Ethical framework for the recruitment and retention of internationally educated health professionals in Canada

On this page

• Context
• Scope
• Intended audience
• Objectives
• Principles of the framework
  • Global approach
  • Health workforce sustainability
  • Accessible and accurate information for IEHPs
  • Fairness
  • Anti-racism and diversity, equity, and inclusion (DEI)
  • Collaboration
• Next steps
  • Awareness of the framework
  • Reporting on the framework
  • Enablement of the framework

Context

Over the past several years, federal, provincial, and territorial (FPT) governments have been working together on priority actions to support the health workforce in Canada. In addition to measures being taken to bolster domestic supply and retention, a key area of focus has been supporting the attraction and integration of internationally educated health professionals (IEHPs) into the health workforce in Canada.

Canada is among many countries worldwide facing health workforce shortages. In 2022, the World Health Organization (WHO) estimated that global shortages of health workers will reach 10 million by 2030.^{Footnote 1} Immigration of IEHPs is one way that Canada continues to enhance its health workforce. Canada has a long history as a destination of choice for people all over the world, including IEHPs, looking for a new place to work, study, and build their lives.

Globally, IEHPs are increasingly sought after and within Canada, considered critical for addressing growing healthcare needs.^{Footnote 2} The COVID-19 pandemic, which significantly impacted the health workforce, has further intensified this demand. As Canada continues to face an aging population and critical labour shortages in key sectors, such as health care, newcomers are critical to help spur innovation, grow the economy, and support local communities.

However, there are ethical considerations that need to be taken into account when recruiting IEHPs. The WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO Code), developed in 2010, is intended to serve as a guide for Member States on the ethical recruitment of IEHPs including adhering to principles around fairness, transparency and addressing the mutuality of benefits when recruiting internationally. The WHO Code is not meant to curtail migration; rather, it explicitly states that nothing within the WHO Code "should be interpreted as limiting the freedom of health personnel, in accordance with applicable laws, to migrate to countries that wish to admit and employ them" (Article 3.4).

Canada has been a signatory to the WHO Code since its creation in 2010 and as such, has an obligation to abide by the principles outlined therein. In the current context of the Canadian and global shortage of health workers and the increased recruitment of IEHPs to help fill the gap in Canada, there is a need to raise awareness of the WHO Code and adapt it to a Canadian context that is clear, accessible, and relevant to key actors involved in the IEHP journey to Canada.

The Ethical Framework for the Recruitment and Retention of Internationally Educated Health Professionals in Canada ("the Framework") based on the WHO Code, is intended to facilitate the adoption of ethical, responsible, fair, and transparent practices. The Framework includes voluntary considerations that aim to support the ethical recruitment and retention of IEHPs to Canada. IEHPs play an important role in the delivery of health and social care in Canada and should be recruited and supported in an ethically responsible manner. The Framework has been developed in consultation with stakeholders across Canada involved in the recruitment, retention, settlement, and integration of IEHPs, including IEHPs with lived experience. Federal, provincial, and territorial governments, as well as other key actors, continue to be active participants in advancing the ethical recruitment of IEHPs to Canada, and illustrative examples have been included throughout the Framework.^{Footnote 3Footnote 4}

Scope

The Framework is focused on the recruitment, retention, settlement, and integration of IEHPs into the health workforce in Canada. While the significance of settlement and integration of IEHPs into broader Canadian society is recognized, this Framework primarily concentrates on the professional dimension of an IEHP's journey and their integration into professional roles within health systems in Canada.

In the context of this Framework, the term "professionals" for IEHPs is meant to include all professions or occupations that provide health and social care or diagnostic services to populations in Canada, including both in regulated and unregulated occupations.

For clarity and ease of use of the Framework, four key concepts that are relevant to the IEHP journey are described below.

International recruitment refers to the process of attracting, selecting, and appointing suitable candidates from different countries to health-related roles within Canada. There can be active and passive recruitment. However, the distinction between 'active' and 'passive' recruitment may not always be clear and at times may depend on the context and intent of those involved. As such, the distinction between 'active' and 'passive' recruitment may require a judgement call based on the specific circumstance.^{Footnote 5} Notwithstanding, the Framework generally defines active and passive recruitment as follows:

• Active recruitment refers to the process where an IEHP is approached or targeted by officials or actors from Canadian jurisdictions for employment opportunities, with the intention of recruiting the IEHP to a role in the Canadian health and social care sector. It may include both physical or virtual targeting, such as recruitment drives, and these actions may or may not lead to substantive employment. General engagement by Canadian officials with regard to immigration opportunities to Canada (i.e., information sessions on immigration pathways) is not seen to be active recruitment, as this information is generally not connected to specific job opportunities.
• In contrast, passive recruitment refers to the process by which IEHPs determine without direct (virtual or in-person) engagement by Canadian officials or agents, to immigrate to Canada and apply for positions within the Canadian health and social care sector. Individuals may learn about job opportunities from channels such as company websites, international job boards, or social media.

Retention refers to strategies and efforts made to keep all health workers, IEHPs and domestically trained health workers alike, employed within the Canadian health workforce and health and social care system.

Intended audience

The Framework outlines voluntary principles to guide a wide range of actors in the ethical recruitment, retention, settlement, and integration of IEHPs. Actors refer to the relevant players involved in the IEHP journey who have accountability for applying the principles of the Framework.

While each actor may be balancing an array of different priorities, each plays a crucial role in this process and should review, understand and apply these principles, within their roles and context, to contribute to the effectiveness of the Framework and ultimately a cohesive and supportive environment for IEHPs.

Each actor should understand their role and responsibilities regarding their impact on an IEHP's journey and consider the perspective of international health personnel and international health systems capacity. Actors should be aware of monitoring and evaluation practices and collaborate with Health Canada and PT governments to enable the effectiveness of the Framework. Adherence to the voluntary standards and practices may encourage wider awareness and adoption.

The Framework was designed to be as inclusive as possible, but may not have captured all the actors who may benefit from the guidance included. Some actors may be directly involved in the journey of an IEHP, including those that make decisions that directly affect the IEHP. This includes, inter alia, federal and provincial governments, regulators, IEHP assessors, and employers. Other actors may have more facilitative roles or interactions vis-à-vis IEHPs, either directly or indirectly. This includes, inter alia, local communities where IEHPs settle, settlement organizations, workplaces, IEHP advocacy and support services. Academics and researchers also may have an indirect role in supporting the development of evidence-based research to support ethical recruitment and retention of IEHPs.

Finally, there are significant beneficiaries from this Framework, which include IEHPs, their families, as well as the patients receiving health and social care in the Canadian health system.

Figure 1: Text description

The ethical recruitment framework serves as a guide for its intended audience, which is made up of key actors who participate in ethical recruitment. These key actors have been grouped into three categories, though these lists are not meant to be exhaustive, and some implicated parties may not be shown here.

Categories of key actors include:

• Direct actors, such as federal/provincial/territorial governments, regulators, and employers;
• Facilitators, such as settlement organizations and academics/researchers; and
• Beneficiaries, such as internationally educated health professionals and patients.

Objectives

The Framework has 3 objectives:

1. To promote recruitment and retention practices that respect the rights of IEHPs, mitigate negative impacts on the health and social care systems of their home countries, and facilitate their seamless integration into the health workforce in Canada. This objective aims to increase adherence to the WHO Code of Practice, encourage international cooperation, and enhance the sustainability of health systems, particularly in countries facing significant health workforce challenges. It also emphasizes that ethical considerations should underpin all international recruitment and retention activities, advocating for these activities to be closely integrated to support the successful integration of IEHPs into the health workforce.
2. To enhance the Canadian health and social care system and improve patient care through the ethical recruitment and retention of IEHPs. This objective focuses on facilitating the employment of IEHPs in their respective fields to ensure their skills and expertise are fully utilized to positively impact patient care in Canada. Reducing the underutilization of IEHPs also contributes to health system sustainability and helps to address the current health workforce shortage in Canada. This objective also recognizes that ensuring delivery of quality care and culturally safe care, as well as patient safety are critical considerations in supporting integration of IEHPs into the health workforce in Canada.
3. To encourage data-driven approaches to strategic workforce planning, including the recruitment and retention of IEHPs. This objective focuses on the collection and analysis of up-to-date information to support evidence-based decision-making related to health workforce planning. This includes better data, in particular more current data, to understand the role of IEHPs in our health system and to evaluate, assess and monitor the implementation of the Framework, such as supply and distribution data for IEHPs.

Principles of the framework

The Framework is built on a set of guiding principles designed to promote the ethical recruitment, retention, and integration of IEHPs within the health and social care system in Canada. These principles serve as a foundation for ethical practices and provide guidance to actors, from those directly responsible for implementing and monitoring the framework to those who support its application. By adhering to these principles, actors can collectively facilitate a cohesive and supportive process of integrating IEHPs into their chosen professional roles and the communities in which they choose to live.

Global approach

Description

When undertaking recruitment efforts internationally, it is important to be aware of the unique health and health workforce context of source countries and prioritize actions that minimize negative impacts to the health and social care systems of source countries. Communication and dialogue with the appropriate government or authority within source countries for their awareness of recruitment efforts and potential shared benefits should also be undertaken.

To protect countries which face the most pressing health workforce needs, the WHO developed the WHO Health Workforce Support and Safeguards List (WHO Safeguards List), and publishes an updated version every three years. The list currently includes 55 countries which should be prioritized for health personnel development and health system support and provided with safeguards, such as government-to-government agreements or technical and financial assistance. Aligned with the WHO Code, active recruitment of IEHPs from developing countries facing critical shortages is not recommended.

From a Canadian perspective, there may be an interest in engaging with countries whose labour market attributes align with that of Canada's. As a bilingual country, Canadian stakeholders may be interested in engaging with countries where health care providers are primarily French speaking. However, it is a reality that there is a high proportion of French-speaking countries on the Safeguards List.

Active recruitment from countries included on the WHO Safeguards List is not prohibited, but rather needs to be done mindfully and with careful consideration.

To increase the chances of success, jurisdictions are encouraged to signal recruitment efforts in advance to both Immigration, Refugees and Citizenship Canada, and Global Affairs Canada, so that those departments can provide guidance and coordinate efforts with the Government of Canada's diplomatic offices in the host countries.

Any recruitment in these instances should leverage government-to-government agreements, incorporating the following guidelines as best practice, consistent with the WHO^{Footnote 6}:

• Be informed by a health labour market analysis and the adoption of provisions to ensure adequate domestic supply in source countries.
• Explicitly engage health sector stakeholders, including ministries of health, in the dialogue and negotiation of relevant agreements; and
• Specify benefits to the health system of source countries that are commensurate and proportional to the benefits accruing to destination countries.

Furthermore, this Framework recommends that Canadian jurisdictions and actors go beyond those countries listed in the WHO Safeguards List, and apply this bilateral and reciprocal benefit approach with all developing and low-income countries, with a goal of strengthening health systems, including health personnel development.

However, nothing in this Framework should be taken as limiting the right of international mobility for IEHPs (in accordance with applicable laws), especially noting that Canada is and will continue to be a country of immigration, with a long history as a welcoming destination of choice for people from all over the world looking for a new place to work, study and build their lives.

Relevance

Canada is one of many countries affected by the global shortage of health workers. When pursuing active international recruitment, Canadian actors have a responsibility to understand the health system and labour market context of source countries that they plan to recruit from, and to establish communications with relevant source country authorities.

Key features

• Understanding the Health System and Labour Market Context of Source Countries: Conduct rigorous research in order to understand the unique health system and labour market context of target source countries, and the potential implications of international recruitment on their health system and health workforce.
• Communication and Engagement with Source Countries: Establish dialogue and communication with the appropriate government authorities and health system and labour market leaders when planning active recruitment to understand the health workforce context. While many countries may be experiencing health workforce shortages, there are some who have an oversupply of health workers. Dialogue can lead to a shared understanding of the benefits for both Canada and the source country. It is important to have a fulsome view of the context prior to active recruitment and consider how the source country may benefit.
• Shared Benefits: Identify methods to develop and achieve shared benefits (e.g., technical, financial, etc.) with source countries when recruiting IEHPs. Agreements with source countries can be implemented through bilateral agreements, including memorandums of understanding or mutual recognition agreements.

Implications for Canadian actors

Potential implications for Actors regarding global approach include, but are not limited to, the following:

• FPT governments and recruitment organizations could establish contact with relevant authorities in the source country. Canadian embassies and provincial international offices in the source country can be a useful means to help support establishing connections. This communication is of particular importance for active recruitment activities in developing countries, especially those on the WHO Safeguards List.
• FPT governments, educators, and healthcare institutions should provide shared benefits regarding the recruitment of IEHPs from a source country.
• FPT governments and recruitment organizations should conduct research into the educational requirements and training of a health profession in potential source countries, ensuring that the IEHP is able to meet jurisdictional requirements for credential recognition or licensure, and undertake recruitment only where there is an existing pathway for a candidate to practice in their chosen field in Canada.

Reference resources and examples

• WHO Bilateral Agreements: The WHO has published new guidance on Bilateral agreements on health worker migration and mobility. This guidance is intended to serve as a tool for key actors involved in the development, negotiation, implementation, monitoring, and evaluation of agreements related to international health worker migration and mobility, in order to maximize benefits for all countries involved and support international health security.
• Provincial Bilateral Agreements: In Canada, a number of provinces have signed memoranda of understanding with other countries in support of IEHPs. For example, in 2022, the Government of Alberta signed a Memorandum of Understanding (MOU) with the Government of Philippines to bring more registered and licensed practical nurses to the province. In return, the Alberta government will provide financial, educational and licensing assistance to help support transitions to Alberta.
• United Kingdom (UK) Government-to-Government Agreements: The UK has a number of health workforce government-to-government agreements in place and publishes them online, including with India, Kenya, Malaysia, Nepal, the Philippines and Sri Lanka. For example, in August 2022, the United Kingdom (UK) published a Memorandum of Understanding between the governments of the UK and Nepal on the recruitment of Nepali healthcare workers in accordance with their respective existing national laws and regulations. The release notes it is important to ensure the MoU helps manage health worker migration and is beneficial to the health worker and Nepal, as well as the UK.

Health workforce sustainability

Description

Health workforce sustainability refers to the ability of a jurisdiction to independently develop and maintain a health workforce capable of meeting the healthcare needs of the population, thereby reducing reliance on active recruitment of IEHPs. Strategic workforce planning, reducing the underutilization of IEHPs, and investment in education, training as well as investments in retention of health professionals are key to achieving health workforce sustainability in Canada, while managing domestic realities, such as population aging. Underutilization of skills impacts multiple sectors, including health. Underutilized IEHPs are unable to exercise their full scope of practice or utilize the level of education and training acquired in their country of origin. This encompasses individuals who:

• Are employed within the healthcare sector but at a level lower than their education and skill attainment, or
• Are not employed within the healthcare sector.

Relevance

Canada requires a sustainable health workforce to ensure that healthcare needs are met across all regions and populations. Strategic health workforce planning, which may encompass identifying innovative care models for Canadian jurisdictions, expanding scopes of practice for health professionals, and reducing underutilization of health professionals, is needed to improve and strengthen the health and social care system.

Key features

• Strategic Health Workforce Planning: Develop and employ robust workforce planning mechanisms that considers short- and long-term health workforce needs, such as further domestic training as well as both domestic and international recruitment. This includes identification of the actual need for IEHP recruitment and to align active IEHP recruitment activities with jurisdictional health priorities and needs.
• Prioritize Reduction of Underutilization of IEHPs: To prevent an increase in the number of underutilized IEHPs and work towards a sustainable health workforce, actions should be taken to support IEHPs who are in Canada to enable them to contribute in a meaningful way to the health sector prior to further active recruitment, e.g., developing supported pathways for IEHPs to gain employment within their chosen health professions. IEHPs should only be actively recruited when there is demonstrable evidence of a profession shortage. This is to prevent the scenario where IEHPs are invited to Canada and then struggle to find employment because of insufficient healthcare demand. IEHPs should not be actively recruited internationally when Canada cannot provide the necessary training or additional opportunities for these professionals to meet the standards of practice in Canada.
• Investment in Education, Training and Retention: In line with the WHO Code, invest in education and training and retention strategies for both domestic health professionals and IEHPs already within Canada to reduce the need to actively recruit international health personnel. For source countries whose education and training differ significantly from Canada, there should be efforts made to create pathways in Canada to enable those IEHPs to meet Canadian standards and requirements. Provinces and territories should strive to ensure that IEHPs and domestic health professionals alike are able to access education, training, and continuous professional development.

Implications for Canadian actors

Potential implications for Actors regarding health workforce sustainability include, but are not limited to the following:

• FPT governments and regulatory bodies should strive to understand current barriers in policies or processes and develop solutions and pathways to enable IEHPs to perform at their full scope of practice.
• FPT governments, regulatory bodies, and educators should develop or expand required education and training programs or services to fill existing gaps to allow health professionals, regardless of source country, to secure licensure and/or pass required assessments and exams.
• Support to enhance domestic training capacity should be prioritized in health workforce planning.
• PT governments, educators, and regulators should create and identify clear pathways for IEHPs to transition to alternate health professions, where appropriate, or to enable career advancement, to ensure that they are able to work at the top of their scope of practice based on previous training and work experience.
• Healthcare institutions, professional associations, educators, and employers should provide opportunities for mentorship and networking for IEHPs.
• Healthcare institutions, employers, and other relevant actors should identify and implement various retention strategies to help keep health workers in their jobs and professions.

Reference resources and examples

• Alberta Bill 203 (PDF format): Alberta established Bill 203, the Foreign Credential Advisory Committee Act, to facilitate the recognition of foreign credentials in Alberta.
• The Canadian Association of Schools of Nursing (CASN) IEN Mentorship Program: The program was launched in 2024, with funding from Health Canada, and aims to address the retention and integration of Internationally Educated Nurses (IENs) into the Canadian workforce by reducing transition stress and culture shock. The mentorship program views IEN integration as a two-way process, wherein IENs receive transition support and the health care agencies recruiting them provide an equitable and inclusive workplace to respect diversity.
• College of Nurses of Ontario (CNO) Supervised Practice Experience Partnership (SPEP): This program enables nursing applicants to demonstrate nursing knowledge, skills, judgement, and language proficiency skills to enable registration with the CNO. As of January 2024, 2,900 IENs have received licensure through the program.
• The Directions for Immigrants Study Groups: Directions for Immigrants is a no-cost career service center that helps IEHPs secure professional employment and gain accreditation. They offer free study groups for IEHPs in Alberta who are preparing for Canadian licensure exams or who want to enhance their understanding of the Canadian workplace and job search process. The program also offers job search workshops and individual career coaching sessions.
• Domestic Supply: FPT Governments across Canada are taking action to bolster the domestic supply and retention of health workers, including the development of Indigenous human health resources. On October 12, 2023, FPT Health Ministers reaffirmed their commitment to supporting the health workforce in Canada with a focus on a number of key priorities, including: retention; domestic education and training; foreign credential recognition; labour mobility across jurisdictions; and health workforce data and planning. Key actions include: the creation of Health Workforce Canada, to improve the availability, sharing and standardization of health workforce data to improve planning; a study on the education and training supply and demand for key healthcare professions to identify the best pan-Canadian approaches to meet future healthcare demands for Canadians over the next decade, including addressing misalignment in the distribution of workers across regions and settings; and the release of the Nursing Retention Toolkit: Improving the Working Lives of Nurses in Canada, which focuses on eight core themes with corresponding initiatives that nursing employers can implement to help improve retention.
• The Halton Multicultural Council (HMC) Connections project: The project ended on March 30, 2024, and aimed to support IEHPs to find employment, by providing career planning, job searching, additional training and connections with local health care establishments.
• Healthcare Excellence Canada's Health Workforce Innovation Challenge: This initiative from Healthcare Excellence Canada ran from 2023 to 2024 and was designed to support and spread workforce innovations that improve the working conditions for health workers and patient care. The challenge was open to teams from across Canada and offered funding, coaching, and support to implement and spread their workforce innovations. The initiative was focused on innovations that improved work-life balance, enhanced job satisfaction, and created a more resilient health workforce.
• The Immigrant Services Association of Nova Scotia (ISANS) National Healthcare Language (NHL) Program: The NHL program is designed to help IEHPs develop the communication competencies they need to succeed in the healthcare field. The course content focuses on patient interactions and includes other relevant profession-specific tasks. The NHL program is delivered online across the country and includes modules on medical terminology, patient interaction, and documentation.
• Jurisdictional Example of Workforce Supply Efforts: Nova Scotia's recruitment priorities include ethical international recruitment partnerships as well as developing a domestic pipeline through academic partnerships, program expansions and student engagement. Nova Scotia's efforts to tap into the potentially underutilized domestic IEHP workforce include partnering with regulators to create more streamlined licensure pathways to match IEHPs to roles that match their skills and qualifications while also providing entry points into the occupation (for example NS' new Emergency Medical Responders role in paramedicine) as well as career laddering (leveraging practice and training equivalencies to be able to bridge into advancement positions like Primary Care Paramedics).
• Jurisdictional Bridging Programs: A number of PTs, including relevant jurisdictional actors, are supporting programs to enable IEHPs to bridge into the profession in which they were trained or to seek employment in alternative health professions. For example, the Ontario Bridge Training Program (OBTP) provides support to internationally trained newcomers to find jobs that align with their previous education and experience, including access to occupation-specific training and licensure in various sectors. In the health care sector, examples of current OBTP initiatives include targeted training programs for IENs and alternative career training in healthcare, promotion, education and public health for international medical graduates (IMGs). Ontario also offers the Nursing Program Transformation Initiative, which includes an IEN to Registered Practical Nurse (RPN) or Registered Nurse (RN) pathway, a Personal Support Worker (PSW) to RPN, and an RPN to BScN bridging pathway. Additionally, the Ontario Internationally Educated Physical Therapy Comprehensive Bridging Program is designed to provide internationally educated physiotherapists (IEPTs) with educational and clinical opportunities to succeed with their national exams and in the Canadian workplace.
• Nova Scotia Refugee Opportunities: Nova Scotia has successfully leveraged immigration pathways, like the Economic Mobility Pathways Pilot (EMPP), that have allowed NS to recruit Continuing Care Assistants from Kenya, providing skilled refugee workers with the opportunity to contribute to the province's healthcare system, while offering them a pathway to permanent residence in Canada. Similar to NS, other PTs have also leveraged the EMPP to provide opportunities to refugees and other displaced people in the healthcare sector.
• Ontario Internationally Educated Physicians Advisory Committee (IEPAC): Building on Ontario's ongoing work to grow the health workforce, the IEPAC works with the province to break down barriers to make it faster and easier to recruit, license and register internationally educated physicians and medical graduates so they can begin working in Ontario and caring for patients sooner.
• The University of Toronto Physiotherapy Practice within the Canadian Health Care Context Program: This course is designed to provide internationally educated physiotherapists with an understanding of the Canadian healthcare system, culture, and context for practice. Learners are exposed to a diverse range of topics including: cultural competence, the role of the federal and provincial governments, acts and regulations guiding PT practice and client-centered care in a variety of PT roles and settings.

Accessible and accurate information for IEHPs

Description

Communication with IEHPs related to recruitment and employment should be accurate, accessible, open, and transparent. Communication products should also be developed from the perspective of IEHPs. This extends to the provision of comprehensive information from actors to IEHPs starting from initial recruitment and immigration, all the way to settlement and integration.

Relevance

The immigration system and professional accreditation processes are complex and may involve multiple steps at the provincial, territorial, and federal levels. IEHPs have stated that there is a lack of accessible and integrated information to inform IEHPs on decision-making pre and post arrival in Canada, which can create barriers and knowledge gaps.

Key features

• Communication on Recruitment Processes and Pathways to Licensure: Provide clear, accurate and timely information to IEHPs about recruitment, immigration, and licensure processes. This includes providing accessible, realistic information about the complexity, cost, and time associated with foreign credential recognition and licensure to practice in Canada.
• Communication on Working and Living Environments in Canada: IEHPs should be informed of the scope of their profession, employment conditions, rights, and obligations, as well as the realities of practicing in Canada, and anticipated lifestyle.
• Informed Decision-Making: Facilitate informed decision-making by providing full and transparent information about the terms and conditions of recruitment and employment before commitments are made.
• Integrated Information: Supporting provision of integrated, comprehensive information to IEHPs is critical and will likely require collaboration between actors. Collaborative efforts to provide information that is not only relevant and accurate, but also interconnected, seamlessly aligning with other steps in their professional journey will be important.

Implications for Canadian actors

Potential implications for Actors regarding accessible and accurate information for IEHPs include, but are not limited to, the following:

• The Federal government should continuously improve accessible communication materials related to immigration timelines, requirements and procedures, clearly convey that these timelines and requirements are distinct from professional accreditation processes. Materials should also articulate that immigration procedures, are separate from and do not contribute towards professional accreditation.
• Regulatory bodies should develop accessible communication materials related to timelines and requirements for licensure acquisition, ideally in partnership with FPT governments and with direct reference to immigration timelines and requirements, to support IEHPs' understanding of their immigration and licensure journeys.
• FPT governments, recruitment organizations, and employers should provide comprehensive information regarding the community where the IEHP (and their families) will settle and the realities of living in particular Canadian jurisdictions, such as cost of living, housing, health care services, child care, and transportation. These actors should also work collaboratively to provide access to resources to assist IEHPs with settlement and integration, and foster welcoming communities. This also includes education for employers to support their role in IEHP integration.
• FPT governments, regulatory bodies, employers, and other relevant actors should model transparency and accountability amongst and between one another in the recruitment process.

Reference resources and examples

• The Alberta International Medical Graduates Association (AIMGA): AIMGA offers a comprehensive range of programs and services to IMGs to facilitate their successful integration into the Canadian health care system. These services include, among others: (i) information and orientation sessions, including an overview of the pathways to licensure, services and programs, and career sessions; (ii) one-on-one consultations assisting with applications, resumes, and interview preparation, etc.; (iii) observership/mentorship opportunities; (iv) exam study groups; (v) conducting needs assessments of members; (vi) a Career Transition Program assisting IMGs who are considering an alternative career pathway in health; and (vii) workshops on various topics based on the needs of IMGs. AIMGA also offers a number of learning programs to enhance knowledge on specific topics, including patient-centred care, communication skills, cultural competence, working within the Canadian healthcare system, application processes, resumes, interviews, and exam preparation. AIMGA also undertakes research and evaluation and advocates for IMGs in Canada.
• The National Newcomer Navigation Network (N4): N4 is a national network for the diversity of providers who assist newcomers in navigating the complex Canadian healthcare and social service systems. The IEHP Research Hub is a comprehensive online platform that provides IEHPs with a variety of resources, tools, reports, and an up-to-date list of supports in their journey to practice in Canada. In addition, the Research Hub provides resources for organizations supporting IEHPs (stakeholders) and employers, such as toolkits, checklists, webinars, and resource libraries. It promotes collaboration, knowledge sharing and integration of IEHPs into provincial/territorial healthcare systems.
• Jurisdictional Example of Prioritization of Accessible and Accurate Information: Nova Scotia prioritizes providing accurate, transparent, and accessible information to IEHPs and is actively working with settlement partners to map the IEHP journey, in particular for registered nurses, focusing on a targeted action plan with partners like the Immigrant Services Association of Nova Scotia (ISANS) and Nova Scotia Internationally Educated Nurses Network (NSIENN). Nova Scotia's More than Medicine recruitment portal provides healthcare job seekers with a single entry point approach that streamlines the recruitment approach by including job postings and access to information and resources on immigration pathways and community information about NS.

Fairness

Description

Health professionals who have met the requirements and standards of their profession in Canada, regardless of country of origin or training, should have the same legal rights, benefits, working conditions, and responsibilities as domestically trained health professionals. This principle emphasizes the importance of equitable treatment and non-discrimination.

Relevance

A key principle of the WHO Code is the equitable and fair treatment of migrant health workers. While this may seem to be an obvious element, and one that is covered by labour laws in Canada, IEHPs have observed differences in their treatment as health professionals in the workplace compared to their domestic counterparts, despite meeting the same Canadian standards and requirements.

Key features

• Equal Treatment: There should be equal opportunities and requirements for both domestic and internationally educated health professionals. For example, mandating return of service in rural, remote, or underserved areas to IEHPs but not to domestic health professionals, may place vulnerable individuals (i.e., IEHPs) who are learning and adapting to the Canadian system, in a position of providing services to a vulnerable population in areas with a scarcity of resources. Improved professional and community supports to help enable the success and integration of IEHPs in rural and remote areas are particularly important in these instances.
• Respecting Rights: IEHPs should receive equal remuneration and be safeguarded by the same legal statutes as domestic health professionals. IEHPs are entitled to the same rights, protections, and legal recourse as domestically trained health professionals and should not be subjected to discrimination or unfair treatment in their professional practice.
• Professional Growth: IEHPs should have the same access to professional development such as educational opportunities, training, and mentorship, as their domestic counterparts.
• Communication: It is possible that there are valid reasons for different treatment for IEHPs from Canadian trained health workers, and that the unfairness aspect is perceived by IEHPs rather than being actually unfair. When perceived unfairness, rather than actual biases, underscores observed differences, it suggests there is a communication gap with IEHPs that needs rectification.

Implications for Canadian actors

Potential implications for Actors regarding fairness include, but are not limited to, the following:

• Employers and unions should ensure that IEHPs are compensated fairly and have the same employment rights and conditions as their domestic counterparts.
• FPT governments should review and/or consider implementing fairness acts, or related acts, to ensure the equal treatment of IEHPs.
• Employers should review responsibilities that are tasked to IEHPs, but not to their domestic counterparts, and evaluate if there is basis to assign the responsibilities to IEHPs exclusively.
• Employers should draft contracts in a manner that is clear and comprehensible and encourage IEHPs to seek further clarification if needed.
• Employers, are encouraged to have open dialogue and communication with IEHPs to avoid perceived unfair treatment.

Reference resources and examples

• Federal, Provincial and Territorial Employment Standards: The Government of Canada provides a link to the various provinces and territories for employment standards. Healthcare professionals should consult the employment standards for their province or territory to understand their rights and obligations.
• Provincial and Territorial Employment Standards Offices: Each province and territory has an employment or labour standards office that deals with labour and employment laws. They talk to individuals about fair pay, hours of work, rest periods and working conditions, and provide other services as well.
• The Government of Canada Rights in the Workplace: The Government of Canada webpage outlines the right Canadians have to be treated fairly in workplaces free from discrimination, as well as laws and programs to protect this right.
• Nova Scotia's Legislative Framework: Like other jurisdictions, Nova Scotia is committed to ensuring fairness in the treatment of IEHPs. Through a range of different legislative frameworks and standards, Nova Scotia ensures equal treatment of IEHPs and domestically trained professionals, including equal pay and working conditions as well as measures to address non-compliance.
• Ontario Office of the Fairness Commissioner (OFC): This office was created in 2006 to help ensure that Ontario's regulated professions and trades have registration practices that are transparent, objective, impartial and fair for everyone, regardless of where they were educated or trained. Similar offices have been established in other Canadian jurisdictions.
• Streamlining Existing Regulatory Pathways: Ontario's Regulated Health Professions Act was amended to prohibit health regulatory colleges from requiring Canadian experience as a registration requirement unless an exemption is provided for in regulation. Additionally, regulations under the Act permit applicants to use a language proficiency test approved under the Immigration and Refugee Protection Act for registration with a health professional regulatory college.

Anti-racism and diversity, equity, and inclusion (DEI)

Description

Combating racism and fostering a diverse, equitable and inclusive environment within the health and social care sector for all health professionals, regardless of country of origin or training is essential. This principle emphasizes the importance of recognizing and addressing systemic inequities, promoting cultural competence, and ensuring that all health professionals, including IEHPs, are treated with respect. Health care system players are responsible for providing resources to IEHPs to support their understanding of the Canadian cultural context, including culturally safe and competent care, and educating those who interact with IEHPs on their potential cultural biases.

Relevance

IEHPs have observed bias from employers with a preference for Canadian health professionals and experienced discrimination by several system actors throughout their journey within the Canadian health and social care system. These experiences contribute to a negative work environment where IEHPs do not feel valued or included and may lead to further loss of the health workforce. Additionally, IEHPs have cited that there is a need for education regarding the cultural context of practice within the Canadian healthcare system to support successful delivery of care, including culturally safe care. When perceived discrimination, rather than actual biases, underscore observed differences, it suggests a communication gap with IEHPs that needs rectification.

Key features

• Commitment to Anti-Racism: Actively identifying, addressing, and eliminating racist policies, practices, and behaviours within healthcare organizations.
• Promoting DEI: Embracing diverse backgrounds and experiences of all health professionals, encouraging diverse representation at all levels of the health workforce, and building inclusive work environments where health professionals feel valued, respected, and supported.

Implications for Canadian actors

Potential implications for Actors regarding anti-racism and DEI include, but are not limited to, the following:

• FPT governments, healthcare institutions, educators and employers should develop and promote cultural bias training to those who are involved in the IEHP journey to reduce the discrimination that IEHPs face. The health workforce should be trained on how to support integration of IEHPs and provided cultural training that enables them to embrace diversity in the work place. This could include proactively providing the workforce with information on the timeline for integrating IEHPs and potential benefits.
• Educators, healthcare institutions, and employers should develop and provide cultural competency training for IEHPs.
• Professional associations, regulatory bodies, and employers should provide anonymous reporting channels or delegate a representative for IEHPs to file reports or complaints. Awareness of these channels should be promoted, as well as the regular review and action of reports.
• FPT governments, regulatory bodies, professional associations and additional relevant actors should include the voice of IEHPs in strategic planning.

Reference resources and examples

• Nova Scotia Health Equity: NS' efforts to combat systemic inequities include efforts to adopt mandatory cultural competence and anti-racism training in healthcare, with a specific focus on understanding the challenges faced by IEHPs. This is emphasized under the Provincial Health Equity Framework. These initiatives, led by employers and regulators, work toward a more inclusive environment, ensuring that all health professionals, regardless of their background, are respected and supported in their practice.
• Nova Scotia OHPR Community Fund: This initiative by the Office of Healthcare Professionals Recruitment (OHPR) was designed to support communities in Nova Scotia in their efforts to recruit, welcome, and retain healthcare professionals. Projects eligible for funding included those supporting recruitment, retention and welcoming healthcare professionals to communities; helping reduce social and cultural barriers to recruiting and retaining healthcare professionals through initiatives that support equity, diversity and inclusion; and developing the capacity of communities to be successful in recruiting and retaining healthcare professionals.
• The British Columbia College of Nurses & Midwives (BCCNM) Practice on Cultural Safety: The BCCNM published practice standards for the nursing profession in British Columbia regarding cultural safety and humility in healthcare. Indigenous-specific racism and discrimination negatively affects Indigenous clients' access to health care ​and health outcomes. Core concepts of the Indigenous Cultural Safety, Cultural Humility, and Anti-Racism practice standard include self-reflective practice, building knowledge through education, and person-led care. It also provides reflection questions and potential actions that can be taken to apply each principle.
• The Ontario Health Cultural Competence in Healthcare for Ontario Health Employees Course: This program offered by Ontario Health is certified by the College of Family Physicians of Canada. The course aims to enhance understanding of cultural competence in healthcare, including the patient's perspective and how to incorporate it into the healthcare setting. The course is structured with pre-reflective questions, interactivity guides, and chapters on defining the cultural continuum, cultural competence in healthcare, and putting cultural competence into practice, and stresses the importance for frontline healthcare professionals to understand and apply First Nations, Inuit, Métis and urban Indigenous cultural sensitivity and safety to provide effective care.
• The Government of Ontario Anti-Racism Directorate Resources: The Data Standards for the Identification and Monitoring of Systemic Racism, also known as Ontario's Anti-Racism Data Standards (Standards) were established to help identify and monitor systemic racism and racial disparities within the public sector. The Standards establish consistent, effective practices for producing reliable information to support evidence-based decision-making and public accountability to help eliminate systemic racism and promote racial equity. The Standards set out requirements, rationale, and guidance at every stage from planning and preparation to analysis and reporting. This includes, collecting, using, disclosing, de-identifying, and managing information, including personal information.
• Alberta Taking Action Against Racism: The initiative aims to combat racism, promote social inclusion and celebrate diversity and multiculturalism. It outlines the government's commitment to lead by sharing the value of diversity, removing systemic barriers to accessing government programs and services, and ensuring Albertans have fair access to information, resources, services, and opportunities.
• Mandatory Intercultural Competency Training in the Atlantic Immigration Program (AIP): The AIP is an employer-driven program that allows the Atlantic provinces to prioritize sectors with immediate labour market needs, including the healthcare sector. The Program was designed with the needs of the healthcare sector in mind and has flexibilities that allows it to respond to this critical labour market need. Before employers make a job offer to hire a candidate through the AIP, they must first become designated by the provincial government of the Atlantic province where the candidate will be working. To become a designated employer, two training courses need to be completed: the onboarding training and the intercultural competency training (ICT). The ICT covers important topics such as creating welcoming and culturally inclusive workplaces, newcomer experiences and cultural awareness.

Collaboration

Description

This principle highlights the importance of coordinated efforts among Canadian actors involved in the IEHP journey. Collaboration is essential for the overall effectiveness of the Framework. When developing initiatives impacting IEHPs, organizations should consider if additional stakeholders need to be engaged. A multi-stakeholder approach is needed to ensure that the recruitment, retention, settlement, and integration of IEHPs is as seamless and streamlined as possible in all provinces and territories, and to ensure that accurate and timely data is collected and made available across Canada. Knowledge sharing and continuous communication between various actors is needed to establish and deliver connected pathways for IEHPs to gain employment and access support.

Relevance

Disconnects between Canadian actors can lead to numerous barriers and difficulties for IEHPs navigating through recruitment, settlement, and integration, which includes the immigration and licensure processes. Multistakeholder approaches can help to address current gaps and barriers that prevent IEHPs from working in roles that match their education and experience. Additionally, these efforts can enhance understanding of the existing pathways, processes, requirements as well as current efforts to support IEHPs.

Key features

• Integrated Support Systems: Deliberately build relationships between key actors, such as government agencies, regulatory bodies, employers, and settlement and integration organizations to establish integrated and coordinated support systems for IEHPs. This includes government bodies and organizations involved in immigration, foreign credential recognition, employment, settlement, and others. Effective integrations of IEHPs into the Canadian health workforce includes, but is not limited to, efforts to provide clear and accessible information, navigation supports, financial support, occupation-specific language training (if needed), and workplace mentoring.
• Continuous Communication: Regular and open communication among actors is needed to align efforts, reduce duplication of efforts, and share leading practices to continuously improve support services for IEHPs.
• Considering Canadian Context Challenges: Develop solutions collaboratively for recruitment, retention, and integration that factor in unique characteristics within each jurisdiction, such as geographic disparities, patient population, and linguistic duality.

Implications for Canadian actors

Potential implications for Actors regarding collaboration include, but are not limited to, the following:

• FPT governments should coordinate their recruitment, retention, and integration activities when recruiting from the same source countries.
• There should be regular forums for key actors (e.g., PT governments, employers, professional associations, regulators, IEHPs, and settlement and immigration organizations) to discuss and develop potential solutions for the current gaps in the IEHP journey.
• Opportunity to implement pan-Canadian approaches with regards to common pathways to licensure for different professions. Elements of such approaches exist but could be enhanced and improved to help improve Canada and all its jurisdictions as a destination of choice for IEHPs.

Reference resources and examples

• Healthcare Excellence Canada's (HEC) Policy Lab and Report on the Retention of Internationally Educated Healthcare Workers (IEHW): In January 2024, HEC held a policy lab to explore ways to retain IEHW. Policy labs are structured co-design processes. Participants work together to solve complex policy questions. They use the best available evidence and lived experiences of participants. Its goals were: to understand factors that influence successful retention of IEHW; and to co-design appropriate policy solutions and strategies across the multiple sectors that influence retention of IEHW. Based on background evidence, collaborative design work during the policy lab and follow-up interviews, participants identified eight policy considerations to support IEHW retention, as well as several systemic challenges. The collaborative policy lab process included IEHWs, policy-makers, community leaders, researchers, subject matter experts, patient partners and representatives from professional associations and regulatory bodies. This work is captured in HEC's August 2024 report entitled Policy Considerations for the Retention of Internationally Educated Healthcare Workers.
• Jurisdictional Example of Collaborative Efforts: Nova Scotia has engaged in multi-stakeholder collaborations, including memorandums of agreement with international educational institutions in other countries for physicians, partnerships with employers, health authorities, regulators and community partners under the $2M Office of Healthcare Professionals RecruitmentCommunity Fund. This works toward a whole of system approach to recruitment, settlement and retention. Nova Scotia also works closely with several partners at the provincial and federal government levels with regard to international recruitment. Many of those partners include embassies, immigration and settlement support organizations.
• N4 "A Missing Part of Me" Report (PDF format): N4 published a pan-Canadian report on the licensure of IEHPs. The report explores barriers that IEHPs experience on their path to licensure in Canada, along with facilitating factors through consultation with 76 individual and organization stakeholder visits in 2022. The N4 team discovered overarching, pan-Canadian barriers, and promising facilitators that organizations and policy makers can explore.

Next steps

FPT governments will be responsible for leading the implementation, supporting the adoption, and evaluating and monitoring implementation of the Framework.

Awareness of the framework

To promote the awareness of the Framework, FPT governments will work collaboratively to increase awareness of the Framework with relevant actors. This could include, but is not limited to:

• the creation of actions plans related to the ongoing implementation of the Framework.
• press or media releases through the use of social media and organizational newsletters, to highlight the benefits of the Framework and encourage its use.
• webinars and drop-in sessions to explain the Framework in detail, which will help promote a comprehensive understanding of the Framework

Reporting on the framework

FPT governments will collaborate to support periodical reporting on the implementation of the Framework. This can be actioned through the Committee on Health Workforce, a federal-provincial collaborative table that considers issues related to the health workforce in Canada. For efficiency, periodical reporting will align with the reporting requirement (i.e. every 3 years) used by the WHO for Member State reporting for the WHO Code.

To enable robust and relevant reporting, the development of metrics is recommended. Metrics will help assess the relevance and effectiveness of the Framework. In addition, better data on the IEHP landscape in Canada will be of significant value to assist in both implementation of actions under the Framework and reporting.

Enablement of the framework

FPT governments will work with actors to support efforts and initiatives made for the recruitment, retention, settlement, and integration of IEHPs. Initially, this will focus on identifying appropriate tools and resources that can be of value to various actors to support implementation.