The ethics of recruiting international health-care workers: Canada’s gains could mean another country’s pain
By Margaret Walton-Roberts, Wilfrid Laurier University and Ivy Lynn Bourgeault, L’Université d’Ottawa/University of Ottawa
Canadians know we are facing a health workforce crisis, from the estimated 6.5 million who do not have a primary care provider, to those waiting months for medical imaging and hours in emergency rooms. While the World Health Organization (WHO) declared the COVID-19 Public Health Emergency over in May 2023, Canada’s health workforce crisis has no end in sight.
As researchers with the Canadian Health Workforce Network, we see the roots of this crisis in poor workforce planning and the inadequate integration of immigrant health workers. The consequences of poor planning are evident, as are the ethical ramifications of solving our problems through global recruitment.
Canada’s health workforce crisis is more than a national issue
The Canadian Academy of Health Sciences and the Royal Society of Canada established an expert panel to assess Canada’s role in global health and identify opportunities for Canada to “be true to its announced values of equity, human rights, and global citizenship.”
One way to promote Canadian health leadership is to align practices with the WHO’s Global Code on the Practice of International Recruitment of Health Personnel. This voluntary code was agreed to by all member states in 2010. Its key principles are ethical recruitment, a commitment to planning and international co-operation.
- Ethical practices include discouraging active recruitment from countries listed on the WHO’s health workforce support safeguards list, which identifies “countries with the most pressing health workforce needs related to universal health coverage.”
- Robust health workforce planning strategies include strengthening health workforce data and implementing plans with a goal of health workforce sustainability and self-sufficiency. Robust data can ensure policies and planning are evidence-based, and document the impact of international recruiting on health systems. The goal should be sustainable, self-sufficient health workforces, including appropriate education, training and retention policies.
- International co-operation between source and destination countries includes technical assistance and financial support to ensure benefits are mutual.
Why is the WHO Code important to reflect upon now?
Recent Canadian health workforce reports identify the recruitment and integration of internationally educated health personnel (IEHPs) as part of the solution to the health worker crisis. The Parliamentary Standing Committee on Health held hearings on addressing Canada’s health workforce crisis, and the top four recommendations from its March 2023 report all referenced IEHPs:
- greater collaboration between all levels of government and relevant stakeholders to streamline the process to recruit from countries that are known to train more health workers than they need domestically;
- to provide more residency positions for international medical graduates;
- expand pathways to qualifying for a licence to practice medicine in Canada (licensure) for international physicians who have already completed their residency; and
- support expedited pathways to licensure and practice.
The Canadian Academy of Health Sciences report also offers “pathways forward to ease the health workforce crisis,” including improving the integration of IEHPs.
Provincial recruiting strategies
Sub-national governments are also focused on international recruitment and integration. In British Columbia, Health Match BC is assisting health professionals to immigrate, and legislation now makes it easier for internationally educated nurses to work in the province.
Alberta developed a health workforce strategy that includes attracting IEHPs. Saskatchewan launched an international health worker pool for Provincial Nominee Program candidates. Manitoba started recruiting health-care workers directly from the Philippines.
Ontario has both made it easier for health workers from other provinces to practice there, and also directed its licensing bodies to streamline integration processes for immigrants in the province with a nursing or medical credential.
Québec launched an international recruitment drive to hire over 1,000 French-speaking nurses in February 2022.
New Brunswick partnered with Vitalité Health Network to send nurse recruiters to Senegal and Ivory Coast (countries on the WHO’s safeguard list). Nova Scotia has recruited 65 refugees from Kenyan refugee camps who will be employed in the continuing care sector. Newfoundland and Labrador has launched a mission to recruit nurses directly from India.
How compatible are these practices with the WHO Code?
Recruitment and integration efforts have seen provinces develop novel and seemingly ethical plans to recruit IEHPs and provide them a pathway to practice in Canada. However, recruiting health workers from countries on the WHO’s safeguard list without robust and reciprocal benefits for the countries sending them fails the ethical test.
Merging employment and refugee selection channels also suggests ethical concerns beyond health workforce issues, since refugee systems are based on the vulnerability individuals face, not their occupational compatibility.
The absence of health workforce planning discussions is notable. Canada’s ability to approach self-sufficiency is limited by its lack of robust plans, and by the lack of data to support planning. This includes how immigration fits into the health workforce. The proposal to establish a Centre of Excellence on health worker data can begin to address these gaps.
Siloed responses from health and international development government ministries means we miss opportunities to support international co-operation and develop integrative solutions to health workforce issues beyond Canada’s own international recruitment efforts.
We encourage greater attention to these different facets of the WHO Code as national, provincial and territorial governments seek to address their present and ongoing health workforce challenges. This approach would be more in keeping with Canada’s role on the global stage than is presently the case.
Margaret Walton-Roberts, Chair professor, Geography and Environmental studies, Wilfrid Laurier University and Ivy Lynn Bourgeault, Professor, School of Sociological and Anthropological Studies, L’Université d’Ottawa/University of Ottawa
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