year Return-of-Service (ROS) agreements to help ensure
that IMG participants fill the need for physicians in communities considered underserviced by
MOHLTC (see further discussion below). As the website states,
Provided the 5-year ROS agreement is successfully completed with an underserviced community, the
investment paid for by the Government of Ontario is considered recovered.89
Ontario - Nursing
Provincial government funds addressing the issue of IENs has primarily gone into bridging
programs. In Ontario, this is specifically called, the Creating Access to Regulated Employment
(CARE) for Nurses bridge training program which was first announced by the Ontario government
in May 2001 as a partnership between the Ministry of Training, Colleges and Universities, St.
Michael's Hospital, Yee Hong Centre for Geriatric Care, Woodgreen Community Centre and
Kababayan Community Centre, with support from the Ontario College of Nurses and the Ontario
Ministry of Health and Long Term Care, Nursing Secretariat. Its results are expected to be as
follows:90
•
•
•
•
•
•
•
•
approximately 400 participants will have gone through the project.
provision of a sustainable program to approximately 200 participants annually
creation of prior learning assessment tools/processes leading to course exemptions or
advanced standing
new and adapted curriculum options to address gaps in skills and education
new and adapted processes, and curriculum and tools to address the 2005 baccalaureate
requirement for nurses and ensure program remains relevant
how-to process guide – a tested educational model and materials that are sufficiently flexible
to be adapted to other health care professions
contribution to the field of best practice approaches through dissemination of program and
approach to other stakeholders
contribution to the reduction in health human resource shortages, thus enhancing access to
and quality of patient care in Ontario
In April 2003, an additional investment of $475,000 the CARE program was announced to help
more than 100 IENs practise in Ontario.91 One of the related objectives of this new announcement
was “to prepare internationally trained nurses to meet the requirements for the new nursing
baccalaureate degree, which will be required in 2005 for everyone who wants to practise as a nurse
in Ontario.” At that point, the CARE program “has more than doubled the success rate for
internationally trained nurses writing the examination for registration to over 70 per cent from 33
per cent.”92IV
Ontario - Midwifery
The International Midwifery Pre-registration Program (IMPP) was established in 2002 through
financial support from the Access to Professions and Trades initiatives of the Ministry of Training,
Colleges and Universities. It is similar to the CARE program for nurses in that it is a bridging
program.
IV
See also http://www.care4nurses.org/
42
The IMPP can be characterized as an “enhanced PLEA” process, allowing international midwives to
have their skills assessed within a program that can include upgrading, with no supervision being
necessary upon graduation. It still involves written and objective structured clinical exams, and
candidates create portfolios which are used to identify weak areas. It also includes educational courses
and a clinical clerkship. It is offered at arm’s length from the regulatory college by Ryerson University
Continuing Education. 2004/05 will be the third cycle of IMPP.93
In 9 months, it specifically provides experiences internationally educated midwives, fluent in
English, who have practised midwifery within the past five years with an assessment of their skills,
information about midwifery practice in Ontario, clinical placements, mentoring and a final preregistration exam.94 The admission process to the program is described as very competitive and the
costs for participants in the 2005–2006 program is approximately $4,900.00, plus textbooks and
clinical equipment (approximately $500.00), plus possible relocation costs for the three- to fourmonth clinical clerkship program.
The results expected from this project include:95
•
•
•
•
a comprehensive process and sustainable program that will provide internationally trained
health-care professionals with the skills, knowledge and Canadian work experience necessary
to reach midwifery licensing standards in Ontario
the addition of approximately 25 qualified midwives annually to help address future
provincial health care needs
how-to process guide - a tested model and materials that are sufficiently flexible for
adaptation by other organizations and occupations
new or adapted curriculum: occupation-specific language supports, technical skills,
workplace/sector orientation
Interestingly enough, some of the initiatives undertaken by the IMPP may also be employed in the
assessment and bridging of IMGs. Because IMGs are a larger group than IEMs, this will not only
help to make such initiatives more financially viable for Ryerson’s continuing education department,
they will also increase their impact to other internationally trained health care providers.
Ontario - Psychology
As far as the documentary and key informant interview data suggests, there are no specific
government-profession partnership program for internationally trained psychologists in the province
of Ontario other than the initiatives undertaking by the overarching Access to Professions and
Trades Unit.
Manitoba - General
The provincial Department of Labour and Immigration (DLI) through its Settlement and Labour
Market Services Branch formulates policy and supports activities that facilitate immigrants' access
to the labour market. To date it has established partnerships with post-secondary institutions,
professional licensing bodies and others to “establish ways of recognizing the knowledge and
capabilities of highly skilled immigrants.”96 It has also established and funded a Prior Learning
Assessment (PLA) centre which is to ...
43
work with regulatory bodies to change the methods used to assess and accredit foreign-trained
professionals. The aim is to support the licensing bodies to ensure their assessments are
comprehensive, flexible and diagnostic. This may include credentials review, transfer of credit,
challenge/confirmatory examinations, demonstrations of skills/knowledge, portfolios and others.97
The DLI has also established a Credentials Recognition Program which “provides financial and
career counselling supports to assist immigrants with professional and/or technical backgrounds in
gaining recognition for education and work experience obtained outside of Canada.” (p. 2); an
Academic Credentials Assessment Service; employment services for immigrants; and manages the
Province’s PLAR strategy which involves three cornerstone activity areas:
increasing capacity in post-secondary institutions; expanding PLAR advisory services into the
communities ... ; and increasing PLAR activities in industry, including business, labour, regulatory
bodies, sector councils, other business organizations and Apprenticeship.98
Manitoba - Medical
From 1999 to 2001, the Settlement Branch of the DLI has provided funds to the Association of
Foreign Medical Graduates to:
... provide orientation/counselling to IMGs on licensure process; organise and co-ordinate enhanced
study sessions for exam preparation; co-ordinate the development and delivery of a series of lectures
on exam relevant topics by local practising physicians; provide opportunity for IMGs to attend
Continuing Medical Education lecture series offered by the Faculty of Medicine, [University of
Manitoba]; enhance their collection of study materials; and identify potential alternate careers for
IMGs for further research and program development.99
In 2001, Manitoba launched the first permanent program in Canada to assist in the integration of
IMGs called the Medical Licensure Program for International Medical Graduates (MLPIMG), a
partnership between Manitoba Health, the College of Physicians and Surgeons of Manitoba (CPSM)
and the University of Manitoba Faculty of Medicine. Its main intent is to increase the number of
primary care practitioners in rural areas in part requiring the IMG to gain sponsorship with a rural
regional health authority. Other qualifications for this program include that the:
... physicians must be Canadian citizens, have been living in Manitoba for at least one year, have
passed the MCCQEI, have a postgraduate position, and have completed a CAPE (Clinicians
Assessment and Professional Enhancement) assessment. The assessment takes three days. There is
no application fee but the assessment fee is $3500. The four components are multiple choice questions,
structured oral interview, therapeutics assessment, and clinical and communication skills evaluation.100
If the IMG passes the CAPE assessment satisfactorily, he or she may apply for conditional
registration with the CPSM. Further,
They will have up to 5 years to complete the Medical Council of Canada Qualifying Examinations and
seven years to obtain the Certificate of the College of Family Physicians of Canada (CCFP). During
that period the International Medical Graduate will practise in an underserviced area of the province
(as declared by the Minister of Health for the Province of Manitoba) with a medical practice advisor
who will provide support and guidance to the individual.101
44
If, however, the IMG does not pass the CAPE assessment, he or she, may be eligible for a training
program offered through the University of Manitoba Faculty of Medicine:
This individualized program is designed to enhance the physician’s previous training and address the
specific learning needs as identified in the assessment process. The enhanced training must be
completed within one year.102
It is intended that up to 12 IMGs will undergo the CAPE assessment per year and that ten training
upgrade positions will be made available through the University of Manitoba.103
The province also funds the delivery of Canadian Communications for Physicians Trained Abroad a 300-hour communication program for Physicians trained overseas wishing to re-enter their
profession in Manitoba. This is provided at no cost to participants but enrolment is limited to 18.
Priority is given to those candidates who have gone through the CAPE process. First offered in
2001-02, the programs have been offered numerous times with an average of 17 participants
completing each course.
Shortly following this initiative, the CPSM began in early 2003 to open “conditional registration to
IMGs from any country and standardizing the required qualifications.”104 As a result,
All IMGs will be eligible for conditional registration if they have either two years of post-graduate
medical education or one year of post-graduate education with three years of practise experience
within the past five years. This move aims to address human rights concerns and recognizes the
learning value of practise experience. This change will also create opportunities in Manitoba for IMGs
across Canada who until now did not qualify for conditional registration. These licensure changes aim
to address human rights concerns by opening conditional registration to foreign trained doctors from
any country and standardizing the required qualification.105
Most recently, the provincial government has established a physician resource coordination office
which will not only address immigration and recruitment but also retention issues.
Manitoba - Nursing
Although the Province of Manitoba has established a Nursing Recruitment and Retention Fund
(NRRF), the programs that it entails do not specifically target IENs. (see description below in
emigration policy section). The DLI is also exploring since 2004 a PLAR, bridging program and
a Language Support for Internationally Trained Nurses, but this is primarily for the College of
Licensed Practical Nurses of Manitoba.
Manitoba - Midwifery
As mentioned above, Manitoba has established a bridging and upgrading program for internationally
trained midwives with funding from the Settlement and Labour Market Services Branch of the DLI:
The project was developed after the Colleges refresher programs identified gaps in the training and
experience of foreign-trained midwives.106
45
At the time (2001) there were no other programs in place to help internationally trained midwives
gain the skills they need to gain recognition in the province. As noted above the CMM is fully
involved with the CMRC NAS process. A new school of midwifery, initially open only to
Aboriginal students, is also set to be established soon.
Manitoba - Psychology
As far as the documentary evidence suggests, there is no government-profession partnership
program for internationally trained psychologists in the province of Manitoba. Indeed, our
informants told us that “because it’s a private practice issue ... our provincial government’s ability
to track and monitor what they’re doing in private practice around recruitment and retention is much
more limited.” Government Informant 1
Quebec - General
Similar to the APT unit in Ontario, the Ministère de l'Immigration et des Communautés Culturelles
(MICC) established the Groupe de travail sur l’accès aux professions et métiers réglementés (Task
Force on Access to Regulated Trades and Professions) with the mandate to “outline the difficulties
involved in recognizing competencies and training, and to propose solutions to eliminate some of
these problems.” Consultations were initiated in September 2004 as described below:
To initiate discussion, a consultation document [Les personnes immigrantes formées à l’étranger et
l’accès aux professions et métiers réglementés] was prepared by the Groupe de travail and distributed
in September 2004 to nearly 1,500 affected organizations: regulatory bodies, teaching institutions,
immigrant’s aid organizations, professional associations, and representatives of employers and unions.
These stakeholders were asked to submit reports to the Groupe de travail . Forty-seven briefs were
duly submitted to the Groupe de travail . These ... reports outlined the issues and constraints involved
in prior learning assessment and recognition, as well as tools or projects developed to remove certain
obstacles and explore various solutions. The people of Québec were also invited to send the Groupe
de travail their personal experiences, comments, or suggestions, and some fifty individuals responded.
... The Groupe de travail also met with some thirty concerned organizations. ... The Groupe de travail
also consulted with an eight-person committee of professionals of immigrant origin who have been
through the process of assessment and recognition of prior learning and are now involved in
organizations operating within their cultural communities or individuals working within organizations
familiar with immigrant professionals. 107(p.4)
It released its final report in February 2005 with several recommendations including improving
information on accessing regulated professions and trades; improving the PLAR process; providing
more opportunities for bridge training (including professional immersion and mentoring); and
offering financial assistance to immigrants groing through the PLAR process. Overseeing these
recommendations the Groupe de travail also recommended the establishment of:
... a permanent interdepartmental coordination committee bringing together deputy ministers
concerned by the question of access to regulated trades and professions, and headed by the MICC.
This committee’s mandate would be to ensure coherence and continuity of government action on
access to regulated trades and professions and follow up on the Groupe de travail recommendations
chosen for implementation.(p. 6)
46
Overall, the Groupe concluded that:
...the time to act is now. Immigration is vital to Québec’s future growth, but Québec will face everincreasing competition in attracting qualified immigrants. If obstacles to the recognition of experience
and training are not overcome, it will be harder for Québec to attract qualified workers. The prior
learning assessment and recognition process, while respecting the principle of the protection of the
public, must be as fair, transparent, and expeditious as possible, and these principles of fairness,
transparency, and celerity must apply to all regulated trades and professions. (p. 16)
In addition to the recommendations of the Groupe , the MICC has a strategic plan to accelerate the
social and employment integration of immigrants and members of visible minorities. It is
specifically pursuing: the acceleration and personalization of the integration process; the facilitation
of the recognition of skills acquired abroad through exchanges with professional orders and
educational institutions in order to find concrete solutions to the problem of recognition of
credentials; and the encouragement of businesses and public organizations to welcome and retain
a diverse labour force.108
Quebec - Medicine
In 2003, the Collège des médecins du Québec participated in a working group constituted by the
MRCI to find ways in which to better prepare IMGs (outside Canada and United States - diplômés
hors du Canada et des États-Unis DHCEU) for their OSCEs (l’examen clinique objectif structuré
(ECOS)). Several key solutions emerged from this working group including preparatory workshops
and improved access to the libraries of the faculties of medicine faculties. The success rate for these
examinations have increased from 27% in 2002 to more than 50% in 2004 for the candidates who
have participated in the workshops.
In 2002, the Collège also collaborated with the MRCI to set up an information service on the
regulated professions (le Service d’information sur les professions réglementées - SIPR). The SIPR
currently offers IMGs all pertinent information concerning the steps to take to secure a restrictive
permit to practice medicine in Quebec. The Collège ensures that the information is up-to-date.
Since its development, the SIPR has helped close to 450 IMGs progress through the regulatory
system in Quebec.
The Collège also collaborates with the Ministry of Health and Social Services (MSSS) through its
Recrutement Santé Québec (RSQ), to recruit physicians outside of professorial positions and assist
them in preparing a dossier to present to the Collège with the objective of obtaining a restrictive
permit to practise. Again, the Collège ensures that the RSQ has pertinent and up-to-date information
about the requirements for an application for a restrictive permit.
Quebec - Nursing
Similar to Manitoba, there is not much in the way of sponsored partnerships between Quebec
government agencies and the nursing profession with respect to IENs that we could find. We do
know that a background in nursing science either at the university or post-secondary level is
considered to be ‘favoured training’ by the MICC in Quebec, and RSQ actively recruits nurses from
other francophone countries (see above) but strangely enough nurses are not on the list of
“occupations in demand’. Further in the OIIQ’s submission to the Groupe de travail, they called
47
for just such a partnership with the Ministère des Relations avec les citoyens et de l'Immigration
(MRCI) with the intention of developing a targeted recruitment strategy and a coordinated effort
amongst stakeholders.
Quebec - Midwifery & Psychology
Partnerships between government agencies and professional orders in Quebec in the case of
midwifery and clinical psychology were not apparent in the documentary and website data or in the
key informant interviews we undertook. The argument seems to be that these two professions are
not in high demand in the province.
Summary
In sum, there have been numerous task forces, working groups and joint government-profession
committees that have been established to examine the barriers to the integration of internationally
educated health care providers and an almost equal number of programs established to address these
barriers. Generally speaking, we know a great deal about the barriers experienced by physicians and
nurses, and are starting to learn what these are for midwives. Less is known about the barriers for
clinical psychologists, but it likely they are not all that different from other health care providers.
Perhaps related to this, funding for projects and programs have also tended to address the issues
raised by the medical, nursing and midwifery professions (albeit the latter to a lesser extent).
One of the key recommendations across all professions is the importance of a single portal of
information made available to internationally trained health care providers wishing to immigrate to
Canada:
So there’s that aspect of it the people just sort of arriving. And that’s why there was a lot of emphasis
put on a portal for information and trying to think of accreditation or integration processes and trying
to get as much of this done off shore before they come. And then that needs to involve the provincial
Ministries cause they’re then the ones that know what they need. And if they need more training, the
provincial Ministries have to pay for it. Medical Informant 1
Similarly, the IEN report highlighted the importance of a “central source of information ... or
centralized body to engage in the screening of all IEN applicants.” The focus groups conducted for
the CMRC National Assessment Strategy also suggested:
A recommendation proposed and linked to the national approach was to establish a central list of
international educational institutions that are recognized or accredited by the midwifery regulatory
organizations. This would reduce the amount of time and resources each provincial regulatory
organization would require to investigate the educational institution. (Report on Focus Group of
Internationally Educated Midwives, March 2005, p. 16)
To date, some action has been taken towards this kind of centralization thus easing the integration
process with the help of a great deal of public funds.
A couple of key issues, however, are either lingering beneath the surface - such as whether
integrating internationally trained health care providers will ease the burden of underserviced areas or is increasing in salience - such as the ethical considerations involved in the recruitment and
integration of internationally trained health care providers on the countries from which they came.
48
Does Migration Help Solve the Problem of Underserved Areas?
One of the questions that arises from the policies directed towards the integration of internationally
trained health care providers is whether they indeed help to solve the problem of underserved areas.
With respect to physicians, the use of IMGs as a long-term policy solution to the shortages of
physicians in particular areas is considered by many to be questionable. Indeed, there is evidence
to show that IMGs are no more likely to practice in rural or remote regions of Canada than Canadian
graduates.109 For example, Barer and Webber (1999) argue that,
“While it is commonly assumed that a large proportion of physicians practicing in non-urban areas
of the country are IMGs, in fact in 1998 only about 26% of those practicing outside census
metropolitan areas were IMGs. This was not appreciably different than the overall ratio of IMGs to
all practicing physicians in Canada.” [personal communication, Lynda Buske, Canadian Medical
Association, April 1999].
Those that do immigrant health care providers usually only remain in rural areas under some form
of coercive intervention, after which they often ‘leak’ into the overall geographically unrestricted
Canadian physician supply.110 As Grant (2004) states,
“The difficulty arises from the tendency of many immigrant physicians, originally recruited by one
province to address a shortage of physician services in remote and rural communities, to relocate to
larger urban centres in another province. For some Canadian provinces, struggling to keep the
burgeoning cost of their public health system in check, more physicians, from South Africa or
elsewhere, in already over served areas is an unwelcome prospect. ” (p. 2)111
Evidence also shows that the likelihood of IMGs emigrating to the US is comparable to Canadian
graduates.112 It will be interesting to see if the Return-of-Service agreements that are part of IMGO
and the MLPIMG will yield similar results.
The proportion of IENs in rural areas has also been found to be relatively low:
Only 5.6% of the foreign-trained RNs in Canada work in rural and small town areas of the country
compared with 18.7% of Canadian-trained RNs; only 1.9% of rural RNs in Canada are international
nursing graduates. These numbers likely reflect overall immigrant settlement patterns or trends for
Canada as a whole. If so, recruitment of foreign-trained nurses would probably have little impact on
the numbers of RNs in rural Canada.113
It is not readily apparent from the review of documents regarding the integration of IENs whether
the issue of rural, underserved areas is salient. This absence is also apparent in the midwifery and
clinical psychology documents. Conversely, some have argued that nursing shortages are also acute
in major urban centres, such as in the case of Montreal, which is where many internationally trained
nurses are recruited to work.
49
Ethical Issues: International Migration or Self-Sufficiency?
The contributions of IMGs to healthcare in Canada have been great. Canada remains an appealing,
safe place in which to live and work. Canada will continue to be attractive for healthcare professionals
trained overseas. While focused recruitment from abroad will continue, such recruitment is not without
important ethical constraints as there is a worldwide shortage of heathcare professionals, including
physicians. 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. (Final Report of Task Force on IMGs, 2004, p. 4)
One of the key ethical questions that arises from this issue - and one that has become increasingly
salient to all stakeholders involved - is whether we should be viewing immigration as a solution to
our skilled worker shortages or whether we should be attempting to achieve self-sufficiency insofar
as the number of health care providers in the country are concerned.
International migration is commonly viewed as exacerbating shortages in source countries,
particularly in African countries where the WHO has stated that the “shortage and migration of
nurses and midwives continues to threaten the performance of health systems.”114 Indeed,
international recruitment began to generate increasing controversy in 2001, when South African
Ambassador André Jaquet asked Canada's health ministers to stop the "targeted recruiting . . . that
leaves us even less able to grapple with the serious HIV/AIDS pandemic."115 V Just one example
noted in the literature details how when two South African anaesthetists were recruited by a
Canadian institution to open a new Spinal Injuries Unit, the same day the Centre for Spinal Injuries
in Boxburg, near Johannesburg, South Africa - the referral centre for the whole region - was closed
and has not been open since.116
This has not gone unnoticed by the CMA. Its current president, Albert Schumacher, stated before
a House of Commons committee in March 2005: "To continue to rely on and recruit IMGs in this
way is both unsustainable and unethical, and we must overcome our reliance on them, particularly
the active poaching from countries that can least afford it."117 Schumacher argued instead for a
“made-in-Canada solution” by being self-sufficient in meeting its need for physicians. Echoing
these sentiments, CMA past president Peter Barrett stated at the most recent CMA annual meeting
in Edmonton (2005),
In the face of a global shortage of health care workers, he asked, can a country in which 24% of
practising doctors were educated outside its own borders continue to rely on physicians from countries
that can least afford to lose them?118
As aptly summarized in the Final Report of the Task Force on IMGs:
To date, there has been no national consensus on the merits or meaning of physician self-sufficiency
for Canada. This lack of consensus has contributed to a national physician workforce planning
process that remains challenged to comprehensively address the health professional needs of the
Canadian public. (p. 3)
The self-sufficiency issue has also been raised in the case of nursing. For example, in a recent
presentation for an international conference on the global migration of nurses, IEN-DP Chair, Lisa
V
Approximately 2,000 graduates of its medical schools practise here.
50
Little argued that we need more domestic production of nurses; better retention strategies to improve
the quality of work life for nurses, such as increasing their autonomy and decision-making powers,
reducing violence expresses towards nurses, and employing appropriate workloads.119
The key informants we interviews in Québec all stressed that they are trying to meet their healthcare
labour needs self-sufficiently through such initiatives as increasing places in colleges/universities,
opening up more residency spaces, etc. At the same time, they were clear that they would need to
continue to rely on immigration as well due to retirement forecasts, aging of the population, and low
birthrates. RSQ, however, has not resorted to recruiting from countries with significant need of
healthcare workers, such as Sub-Saharan Africa.
In the case of midwifery, self-sufficiency may not be a particularly viable option in large part due
to its small size of the profession, the existence of few education programs and its labour intensive
educational model. As one of our informants noted:
In terms of growing the profession that’s a huge one for everybody because we really want more
students and we want more internationally educated and we really don’t have the capacity to expand
very quickly until we have more supervisors and preceptors. That’s a big challenge. The other one
is just that we are really small. So in terms of things like a bridging program, that’s pretty much
impossible to have in-person bridging programs anywhere other than Ontario because they don’t have
the numbers. Midwifery Informant 3
Moreover, it is generally regarded that in the face of the small school sizes there will continue to be
a reliance on registering foreign-educated workers in order to meet the rising demand for midwifery
services.120 Nevertheless, midwives are also keenly aware of the ethical concerns.
But this is not simply an issue on the Canadian radar. The World Medical Association's Statement
on Ethical Guidelines for the International Recruitment of Physicians recommends that: "Every
country should do its utmost to educate an adequate number of physicians, taking into account its
needs and resources. A country should not rely on immigration from other countries to meet its need
for physicians." 121 Moreover, because of the ethical dilemmas of recruiting nurses from poorer
nations, Commonwealth countries signed a Code of Practice agreeing not to recruit health care
providers from developing countries known to be experiencing shortages.122 Canada, along with
Australia and the U.K. (two other top destination countries), failed, however, to endorse the phrase
demanding some form of compensation for source countries (something for which the African
member nations were lobbying strongly).
Moreover, if we direct our attention and our policies towards international migration - as it seems
to be we are determined to do - a related concern is regarding whether we should actively recruit
internationally trained health care providers (as has been the case123) or simply focus on better
integrating those providers who are already here. This latter group is “a source of untapped skilled
workers and if not integrated into the Canadian labour force, represents a loss of human capital”124
both to Canada and the country from which the provider came. As Linda Silas, President of the
Canadian Federation of Nurses Unions (CFNU)
There are foreign-trained nurses in Canada who with help (some of it very minimal) could be
successfully integrated into our health care system. While CFNU believes that it is immoral to cherry
pick nurses and other health care professionals from the needy citizens of less developed nations, we
51
believe that we have a practical and moral obligation to provide help to those who are in Canada now.
(p. 7)125
Similarly, Dale Dauphinee, Executive Director of the MCC highlighted in a recent article the
following key lessons:
•
•
•
•
•
Raiding the physician resources of developing countries by developed countries is
unacceptable.
It is unacceptable to promote the human capital model but fail to provide the flexibility of
educational and training opportunities for international medical graduates (IMGs) to learn
needed skills and to become acculturated.
The ethics of physician recruitment extend beyond the policy failures that lead to raiding to
include issues of resource management within each recruiting country.
Physician migration to and from Canada is influenced by variables such as loss of physicians
to the United States, physician practice preferences with Canada, and the application of
workforce policies and health plan administrative practices within Canada.
Planners need to consider more carefully both sides of issues: the intended results but also
the unintended consequences of such plans and policies. 126(p. 22)
It is for these reasons that the programs detailed within this report and elsewhere are so important.
52
3.3
The Demographic Context of Health Labour Emigration in Canada
Canada is generally regarded as both an importer as well as an exporter of health labour. Just as we
have found fluctuations in the volume and demographics of health care providers who migrate to
Canada, we find similar fluctuations in the number of providers leaving the country. Across all
professions, the primary destination is to the United States for a variety of reasons delved into more
deeply in our policy section below. Here we present data that are available on the outflow of
Canadian physicians, nurses, midwives and clinical psychologists.
The Medical Brain Drain
It takes 15 years to produce a neurosurgeon, but it takes only a few days to leave the country.
Lysiane Gagnon. The siren call of US riches. The Globe and Mail. April 17, 1999.
Most of the ink spilled on the health care brain drain has been regarding the outmigration of
physicians from Canada and this was particularly heightened in the mid 1990s for reasons which will
become clear. An article in the Vancouver Sun expounded,
Doctors are leaving Canada in near-record numbers and there are fears of a national shortage if the
hemorrhage continues. ... The numbers are even larger if they include medical students who left
immediately after getting their degrees but before being licensed to practise.127
As described by Bruno l’Heureux, then president of the Canadian Medical Association, in this
article,
For 1994 the total approaches 800. ... If you take into consideration the students who left immediately
on receipt of their MD, the number (of departures) is just under 1000. ... This…constitutes a loss of
$750 million per year in tax-financed human capital, primarily to the United States
A few years later, a study of University of Toronto medical students reported in the September issue
of the Canadian Family Physician found 48 per cent of residents intended to relocate to the US. This
was attributed by chair of the department of family and community medicine, Dr. Walter Rosser,
to a lack of respect.128
A study of physicians conducted by Ryten, Thurber and Buske in 1998 also found that the 1989
graduation cohort was diminished by 16% the majority of which was migration to other countries.129
The trend continued with a peak in 1995 with 85% of health grads moving to the United States. This
peak is widely attributed to the outflow of family physician grads when Ontario introduced
geographic billing restriction legislation.130 Physicians left Canada at a rate about 10 times higher
than all other Canadian emigrant workers but this nevertheless represented less than 1% of
physicians in Canada per year. These researchers concluded that “the yield of the Class of 1989
for Canada’s physician workforce is insufficient to meet annual physician inflows from Canadian
sources to serve population growth and to replace retiring or emigrating physicians.”131 This was,
however, at the peak of the migration of physicians away from Canada (see Figure 3.13 below).
53
Figure 3.13 Physicians Who Moved Abroad & Returned to Canada, 1969 to 2004
(source CIHI, 2005)
In 2000, CIHI data show that 420 physicians moved abroad, down about 28% from 1999.132 Most
were male, specialist physicians who had received their MD education within the previous 10 years.
Postgraduate training in the U.S. was associated with subsequent emigration.133 In the same year,
256 physicians returned from abroad, similarly down about 25% from the year before. The
characteristics of returning physicians were very similar to those that moved abroad.134 Earlier,
McKendry et al. (1996) found that 22% of Canadian physicians said they were likely to move to the
U.S. whereas only 4% of the U.S. based respondents indicated a willingness to move back to
Canada.135
In 2004, however, a dramatic shift was noted in that for the first time since 1969 (the period for
which data are available) more physicians returned to Canada than moved abroad. Specifically, CIHI
reported that in 2004, 317 physicians returned to Canada, and 262 moved abroad. In the period
between 2000 and 2004, the number of physicians who left Canada declined by 38%. In 2004, 262
physicians left Canada down from 420 physicians who left in 2000. It was also found that roughly
25% of the physicians who moved abroad in 2004 were IMGs, and 44% received their degree within
the last 10 years. Of the physicians who left Canada, the majority were male (69%). Also, more male
doctors returned from abroad (74%) than female.136
54
Some of the noted limitations of these data are that it includes many physicians who leave Canada
but still keep their medical licenses north of the border,VI and also that it does not include the
Canadian medical school graduates who start their careers outside Canada.137
The Nursing Brain Drain
With respect to nurses, a recent CIHI report noted that over 5000 nurses maintained their Canadian
licence while working outside of Canada in 2003.138 Over 80% were employed in the United States
so much so that Canadian nurses are one of the main sources of IENs in the U.S. (22% versus 32.6%
for the Philliphines)139. As stated by Aiken et al. (2004):
Canada has long been a source of nurses for the United States, especially in border states, where
Canadian nurses' credentials are generally accepted by endorsement because of the comparability in
educational and licensure requirements. (p. 72 –73)
Other countries that attract Canadian nurses are Saudi Arabia, the United Kingdom and Hong Kong.
(see Figure 3.14) These totals, however, only include nurses maintaining their Canadian license
while working abroad thus these data incomplete at best.140 To date, no study has investigated
whether RNs that maintain their registration in Canada while abroad are more likely to return to
Canada than those ceasing registration. Moreover, this snapshot in time also masks the trends over
time that indicates a net loss in the 1990s of 5,000 to 16,000 RNs.141
Figure 3.14
VI
Percentage of RNs with Secondary Registrations by
Location of Employment, Canada, 2003
According to the Canadian Medical Forum Task Force on Physician Supply (1999). Physician Workforce
CMAJ, Nov. 22, 1999. http://www.cma.ca/index.cfm/ci_id/19522/la_id/1.htm, there are approx. 8000
Canadian medical graduates practicing in the U.S. of which 2440 maintain active licenses in Canada.
55
The Midwifery and Clinical Pyschology Brain Drain
Very little is known of the extent of midwives and clinical psychologists leaving Canada. In the
case of midwives, because there are so few spots in the education program, aspiring midwives are
often faced with the decision to leave Canada for training in the hopes that they can become
integrated when they return. To date, this has not been a trend that is being tracked in any
systematic way. Moreover, it is a problematic assumption to make because unlike medicine and
psychology there are few U.S. based programs that are acknowledge by provincial midwifery
regulators as being equivalent to Canadian standards.
In the case of clinical psychologists, a survey conducted by the CPA found that:
the data that we collect every year from accredited programs tells us that an average proportion of
about 10% of students of the Canadian programs upon graduation go to the U.S....but what we don’t
know is are those American students returning home or are those Canadians going to work in the U.S.
Psychology Informant 2
One of the key factors leading to emigration may be the lack of public funding for their services:
in the U.S. what the insurance companies do is they pay the license provider to provide the needed
service. So if someone needs psychotherapy and you’re a licensed psychologist or a licensed
psychiatrist or a licensed social worker... then your services will be remunerated. In Canada, the
public health insurance programs do not pay for the needed service. They pay specific providers. So
psychologists are the single, largest, specialized, regulated provider of mental health services in this
country. ... you know, six to 10 years in graduate school with this specialized skill set to assess and
treat, and diagnose, by legislation certainly in Ontario, right? It’s one of the License Acts that
psychologists have and our services are not remunerated. Psychology Informant 2
This is clearly an issue of concern for the profession but it is not clear if and how it affects
outmigration from Canada.
Summary
In sum, although we have better data on the inflow of health care providers into Canada than we do
of the outflow. Similar to the case for immigration, what is also clear from these demographic
trends is that various health care and health human resource policy have an important influence and
indeed the issues of immigration and emigration are linked (as we will discuss more fully below).
56
3.4
The Policy Context of Health Labour Emigration in Canada
Some attention has been devoted to the problem of the emigration of nurses and of physicians but
again; we find little coordinated policies evident. For example, we know that the reasons cited by
health care émigrés from Canada were primarily job-related, including job availability and
satisfaction, and the amount of resources devoted to the health care system.142 143 144 145 146 147 In this
section we begin to map out the policy context regarding the following key emigration issues:
•
the impact of local remuneration and working conditions;
•
trade agreements
•
factors affecting return migration.
Remuneration & Working Conditions
Many have linked anger over health care cuts to the emigration of physicians and nurses in the mid
1990s.148 149 For example, Dr. Lorne Tyrrell, dean of medicine and dentistry at the University of
Alberta, said "This came home to me the other day when I spoke to a young ENT surgeon who is
moving to North Dakota. When I asked him why he would leave Canada when we have such an
acute need for specialists like him, he told me that opportunities to do surgery here were too
restricted. His waiting room is always full here, but he only has access to an operating room in his
Edmonton hospital for 2 hours every 2 weeks. In North Dakota, he gets 2 afternoons a week in the
OR."150 Over time, these cuts took their toll as Grant and Oertel (1997)151 describe:
With the widespread preoccupation of provincial governments with deficit reduction, and with the
general failure of user-fees and other demand-side initiatives, the number and earnings of physicians
became the target of various "cost containment" measures. Provincial initiatives sought to address the
fees, incomes, and number/location of physicians:
•
Fee schedules. Negotiations between the province's government and its medical association
over fee-for-service payments became more "one-sided" with some governments choosing
a "take it or leave it approach" or unilaterally imposing fee schedules (Deber et al 1994).
•
Utilization rates. Several provinces (New Brunswick, Newfoundland, Quebec) placed
absolute "caps" on their overall health care budgets or total payments to physicians. Others
(Ontario, British Columbia) limited individual physician incomes and/or the rate of increase
in aggregate physicians billings....
The impact of these initiatives on the income of physicians became apparent by 1993. ...After
suffering a substantial erosion in real earnings during the 1970s, Canadian physicians enjoyed a steady
improvement in average income from $109,471 in 1981 to $126,322 in 1992. But in the subsequent
three years, real earnings fell substantially such that by 1995 most of the gains physicians had made
during the 1980s were dissipated.
Another reason for the outflow to the U.S. was directly related to the reduction in residency
positions a trend which not only affected IMGs, it left little options for graduates by to find
residencies elsewhere.152 The departure of Canadian physicians to the United States was also
facilitated by the rapid expansion of Health Management Organizations (HMOs) there which
found Canadian trained family physicians ideal gatekeepers. Some of the key reasons our
informants mentioned for emigrating from Canada included better remuneration, more operating
time and better equipment. Together these influences help to explain the peak in physician outflow
that is displayed in Figure 3.13 above.
For nurses, the southward ‘brain drain’ was particularly dramatic in the mid-1990s, when countrywide cuts in the hospital sector put many nurses out of work, to the delight of eager US recruiters
57
who lured Canadian nurses with signing bonuses of up to US$30 000.153 154A Registered Nurses
Association of Ontario study of Ontario RNs who left Canada between 1991 and 2000 found that
most (69.5%) said that job opportunities were the main reason they left Canada (specifically, the
lack of full-time employment). Family or personal reasons were cited next (25.5%), followed by
pay and benefits (12.9%) and travel/weather 5.5%).155 A report by the CNA states that
nurses here want full-time employment, appropriate workloads, involvement in decision-making and
educational opportunities. During the cutbacks of the 1990s, many nurses were forced into part-time
or casual jobs, and by the late 1990s 48% of nursing positions provided only part-time work. Desperate
for stable employment, up to 15% of new Canadian graduates now move directly to the US; the CNA,
which represents 115 000 nurses, wants to reduce this to 5%.156
These reasons are not dissimilar from those found for nurses internationally (see Table 3.10).157
Table 3.10 Push and Pull Factors Influencing International Migration of Health Care Providers
Trade Agreements
Some analysts we came across in the literature stress the importance of looking beyond the particular
policy contexts of nation state to understand the broader impact of trade agreements, such as the
North American Free Trade Agreement (NAFTA), the World Trade Organization (WTO),and the
GATS on the flow of health labour. 158 159 These trade agreements urge national governments to
reduce or eliminate requirements and regulatory devices that impede or block the movement of
goods and services. NAFTA, for example, allows for the following:
Nurses who are citizens of Canada and Mexico may work in the U.S. under the NAFTA ("TN") status.
Canadian nurses must demonstrate the following:
1. They have a written offer of employment from a U.S. employer for a period of not exceeding one
year;
2. They are licensed in Canada and in the state of intended employment. Eighteen U.S. states endorse
Canadian licenses without the exam.
3. They have proof of Canadian citizenship; and
4. They pay a US $56.00 fee to enter the United States (payable at the U.S. border).160
Although it has been found that as a consequence of NAFTA there has not been a massive migration
of nurses from Mexico to the U.S.,161 it has made it easier for Canadian nurses to find work in the
U.S. This difference is due in large part to the equivalency of education and training.162 The
overarching GATS also facilitates increased labour migration because of its efforts towards aligning
the competency and recognition requirements for health care providers between countries. So
58
historically where national boundaries separated licensing, regulatory and credentialing systems, the
facilitation of enhanced international trade in services may weaken the autonomy and authority of
nationally-based professional regulatory systems. 163 Taken together, these trade agreements
represent new challenges in understanding the migration of health care providers that remain to be
fully explored.
Return Migration
Very little is know about the factors affecting return migration of health care providers who leave
Canada and often economic overshadow personal factors in such decisions. In the case of
physicians, Webb (1997) argues that “[m]any Canadian doctors have emigrated [to the US] only to
return within a year or two, frustrated with a market-driven health care system and a much more
eclectic and individualistic society.”164 Anecdotal evidence suggests that HMOs in the States are
difficult to deal with, family is missed and very interestingly, some doctors have said that they find
it very difficult working in an environment where healthcare costs are not paid by the state. Another
salient factor noted by more than one of our key informants may be that global unrest is a catalyst
for the return of physicians to Canada. In the post 9-11, Iraq war era, it could well be that Canada
is considered safer than Europe and certainly the US. This may be true across professions. Further,
in the case of nurses, because the job market for nurses has opened up again, particularly in Ontario,
the tide appears to have reversed.165
Our documentary and website search also uncovered two examples of ‘repatriation’ programs. One
is offered by the CPSO as part of its IMGO package:
The Repatriation Program offers funded training positions to physicians who have completed
postgraduate training outside of Canada and require up to two years additional training to meet the
certification requirements of the Royal College of Physicians and Surgeons of Canada. Upon
graduation, successful candidates practise in an under serviced area for a duration equal to the length
of Ontario training received. Physicians must be Canadian Citizens or Landed Immigrants. The
Ontario Ministry of Health and Long-Term Care administers this program. 166
The other is offered for nurses by the Manitoba Ministry of Health which focuses primarily on
‘relocation assistance’:167
The ‘Come Home to Manitoba’ campaign continues to provide relocation assistance of up to $5,000
to nurses coming to Manitoba. Since the fund was established, almost 500 nurses have applied and
been paid relocation assistance. In the past year, 178 nurses moved to Manitoba to work. Applications
continue to be received from nurses requesting assistance with their move.
Between April 2001 and March 2002, this campaign received 475 applications. Although many
applications were from other provinces (see Table 3.11), a sizeable were from nurses practising
outside of Canada. Similar capped relocation expenses of $15,000 is also available to regions for
the recruitment of specialists and midwives to a lesser extent.
59
Table 3.11 Relocation of Applicants to ‘Come Home to Manitoba’ Program, 2001-2002
Within Canada
Number of Applicants
Nunavut
2
NWT
3
Yukon
3
British Columbia
66
Alberta
39
Saskatchewan
21
Ontario
89
Quebec
11
New Brunswick
16
PEI
2
Nova Scotia
21
Newfoundland
12
Labrador
2
Outside of Canada
Number
USA
75
Philippines
79
British West Indies
1
Saudi Arabia
5
England
5
Australia
4
Monaco
1
Bahamas
1
New Zealand
1
Korea
5
Other
11
TOTAL:
475
In sum, a variety of human resource policy influences can impact upon the emigration of Canadian
health care providers just as it can influence the immigration of internationally trained providers.
The imperative, therefore, is to be able to use these policy levers in a direction of retaining as many
of the Canadian trained providers as we can with the aforementioned goal of self-sufficiency.
60
4. Concluding Comments
There are a great deal of convergences in the ways in which policies and programs have been
proposed and implemented to deal with these issues in medicine, nursing, midwifery and to a lesser
extent psychology despite dramatic differences in the size of these professions and their relationship
vis-a-vis public funding. An interesting issue that arises from this comparative analysis is between
the cases of medicine and midwifery on one hand and nursing and psychology on the other.
Specifically, the latter two professions have two different levels of regulatory status (in most
provinces) being RNs and LPNs and psychologists and psychological associates respectively.
What this enables is a possible two step process for integration for internationally trained health care
providers. This is not presently possible in medicine and midwifery other than through the
temporary licenses and conditional registration programs. Having a “lower” initial entry point - or
perhaps stated more positively as a two-step process - would enable internationally trained health
care providers to gain important Canadian experience while at the same time honing their skills and
being gainfully employed. This is one potential policy solution that could be explored further
through physician assistants (which exist in the U.S.) and maternity care assistants (which exist in
the Netherlands and in the U.K.)
We also have to be clear on the implications of some of the demographic data. For example, given
that we have found that internationally educated health care providers tend to be older, they may not
be the most effective solution to the human resource crisis we face. In light of such data, the report
Navigating to Become a Nurse in Canada states,
Given that one of the root causes of the shortage of nurses in Canada is an aging workforce, a large
proportion of these IENs reflect the same age profile. They will not be in a position to fill the gap
when thousands of Canadian nurses retire. On the other hand, a large number of these IENs have
several years of experience, which is a great asset to Canadian employers. (p. 21)
That is, better integration of internationally educated health care providers should be undertaken
not so much as a solution to shortages but as an equity issue in its own right. A multi-pronged
approach must be taken of which more efficient integration of internationally providers is a part but
must also include attention to factors affecting recruitment and retention. This is why it was
important to examine both the flows into and out of Canada and the policy and contextual factors
influences these flows.
As has been hinted throughout this report, the issues of immigration to and emigration from Canada
are intricately linked despite the fact that the more salient issue at this time is around immigration
and integration in particular - that is a ‘brain waste’ rather than a ‘brain drain’ issue. A related
ethical issue of increasing international significance is whether we should be viewing immigration
as a solution to our skilled worker shortages or whether we should be attempting to achieve selfsufficiency insofar as the number of health care providers in the country are concerned. Moreover,
if we direct our attention and our policies towards international migration - as it seems to be we are
determined to do - a related concern is regarding whether we should actively recruit internationally
trained health care providers (as has been the case) or simply focus on better integrating those
providers who are already here. This latter group is “a source of untapped skilled workers and if not
61
integrated into the Canadian labour force, represents a loss of human capital” both to Canada and
the country from which the provider came.
Because of Canada’s unique position of being both an importer as well as an exporter of health care
providers, it is imperative upon us to use this position to become a world leader in ways in which
to attend to the issues that both draw health care providers to our country and away from it. In both
cases, a strong argument can be made for better recruitment and retention strategies within Canada
to stem the tide of those leaving the health professions - not just for other countries, but altogether and reducing the necessity for us to go outside our borders to recruit. As Buchan and Sochalski
(2004) have so eloquently summarized in the case of nurses168:
These accelerated levels of nurse migration may be a symptom of systemic problems in the nursing
workforce in both the source and destination countries. If national governments and international
agencies wish to respect the rights of an individual nurse to move but also wish to create an "ethical"
environment in which the individual is under no pressure to leave, they must engage actively and
positively in these dynamics.(p. 591)
Similarly, Bach (2003) has argued that:
It is an indictment of governments and employers that they prefer to rely on the relatively
straightforward panacea of international recruitment rather than focusing on underlying problems of
pay and working conditions. Improvements in these areas would ensure increased recruitment and
retention amongst the existing health sector workforce. (p. ix)
Thus, we are faced with three key policy options in Buchan and Sochalski’s opinion:.
•
•
•
The first option is to support improvements in pay, working conditions, scheduling, career
prospects, and the security and prestige of nurses in their own countries in order to modulate
The second option is to encourage and facilitate bilaterally or multilaterally managed flows
of nurses between countries. This should also include the possibility for the nurse to return
to the home country if desired. Some countries have already begun to discuss this issue.
The third option is to institute arrangements whereby compensation flows from the recruiting
country back to the source country. This could be direct or indirect financial compensation,
remittances pledged from nurses, educational support as part of a donor package, or the
return flow of better-trained staff. Some source countries favour financial compensation but
there is little evidence of this approach being operationalized.(p. 592)
Because of Canada is sometimes viewed as a ‘weigh-station’ for ultimate U.S. destination, it makes
our policy decision-makers somewhat more hesitant to enter into financial reciprocation agreements
with source countries. It is a truly complex issue to manage health human resources while at the
same time acknowledging the free movement of labour and the expenses laid out for the education
of health care providers elsewhere.
62
5. Future Research Directions
Based on the findings from this pilot study, we are pursuing two studies with funds from the SSHRC
and from the CIHR.
The first study (2006-2009) involves an examination of the experiences of internationally trained
health care providers in Canada. The objectives of this study are to examine:
•
the policy, the decision-making processes and regulatory environments addressing the issue
of the immigration of physicians, nurses and midwives into Canada;
•
the experiences of immigrant physicians, nurses and midwives who are included and
excluded from practicing in Canada; and
•
the factors influencing immigrant health care providers relative successful at becoming
integrated into the Canadian health care system.
For each of these three case studies, data will be collected through: 1) the acquisition of key public
domain policy documents from the various provider/stakeholder groups; 2) interviews to be
conducted with key informants involved in the policy decision-making process and 3) experiential
interviews with internationally trained physicians, nurses and midwives who have either successfully
integrated into the Canadian health care system and those who have not. It involves a partnership
between Dr. Bourgeault and a specialist in immigration and race relations, Dr. Victor Satzewich.
The second study funded by CIHR (2006-2010) involves a large international research team and
local community decision-makers that will undertake a comparative examination of the policy
context around the integration of internationally educated health care providers in Canada, the U.S.,
the U.K., and Australia - the key destination countries. Based on the broad literature review
undertaking during this pilot study phase, it became apparent that Canada is not particularly unique
among high-income countries in the extent to which it contributes to or draws upon migrant health
labour or to which it is implicated in these ethical issues. The U.S., the U.K., and Australia share
many features with Canada but also important differences. Comparative research recognising their
distinct geographic, political and policy contexts would allow us to contrast migration policies
across jurisdictions and contribute to efforts supporting a more effective, sustainable and equitable
system of health care migration.
Thus, this study aims to critically examine from a comparative perspective:
•
the various stakeholders involved in the migration of physicians, nurses, and midwives into
and out of Canada, the U.S., the U.K., and Australia;
•
the perspectives, positions, interrelations and influences of these various stakeholder groups
on the framing of policy ‘problems’ pertaining to health care provider migration and on the
overall policy process;
•
the regulatory environments and broader policy contexts in Canada, the U.S., U.K. and
Australia; and finally,
•
the resultant policies in each of these four countries.
For each of the four countries, data will be collected through: 1) the acquisition of key public
domain policy documents from the various provider/stakeholder groups; and 2) interviews to be
63
conducted with key informants involved in the policy decision-making process and key. These data
will be analysed using the constant comparative technique of qualitative policy analysis.
Beyond our own research program, we have also been invited to participate in Health Canada’s
upcoming research forum entitled Setting a Research Agenda for Internationally Educated Health
Care Professionals: Asking the Critical Questions which is to take place December 7, 2005 in
Vancouver. As they stated in their invitation:
The internationally educated health care provider presents several challenges to their respective
regulatory bodies and associations. As highly educated immigrants they receive priority when
applying to enter Canada. However, when they come to Canada, they have difficulty integrating into
our health system. Integration not only includes language and cultural differences, but also a complex
assessment process required to ensure the Canadian population that they have the same knowledge,
skills and competencies as those already in practice. ... Federal, provincial and territorial governments
have identified seven health professions (Medicine, Nursing, Pharmacy, Physiotherapy, Occupational
Therapy, Medical Laboratory Technology and Medical Radiation Technology) which they believe
should receive priority actions when planning for human resources in health. The International
Medical Graduate Task-force identified issues that are common to all internationally educated
professionals. It is Health Canada's desire to build on the work done responding to the
recommendations of the IMG taskforce. Six of seven international medical graduate task force
recommendations have been implemented, the seventh being a research agenda still has to be
developed. Health Canada is seeking the participation of researchers from each of the seven identified
health professions to develop critical research questions which address common issues. A second goal
is to consider on-going or future research activity occurring in one profession, which might be
transferable to one or more of the other professions. Our hope is to conclude the day having developed
some critical questions, some partnerships among the researchers willing to develop the research
questions and to identify the preliminary next steps including identifying specific funding sources.
Thus the funding for this research has been especially timely and will be built upon in future
research endeavours.
64
Appendix 1
List of Relevant Websites:
National
Canadian Institute for Health Information
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_14dec2004_e
CIHI “Midwives”
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=process_download_form_e
Health Personnel Trends in Canada, 1993 to 2002
Citizenship and Immigration Canada
http://www.cic.gc.ca/english/skilled/qual-5.html
Human Resources and Skills Development Canada
http://www.hrsdc.gc.ca/en/cs/comm/hrsd/news/2004/040514.shtml
Federal-Provincial-Territorial Working Group on Access to Professions and Trades
http://www.cicic.ca/apt/apt.vol1.n1.en.asp
http://www.cicic.ca/apt/apt.vol1.n2.en.asp
Programs and Services for Immigrants
http://www.accc.ca/english/services/i-services/bt_programs.htm
The International Medical Graduate Implementation Steering Committee
http://testunix.mediaforce1.com/imgtaskforce/
Royal College of Physicians and Surgeons of Canada - International Postgraduate Medical
Education
http://rcpsc.medical.org/residency/certification/img_e.php
Information for foreign-trained medical doctors
http://www.cicic.ca/professions/3112en.asp
Tips for Foreign Medical, Nursing, Healthcare and Biotechnology Professionals Looking for
Work in the United States and Canada
http://www.pulsehr.com/Resources/Tips_For_Foreign_Healthcare_Professionals.htm
Canadian Nurses Association
http://cna-aiic.ca/CNA/news/releases/public_release_e.aspx?id=161
http://cna-aiic.ca/CNA/news/releases/public_release_e.aspx?id=140
http://cna-aiic.ca/cna/documents/pdf/publications/Brf_Std_Cttee_Finance_nov04_e.pdf
http://cna-aiic.ca/CNA/documents/pdf/publications/Citizenship_Immigration_e.pdf
CIHI “Nurses”
65
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=process_download_form_e
Health Personnel Trends in Canada, 1993 to 2002
Recruitment of Foreign Nurses
http://www.pulsehr.com/Foreign_Nurse_Recruitment.html
Information for foreign-trained registered nurses and psychiatric nurses
http://www.cicic.ca/professions/3152en.asp
Possibilities Project
http://www.possibilitiesproject.com/features/year5/sep2003/nursing_upd/nursing3.asp
Information for foreign-trained midwives
http://www.cicic.ca/professions/3232en.asp
Information for foreign-trained psychologists
http://www.cicic.ca/professions/4151en.asp
Mutual Recognition Act
http://www.cpa.ca/documents/MRA.pdf
Provincial
Ontario
Government of Ontario - Regulated Health Professions Act, 1991
http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/91r18_e.htm
The College of Physicians and Surgeons of Ontario
http://www.cpso.on.ca/Info_physicians/applicants/regist.htm
http://www.cpso.on.ca/Info_physicians/applicants/rpafactsh.htm
Association of International Physicians & Surgeons of Ontario (AIPSO)
www.cassa.on.ca/AIPSO
Ontario Network for Internationally Trained Professionals
http://www.onip.ca/
Ontario International Medical Graduate Clearinghouse
http://www.oimgc.utoronto.ca/
International Medical Graduates
http://www.health.gov.on.ca/english/providers/project/img/img_faq.html
College of Nurses of Ontario
http://www.cno.org/international_en/index.html
66
http://www.cno.org/reg/nonmemb/reg_exams.html
New registration requirements come into effect at the College of Nurses of Ontario
http://www.cno.org/new/releases/2005-01_NewRegReqs.htm
Internationally Trained Workers: Access to the nursing profession in Ontario
http://www.edu.gov.on.ca/eng/document/nr/02.03/nurse.html
Canadian Association of Midwives Ontario
http://members.rogers.com/canadianmidwives/province_ontario.html
Association of Ontario Midwives
http://www.aom.on.ca/About/Becoming_a_Midwife.aspx
Government of Ontario Opening Doors
http://www.edu.gov.on.ca/eng/general/postsec/openingdoors/apt/midwifery_fact.html
Ryerson University
http://ce-online.ryerson.ca/ce/program_sites/program_default.asp?id=2161
The College of Psychologists of Ontario
http://www.cpo.on.ca/
The Regulated Health Professions Act and the Psychology Act
http://www.e-laws.gov.on.ca/DBLaws/Statutes/English/91p38_e.htm
Registration
http://www.cpo.on.ca/Registration/Psychologist/RegPsychologistMain.htm
Quebec
Immigration Quebec
http://www.immigration-quebec.gouv.qc.ca/anglais/immigration/permanent-worker/favoredtraining.html
Collège des médecins du Québec
http://www.cmq.org/asp/english.asp
Réglementation Loi Medicale
http://www.cmq.org/Pages/sections/college/reglemen/index.html
67
Canadian IMG DHCEU (Diplômé hors Canada et États-Unis) Canadian/International Medical
Grads (Residents of the Province of Quebec)
http://www.med.mcgill.ca/postgrad/applicantinfo_mf_candianimg.htm
Ordre des infirmieres et infirmiers du Quebec (OIIQ)
http://www.oiiq.org/infirmieres/candidate/index.asp
For Nurses trained outside of Quebec
http://www.oiiq.org/infirmieres/diplomes/index.asp
Access to the Profession-Quebec
http://www.oiiq.org/uploads/publications/memoires/acces_profession.pdf
http://www.oiiq.org/infirmieres/diplomes/permis.asp
http://www.oiiq.org/infirmieres/diplomes/immigration.asp
http://www.oiiq.org/infirmieres/diplomes/examen_office.asp
Ordre Des Sages Femmes Du Quebec
http://www.osfq.org/ordre/index_loi.html
Canadian Association of Midwives-Quebec
http://members.rogers.com/canadianmidwives/province_quebec.html
Ordre des psychologues du Québec
http://www.ordrepsy.qc.ca/Eng/public/ordre/01_ordre.asp
Manitoba
Immigration and Multiculturalism Manitoba
http://www.gov.mb.ca/labour/immigrate/immigration/2.html
The College of Physicians and Surgeons of Manitoba
http://www.umanitoba.ca/colleges/cps/Registration/medreg.html
http://www.umanitoba.ca/colleges/cps/Registration/eicsinfo.pdf
Province of Manitoba - Medical Act
http://web2.gov.mb.ca/laws/statutes/ccsm/m090e.php
The Medical Licensure Program for International Medical Graduates (MLPIMG) will assist
foreign trained physicians to obtain medical licensure to practise as primary care physicians in
Manitoba.
http://www.gov.mb.ca/health/mlpimg/
Registered Nurses Act Manitoba
http://www.crnm.mb.ca/downloads/regnursesactregulweb.pdf
68
College of Registered Nurses of Manitoba
http://www.crnm.mb.ca/reg.php
Legislation: The Midwifery Act
http://www.canlii.org/mb/laws/sta/m-125/20041104/whole.html
Canadian Association of Midwives Manitoba
http://members.rogers.com/canadianmidwives/province_manitoba.html
College of Midwives of Manitoba
http://www.midwives.mb.ca/
The Psychological Association of Manitoba - Legislation: The Psychologist Registration Act.
http://www.cpmb.ca/documents/Psychologists%20Registration%20Act.pdf
Proposed by-laws
http://www.cpmb.ca/
69
Appendix 2
ON THE MOVEMENT OF HIGHLY SKILLED HEALTH PROFESSIONALS:
A Comparative Examination of Canadian Policy regarding Health Labour Migration
Letter of Information
My name is Kim Matthews. I am a Ph.D. student working with Professor Ivy Lynn Bourgeault, a health
studies researcher at McMaster University in Hamilton, Ontario. I am assisting her in conducting a study of
migration of health care professionals into and out of Canada. Funding for this research comes from the
Social Sciences and Humanities Research Council of Canada through their Initiative in the New Economy
Skills Research Initiative. Dr. Bourgeault and I will be interviewing a variety of decision makers and health
care providers and we would like to invite you to participate.
The interview will take approximately 30 minutes to one hour. The questions will largely be open-ended
regarding your views and experiences with the migration of health care providers. Question areas will likely
include the following:
- a description of the role of your agency, institution or organization in this process;
- a description of the present state of affairs in terms of the migration of physicians, nurses, midwives or
clinical psychologists;
- a description of the various policies that influence this situation;
- the identification and description of the position of various stakeholder groups; and
- identification of critical debates and disjunctures of policy.
We would like to tape record the interview. The tapes will be transcribed word for word and then erased.
No identifiers will be on the interview transcripts and they will be kept in a locked filing cabinet until the end
of the study, at which time these will also be destroyed unless you give permission that they may be retained.
Every effort will be made to maintain the confidentiality of the interview material. Unless you indicate
otherwise, any material used in the publication resulting from this study will have identifying characteristics
or statements omitted or paraphrased to help ensure confidentiality. Participation in this study is voluntary.
You may refuse to participate, refuse to answer any questions or withdraw from the study at any time without
consequence and the data you have provided will be destroyed if you so wish. There are no known risks to
participating in this study.
This letter is yours to keep. If you have any questions about this study or your participation in it, please do
not hesitate to contact Dr. Bourgeault at (905) 525-9140 ext. 23832 or email her at [email protected]
If you have any questions about the conduct of this study or your rights as a research subject you may contact
the McMaster University Research Ethics Board at (905) 525-9140 ext. 23142 or [email protected]
Thank you for your interest in this research.
70
Appendix 3
ON THE MOVEMENT OF HIGHLY SKILLED HEALTH PROFESSIONALS:
A Comparative Examination of Canadian Policy regarding Health Labour Migration
Project Consent Form
I have read the Letter of Information, have had the nature of the study explained to me and I agree to participate. All
questions have been answered to my satisfaction.
Please indicate (with your initials) your agreement or disagreement to each of the following requests and sign the form
at the bottom. You will be provided with a copy of this form.
1. Do you agree to the taping of the interview?
YES ________ NO ________
2. Do you wish to remain anonymous in any publications or presentations of the results of the study?
YES ________ NO ________
3. May your transcript be retained after the completion of this study for the purposes of follow-up studies and
comparative analyses by Dr. Bourgeault?
YES ________ NO ________
4. Do you wish to have a copy of the report emanating from this study?
YES ________ NO ________
Name of Participant (please print):
____________________________________
Signature of Participant: _____________________________________
Date: _____________________
Interviewer’s Initial: _______________
71
Appendix 4
Key Informant Interview Guide
for
SSHRC INE Health Care Provider Migration Study
•
Could you briefly describe the role and/or goals of your organization insofar as the
migration of health care providers is concerned?
•
Could you describe the present state of affairs in terms of the migration of
•
physicians
•
into Canada/province
•
how does policy differently address those internationally trained
physicians who are already here and those being recruited?
•
which countries/programs are easily accepted and which are not
and what are the reasons for the difference?
•
training equivalency?
•
language competency?
•
are there any plans to develop reciprocity agreements with
these countries?
•
out of Canada/province
•
do you feel that the issue of physicians migrating from
Canada/province is a critical issue
•
what do you feel are the major push factors?
•
what do you feel is or should be done to stem the tide of
physicians leaving?
•
what do you think are the main reasons for coming back?
•
In terms of demographics (age, gender, etc.), who do you feel are the
physicians most likely to immigrate to/emigrate from Canada?
•
nurses
•
into Canada/province
•
how does policy differently address those internationally trained
nurses who are already here and those being recruited?
•
which countries/programs are easily accepted and which are not and
what are the reasons for the difference?
•
training equivalency? e.g., diploma/degree
•
language competency?
•
are there any plans to develop reciprocity agreements with
these countries?
•
out of Canada/province
•
do you feel that the issue of nurses migrating from Canada/province
is a critical issue
•
what do you feel are the major push factors?
72
•
•
what do you feel is or should be done to stem the tide of
nurses leaving?
•
what do you think are the main reasons for coming back?
In terms of demographics (age, gender, etc.), who do you feel are the nurses
most likely to immigrate to/emigrate from Canada?
•
midwives
•
into Canada/province
•
how does policy differently address those internationally trained
midwives who are already here and those being recruited?
•
which countries/programs are easily accepted and which are not and
what are the reasons for the difference?
•
training equivalency? e.g., degree
•
language competency?
•
are there any plans to develop reciprocity agreements with
these countries?
•
out of Canada/province
•
do you feel that the issue of midwives migrating from
Canada/province is a critical issue
•
what do you feel are the major push factors?
•
what do you feel is or should be done to stem the tide of
midwives leaving?
•
what do you think are the main reasons for coming back?
•
In terms of demographics (age, gender, etc.), who do you feel are the
midwives most likely to immigrate to/emigrate from Canada?
•
clinical psychologists
•
into Canada/province
•
how does policy differently address those internationally trained
clinical psychologists who are already here and those being
recruited?
•
which countries/programs are easily accepted and which are not and
what are the reasons for the difference?
•
training equivalency? e.g., doctorate
•
language competency?
•
are there any plans to develop reciprocity agreements with
these countries?
•
out of Canada/province
•
do you feel that the issue of clinical psychologists migrating from
Canada/province is a critical issue
•
what do you feel are the major push factors?
•
probe about lack of public funding
•
what do you feel is or should be done to stem the tide of clinical
psychologists leaving?
•
what do you think are the main reasons for coming back?
•
In terms of demographics (age, gender, etc.), who do you feel are the clinical
73
psychologists most likely to immigrate to/emigrate from Canada?
•
One commentator has noted that the migration of health care providers involves “[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.” As a result, we have no nationally coordinated policy for health labour
immigration, and even less policy addressing the issue of health labour emigration.
•
Could you identify the key stakeholder groups and their positions in this
regard and the reasons behind their positions?
•
Could you comment on where there are disjunctures of policy?
•
immigration and
•
emigration of health care providers
•
between immigration and health and provincial regulators
•
Labour markets are becoming international in scope and labour mobility a requirement under
international trade agreements.
•
how does this influence Canadian policy?
•
how do you think Canada compares with other jurisdictions?
•
Could you comment on the ethical issues involved in both the emigration and immigration
of health care providers
•
Do our policies distinguish between active recruitment and tapping into an
existing resource
•
2003 Commonwealth Code of Ethics
•
Should source countries be paid compensation for losing health care
providers (to replace the costs of training)?
•
Canada did not sign on to this
74
Endnotes
1
Fooks, C. (2003). Moving Towards National Resource Planning in Canada: Still Looking for a Home,
CPRN/RCRPP.
2
Bach, S. (2003). International migration of health workers: labour and social issues. International Labour
Office Working Paper, Geneva.
3
Hickey, J. P. (1995). "Why don't I send you and your wife two plane tickets....?" CMAJ 152(11): 18651866.
4
Williams, L. S. (1997). "The Road to Wisconsin." CMAJ 156(6): 860-863.
5
C.I.H.I. (2001). Canada's Health Care Providers
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_35_E
6
CIHI (2000). The Supply and Distribution of Registered Nurses in Canada.
7
Fooks, C. (2003). Moving Towards National Resource Planning in Canada: Still Looking for a Home,
CPRN/RCRPP: 7.
8
Hickey, J. P. (1995). "Why don't I send you and your wife two plane tickets....?" CMAJ 152(11): 1865-1866.
9
Ryten, E., et al. (1998). "The Class of 1989 and physician supply in Canada." CMAJ 158(6): 723-8.
10
Williams, L. S. (1997). "The Road to Wisconsin." CMAJ 156(6): 860-863.
11
Barer, M. and G. Stoddard. (1991). Toward integrated medical resource policies for Canada. Report of the Conf.
of Dep. Ministers of Health, Department of Ministers of Health.
12
McKendry, R. et al. (1996). "Factors influencing the emigration of physicians from Canada to the United
States." CMAJ 154(2): 171-181.
13
Wharry, S. (2002). "Pressure mounting to curb MD poaching by rich nations." CMAJ 166(13): 1707.
14
Registered Nurses Assn. of Ont. (2001). "Earning Their Return - When & Why Ontario RN's Left Canada, and
What Will Bring Then Back."
15
Joyce, R. E. and C. L. Hunt. (1982). "Philippine nurses and the brain drain." Social Science and Medicine
16(12): 1223-1233.
16
C.I.H.I. (2001). Canada's Health Care Providers http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_35_E
17
Barer, M. and G. Stoddard. (1991). Toward integrated medical resource policies for Canada. Report of the
Conf. of Dep. Ministers of Health, Department of Ministers of Health.
18
C.I.H.I. (2001). Canada's Health Care Providers
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_35_E
19
OMA Human Resources Committee (OHRC). (2002). "Position Paper on Physician Workforce Policy and
Planning."
20
Barer, M. and G. Stoddard. (1991). Toward integrated medical resource policies for Canada. Report of the
Conf. of Dep. Ministers of Health, Department of Ministers of Health.
75
21
Canadian Medical Association (2001). CMA Masterfile.
22
Canadian Institute for Health Information. (2003). Supply, Distribution and Migration of Canadian
Physicians, 2002. Ottawa, ON.
23
Ibid.
24
Grant, Hugh (2004). From the Transvaal to the Prairies: The Migration of South Africa Physicians to
Canada. Prairie Centre of Excellence for Research on Immigration and Integration. Working Paper 02-04.
25
Canadian Medical Association- November 22, 1999, Canadian Medical Forum Task Force on Physician
Supply, http://www.cma.ca/index.cfm/ci_id/19522/la_id/1.htm
26
Canadian Medical Association (2001). CMA Masterfile.
27
Grant, Hugh (2004). From the Transvaal to the Prairies: The Migration of South Africa Physicians to
Canada. Prairie Centre of Excellence for Research on Immigration and Integration. Working Paper 02-04.
28
Barer, Morris L., & Webber, William A. (1999). Immigration and Emigration of physicians to/from
Canada. Centre for Health Services and Policy Research UBC.
29
Barer, Morris L., & Webber, William A. (1999). Immigration and Emigration of physicians to/from
Canada. Centre for Health Services and Policy Research UBC.
30
C.I.H.I. (2001). Canada's Health Care Providers
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_35_E
31
Barer, Morris L., & Webber, William A. (1999). Immigration and Emigration of physicians to/from
Canada. Centre for Health Services and Policy Research UBC.
32
Hawley, G. (2004). Canada’s Health Care Workers: A Snapshot. Health Policy Research, Issue 8, May.
33
Mason, J. (1988). Midwifery in Canada. The Midwife Challenge. S. Kitzinger. London, Pandora: 99-133.
34
Bourgeault, I.L., & Benoit, C. (2004) Reconceiving Midwifery in Canada. In I. Bourgeault, C. Benoit, & R.
Davis-Floyd (Eds.), Reconceiving Midwifery. Kingston/Montreal : McGill Queen’s University Press.
35
C.I.H.I. (2000). Supply and Distribution of Registered Nurses in Canada, 1999.
36
Little, L. (2005). The Canadian Case. Presentation to Bellagio Institute Conference on the International
Migration of Nurses. July.
37
Joyce, R. E. and. C. L. Hunt. (1982). "Philippine nurses and the brain drain." Social Science and Medicine
16(12): 1223-1233.
38
C.I.H.I. (2004). Supply and Distribution of Registered Nurses in Canada, 2003.
39
Our key informants outlined a special agreement/permit allocated to nurses from France. This facilitates
their entry to Quebec and to the profession.
40
C.I.H.I. (2004). Supply and Distribution of Registered Nurses in Canada, 2003.
41
Calliste, A. (1996). "Antiracism Organizing and Resistance in Nursing: African Canadian Women." The
Canadian Review of Sociology and Anthropology 33(3): 361-390.
76
42
Institute for Research on Public Policy (2005). NEWS RELEASE: Study Reveals Low Returns on
Immigrants' Foreign Education and Experience. 8 February 2005. www.irpp.org
43
Martin, W. (2004). Canadian Midwifery Regulators Consortium’s Research Plan for a National Midwifery
Assessment Strategy. March, College of Midwives of B.C.
44
Brouwer, A. (1999) Immigrants Need Not Apply. The Maytree Foundation. October.
45
According to the Report of the Canadian Task Force on the Licensure of IMGs (Feb. 2004): In June, 2002,
Canada replaced the Immigration Act of 1976 with the new Immigration and Refugee Protection Act. The
new legislation concentrates on skills, training and potential for successful integration into the Canadian
workforce and society. It is intended to be adaptable and responsive, and to choose workers with flexible,
transferable skill sets rather than specific occupational backgrounds. The Act also provides for the creation
of a new landing class for certain temporary workers, including international graduates of Canadian schools
with Canadian work experience who meet the selection criteria as skilled workers. The legislation has the
potential to ease IMG entry into Canada, and lead to increased numbers of IMGs seeking to establish
medical practice in Canada, promoting self-identification as medical professionals during the immigration
process, and seeking professional integration upon arrival.”
46
Brouwer, A. (1999) Immigrants Need Not Apply. The Maytree Foundation. October.
47
Milne, Celia (2003). In a Foreign Land, The Medical Post- Volume 39, Issue 15, April 15.
48
Canadian Resident Matching Service (CaRMS). http://www.carms.ca/jsp/main.jsp
49
Source: http://www.carms.ca/jsp/main.jsp
50
The Collège des Médecins du Québec (CMQ) also administers certification exams in Family Medicine and
other Specialties (such as Hematology & Microbiology and Infectious Diseases, which are accepted in
Québec, New Brunswick, and in certain circumstances, in other provinces/territories. (source:
http://www.img-canada.ca/en/licensure_overview/licensure.html). Further, to obtain recognition of
equivalence of postdoctoral training, IMGs must also serve a minimum of 12 months in a postdoctoral
training program in a faculty of medicine in Québec.
51
Canadian Information Centre for International Medical Graduates. http://www.img-canada.ca/en
52
Milne, Celia (2003). In a Foreign Land, The Medical Post- Volume 39, Issue 15, April 15.
53
Canadian Information Centre for International Medical Graduates. http://www.img-canada.ca/en
54
Canadian Medical Association- November 22, 1999, Canadian Medical Forum Task Force on Physician
Supply, http://www.cma.ca/index.cfm/ci_id/19522/la_id/1.htm
55
Canadian Information Centre for International Credentials. Information for foreign-trained medical doctors.
http://www.cicic.ca/professions/3112en.asp
56
Canadian Information Centre for International Credentials. Information for foreign-trained nurses.
http://www.cicic.ca/professions/3152en.asp
57
OIIQ (2004). Les infirmières formées à l’étranger et l’accèss à la profession au Québec. November
58
Canadian Information Centre for International Credentials. Information for foreign-trained nurses.
http://www.cicic.ca/professions/3152en.asp
59
http://www.healthmatchbc.org/hmbc_nurses.asp?pageid=630
77
60
According to the website of the OPQ, “in October 2000, the Order submitted a request to the Office des
professions du Québec that the diploma giving access to the permit of the Ordre des psychologues du
Québec be changed from a master's degree to a doctor's degree. Although the Office recently launched a
consultation on this subject with various organizations concerned, it is currently impossible to say when the
Order's admission requirements will be changed.”
http://www.ordrepsy.qc.ca/Eng/public/inscription/05_inscription.asp
61
Mutual Recognition Agreement of the Regulatory Bodies for Professional Psychologists in Canada (2001).
June.
62
College of Psychologists of Ontario. Section E: Academic Credential.
http://www.cpo.on.ca/Registration/Psychologist/RegPsychologistMain.htm
63
OACCPP (1997). Access to Trades & Professions: Breakthroughs. Excerpts from Issue No. 3 (May 1997)
http://www.skillsforchange.org/access/breakthroughs/issue_3.htm
64
The Psychological Association of Manitoba. Guidelines for Applicants for Registration.
http://www.cpmb.ca/documents/GUIDELINES%20FOR%20APPLICANTS%20for%20REGISTRATION
65
Martin, W. (2004). Canadian Midwifery Regulators Consortium’s Research Plan for a National Midwifery
Assessment Strategy. March, College of Midwives of B.C.
66
ACCESS! - the report of the Task Force on Access to Professions and Trades in Ontario (1990), Immigrants
Need Not Apply (1999), Initiatives Affecting the Labour Market Integration of Foreign-Trained
Professionals and Trades Workers (2000), Fulfilling the Promise (2002), Roundtable Proceedings:
Improving Access to the Professions and Trades through Prior Learning Assessment & Qualifications
Recognition for Immigrants in BC (2002), and others
67
Yelaja, Prithi (2000). Rejected in Canada, Doctors Head South. Toronto Star-December 30, 2000.
68
Immen, Wallace (2004) Canada urged to integrate foreign-trained MDs. The Globe and Mail- February 18,
2004.
69
CBC News Online | September 14, 2004. Attracting skilled immigrants: The struggle to lure trained foreign
workers. http://www.cbc.ca/news/background/immigration/skilledimmigrants.html
70
AIPSO (2000). Barriers to Licensing in Ontario for International Physicians Report.
http://www.promptinfo.ca/AIPSOBarriers2%20Jun%2000.pdf
71
AIPSO (2000). Barriers to Licensing in Ontario for International Physicians Report.
http://www.promptinfo.ca/AIPSOBarriers2%20Jun%2000.pdf
72
Harding, Katherine (2003). ‘Nursing is different here’ Innovative programs help newcomers overcome the
massive hurdles of Canadian practices and jargon. Wednesday, January 8, 2003.
http://globeandmail.workopolis.com/servlet/Content/fasttrack/20030108/CANURS?gateway=work
73
http://www.netwercc.com/docs/temp/Powerpoint/INTERNATIONALLYEDUCATEDNURSESJune1_files
/frame.htm
74
Nestel, S. (1996/7). "Ontario Midwifery and the Politics of Race." Health and Canadian Society 4(2): 315341.
75
Brouwer, A. (1999) Immigrants Need Not Apply. The Maytree Foundation. October.
78
76
AIPSO (2000). Barriers to Licensing in Ontario for International Physicians Report.
http://www.promptinfo.ca/AIPSOBarriers2%20Jun%2000.pdf
77
From Access to Ontario’s Regulated Professions by International Candidates Research Report and
Compendium (2003) as cited in Martin, W. (2004). Canadian Midwifery Regulators Consortium’s Research
Plan for a National Midwifery Assessment Strategy. March, College of Midwives of B.C. (p. 11)
78
https://www.mcc.ca/SelfAssessment/english/Introduction.html
79
Eggertson, Laura (2005). News @ a glance International MDs. Canadian Medical Association Journal
May 24, 2005; 172 (11)
80
Eggertson, Laura (2005). News @ a glance International MDs. Canadian Medical Association Journal
May 24, 2005; 172 (11)
81
Canadian Press. Foreign-trained doctors, nurses get boost Tue. Apr. 26 2005
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/1114519023042_12/?hub=Health
82
Canadian Press. Foreign-trained doctors, nurses get boost Tue. Apr. 26 2005
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/1114519023042_12/?hub=Health
83
http://ceris.metropolis.net/Virtual%20Library/other/goldberg2/goldberg2.html
84
http://www.regulators4access.ca/
85
Secretariat, Council of Ontario Universities (2005). OPAS receives funding to help foreign-trained
professionals upgrade skills COUNCIL HIGHLIGHTS February 2005 Issue
86
http://www.health.gov.on.ca/english/providers/project/img/img_faq.html
87
Canadian Press. Foreign-trained doctors, nurses get boost Tue. Apr. 26 2005
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/1114519023042_12/?hub=Health
88
http://www.health.gov.on.ca/english/providers/project/img/img_faq.html
89
http://www.health.gov.on.ca/english/providers/project/img/serv_agreem.html
90
Creating Access to Regulated Employment (CARE) for Nurses Project.
http://www.edu.gov.on.ca/eng/general/postsec/openingdoors/apt/care.html
91
Government of Ontario, News Release. April 29, 2003 Ernie Eves government helps internationally trained
nurses practise in Ontari. http://www.edu.gov.on.ca/eng/document/nr/03.04/nr0429.html
92
http://www.possibilitiesproject.com/features/year5/sep2003/nursing_upd/nursing3.asp
93
Martin, W. (2004). Canadian Midwifery Regulators Consortium’s Research Plan for a National Midwifery
Assessment Strategy. March, College of Midwives of B.C. (p. 14)
94
http://ce-online.ryerson.ca/ce/program_sites/program_default.asp?id=2161
95
International Midwives Pre-Registration Program (Access to Midwifery Pre-Registration Program).
http://www.edu.gov.on.ca/eng/general/postsec/openingdoors/apt/midwifery_fact.html
96
Federal-Provincial-Territorial Working Group on Access to Professions and Trades. (2001). NEWS FROM
MANITOBA. APT UPDATE - Vol. 1, No. 2 - March, 2001. http://www.cicic.ca/apt/apt.vol1.n2.en.asp
79
97
Federal-Provincial-Territorial Working Group on Access to Professions and Trades. (2001). NEWS FROM
MANITOBA. APT UPDATE - Vol. 1, No. 2 - March, 2001. http://www.cicic.ca/apt/apt.vol1.n2.en.asp
98
Manitoba Labour and Immigration (2004). Summary of Activities Related to Qualifications Recognition of
Highly Skilled Immigrants, November. p. 6.
99
Manitoba Labour and Immigration (2004). Summary of Activities Related to Qualifications Recognition of
Highly Skilled Immigrants, November. p. 6.
100
Milne, Celia (2003). In a Foreign Land. The Medical Post Volume 39, Issue 15, April 15, 2003.
101
Government of Manitoba. Medical Licensure Program for International Medical Graduates.
http://www.gov.mb.ca/health/mlpimg/
102
Government of Manitoba. Medical Licensure Program for International Medical Graduates.
http://www.gov.mb.ca/health/mlpimg/
103
Canadian Information Centre for International Medical Graduates. IMG Routes to Licensure in Manitoba.
http://www.img-canada.ca/en/provinces/manitoba/img-training-programs.html
104
Manitoba announces recruitment changes for foreign-trained doctors, Canadian Health Reference GuideFebruary 6, 2003.
105
Manitoba announces recruitment changes for foreign-trained doctors, Canadian Health Reference GuideFebruary 6, 2003.
106
Federal-Provincial-Territorial Working Group on Access to Professions and Trades. (2001). NEWS FROM
MANITOBA. APT UPDATE - Vol. 1, No. 2 - March, 2001. http://www.cicic.ca/apt/apt.vol1.n2.en.asp
107
Groupe de travail sur l’accès aux professions et métiers réglementés (Task Force on Access to Regulated
Trades and Professions) (2005). Summary of Recommendations. February.
108
http://www.micc.gouv.qc.ca/publications/pdf/PlanAction20042007_summary.pdf
109
Canadian Medical Association Physician Workforce: Executive Summary
110
Barer, M. and G. Stoddard. (1991). Toward integrated medical resource policies for Canada. Report of the
Conf. of Dep. Ministers of Health, Department of Ministers of Health.
111
Grant, Hugh (2004). From the Transvaal to the Prairies: The Migration of South Africa Physicians to
Canada. Prairie Centre of Excellence for Research on Immigration and Integration. Working Paper 02-04.
112
Canadian Medical Association Physician Workforce: Executive Summary
113
Canadian Institute for Health Information (2002). Supply and Distribution of Registered Nurses in Rural
and Small Town Canada, 2000. Ottawa: Written by Roger Pitblado, Jennifer Medves, Martha MacLeod,
Norma Stewart and Judith Kulig as part of the Nursing Practice in Rural and Remote Canada Study.
Excerpted from: http://cranhr.laurentian.ca/faq14.html
114
WHO (2003). Strengthening nursing and midwifery, report by the Secretariat, 56th World Health Assembly,
Geneva.
115
Sullivan, Patrick (2005). CMA challenges IMG "facts" before Commons committee Canadian Medical
Association Journal March 11, 2005.
80
116
Martineau, T., K. Decker, et al. (2002). Briefing note on international migration of health professionals:
levelling the playing field for developing country health systems. Liverpool, Liverpool School of Tropical
Medicine. P. 10
117
Sullivan, Patrick (2005). CMA challenges IMG "facts" before Commons committee Canadian Medical
Association Journal March 11, 2005.
118
Sullivan, P. (2005). CMA's concern over HR issues growing, annual meeting proves.
http://www.cma.ca/index.cfm?ci_id=10028212&la_id=1&topstory=1
119
Little, L. (2005). The Canadian Case. Presentation to Bellagio Institute Conference on the International
Migration of Nurses. July.
120
Martin, W. (2004). Canadian Midwifery Regulators Consortium’s Research Plan for a National Midwifery
Assessment Strategy. March, College of Midwives of B.C.
121
Sullivan, Patrick (2005). CMA challenges IMG "facts" before Commons committee Canadian Medical
Association Journal March 11, 2005.
122
Cesa, Frank (2004). International Medical Graduates: A Case Study. Health Policy Research- Issue 8, May
2004.
123
According to a CMAJ (2002, 166(2); 232) article, “Salesman succeeds in bringing MD recruits to BC.”,
“Maurice Leblanc has already brought pharmacists to British Columbia from his native South Africa, and
now he’s doing the same thing with physicians. LeBlanc, who has lived in Mackenzie, a town of 6000 in
northern BC, for a decade, traveled to South Africa in 1999 to find pharmacists for his business. When 4 of
the town’s 5 family doctors left the town last winter, the former salesman approached Dr. Jennifer Rice,
medical director of the Northern Interior Regional Health Board in Prince George, and offered to travel to
South Africa to recruit FPs. He asked for $3000 to help defray his travel expenses; Rice, who was used to
paying recruitment companies $7500 for each doctor they recruited readily agreed. ... He did his homework
carefully, building up a list of contacts and pinpointing the cities where he was most likely to find potential
recruits. During the three weeks he met with 72 doctors and returned to Canada with 20 resumes of wellqualified candidates. Rice was “absolutely thrilled”. Six of the doctors are currently going through official
procedures to immigrate and will be coming to the region, and Rice is directing the others elsewhere.
124
Cesa, Frank (2004). International Medical Graduates: A Case Study. Health Policy Research- Issue 8, May
2004.
125
Silas, L. (2004). Slow the exit Speed the entry. Pre-budget Submission, Standing Committee on Finance,
Hon. Massimo Pacetti, MP, Chair House of Commons, Ottawa, Ontario, November 2004.
126
Dauphinee, W. Dale (2005). Physician Migration to and from Canada: The Challenge of Finding the
Ethical and Political Balance Between the Individual's Right to Mobility and Recruitment to Underserved
Communities. Journal of Continuing Education in the Health Professions 25(1):22-29.
127
Bueckert, Dennis. Doctor’s exodus stirs shortage fear The Vancouver Sun May 11, 1995.
128
Chamberlain, Art. New doctors fleeing south, U of T prof says Medical brain drain blamed on lack of
respect. The Toronto Star September 24, 1997.
129
Ryten, E. et al. (1998). "The Class of 1989 and physician supply in Canada." CMAJ 158(6): 723.-9. Ryten,
E. et al. (1998). "The Class of 1989 and physician supply in Canada." CMAJ 158(6): 723-8.
130
Ma P.C. et al. (1997). “Intention to relocate to the United States.” Canadian Family Physician. 43:1533-9.
81
131
Ryten, E. et al. (1998). "The Class of 1989 and physician supply in Canada." CMAJ 158(6): 723.
132
Canadian Institute for Health Information. (2003). Supply, Distribution and Migration of Canadian
Physicians, 2002.
133
McKendry, R. et al. (1996). "Factors influencing the emigration of physicians from Canada to the United
States." CMAJ 154(2): 171-181.
134
C.I.H.I. (2001). Canada's Health Care Providers.
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_35_E.
135
McKendry, R. et al. (1996). "Factors influencing the emigration of physicians from Canada to the United
States." CMAJ 154(2): 171-181.
136
C.I.H.I. (2005). Supply, Distribution and Migration of Canadian Physicians, 2004.
137
CMA disputes report number of doctors rising. The National Post- August 10, 2001.
138
It is also interesting to note that 75% of duplicate registrations are found in Ontario.
139
Buchan, J. , Parkin, T., & Sochalski, J. (2003). International Nurse Mobility: Trends and Policy
Implications.
140
Secondary registrations identify RNs that are living outside of Canada or RNs employed (or living) in a
Canadian jurisdiction different from the province/territory of registration.
141
Little, L. (2005). The Canadian Case. Presentation to Bellagio Institute Conference on the International
Migration of Nurses. July.
142
Loefler, I. J. (2001). "Medical Migration." Croatian Medical Journal 42(5): 504-505.
143
McKendry, R. et al. (1996). "Factors influencing the emigration of physicians from Canada to the United
States." CMAJ 154(2): 171-181.
144
Joyce, R. E. and C. L. Hunt. (1982). "Philippine nurses and the brain drain." Social Science and Medicine
16(12): 1223-1233.
145
C.I.H.I. (2001). Canada's Health Care Providers.
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_35_E.
146
Bilodeau, H., et al. (2001). "Qu'en est-il de l'emigration des medicins quebecois?" Cahiers de Soc. et de
Demograph. Med. 41(2): 239-261.
147
Webb, R. J. (1997). "Shades of greener grass." Canadian Family Physician 43: 1483-1485.
148
Kasperski, J. (2000). “Too Many Hours, Too Much Stress, Too Little Respect” Ontario College of Family
Physicians- July 19, 2000.
149
Harper, T. (1998) Ottawa blamed for doctor exodus- Cutbacks trigger a brain drain, CMA charges The
Toronto Star- June 10, 1998.
150
Gray, Charlotte (1999). How bad is the brain drain? CMAJ October 19, 1999; 161 (8), 1028-9.
151
Hugh Grant & R. Oertel (1997) The Supply and Migration of Canadian Physicians, 1970-1995: Why We
Should Learn to Love an Immigrant Doctor. Canadian Journal of Regional Science: Spring/Summer 1997.
82
152
Gray, Charlotte (1999). How bad is the brain drain? CMAJ October 19, 1999; 161 (8), 1028-9.
153
Gray, Charlotte (1999). How bad is the brain drain? CMAJ October 19, 1999; 161 (8), 1028-9.
154
Sibbald Barbara (2002). The nursing crisis: "Physicians should ponder what this will mean" CMAJ,
September 3, 2002; 167 (5) http://www.cmaj.ca/cgi/content/full/167/5/535
155
Registered Nurses Assn. of Ontario (2001). "Earning Their Return - When & Why Ontario RN's Left Canada,
and What Will Bring Then Back."
156
Sibbald Barbara (2002). The nursing crisis: "Physicians should ponder what this will mean" CMAJ,
September 3, 2002; 167 (5) http://www.cmaj.ca/cgi/content/full/167/5/535
157
Buchan, J., Parkin, T., & Sochalski, J. (2003). International Nurse Mobility: Trends and Policy
Implications: WHORCNICN.
158
Orzack, L. (1998). Professions and World Trade Diplomacy: National Systems and International Authority. In
Olgiati et al Professions, Identity, and Order in Comparative Perspective. Onati: Institute for International Study
of the Sociology of Law.
159
Bach, S. (2003). International Migration of Health Workers: Labour and Social Issues. Paper prepared for the
Sectoral Activities Department, International Labour Office, July 2003.
160
http://www.pulsehr.com/Resources/Tips_For_Foreign_Healthcare_Professionals.htm#Canadian%20Nurses:
%20Going%20to%20the%20United%20States
161
Aiken, L. H. et al. (2004). "Trends in International Nurse Migration." Health Affairs 23(3): 69-77.
162
Bach, S. (2003). International Migration of Health Workers: Labour and Social Issues. Paper prepared for
the Sectoral Activities Department, International Labour Office, July 2003.
163
Orzack, L. (1998). Professions and World Trade Diplomacy: National Systems and International Authority. In
Olgiati et al Professions, Identity, and Order in Comparative Perspective. Onati: Institute for International Study
of the Sociology of Law.
164
Webb, R. J. (1997). "Shades of greener grass." Canadian Family Physician 43: 1489.
165
Gray, Charlotte (1999). How bad is the brain drain? CMAJ October 19, 1999; 161 (8), 1028-9.
166
The College of Physicians and Surgeons of Ontario. Registration Process.
http://www.cpso.on.ca/Info_physicians/applicants/regist.htm
167
http://www.gov.mb.ca/health/nurses/annualreport.html
168
Buchan, J., & Sochalski, J. (2004). The migration of nurses: trends and policies. Bulletin of the World
Health Organization, 82(8), 587-594.
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