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Health Human Resources & Foreign Medical Graduates

Country: 
Canada
Partner Institute: 
Centre for Health Economics and Policy Analysis, McMaster University, Hamilton
Survey no: 
(15) 2010
Author(s): 
Michel Grignon
Health Policy Issues: 
Political Context, Access, Responsiveness, HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no
Featured in half-yearly report: Health Policy Developments 7/8

Abstract

Perceived shortages of doctors and nurses on one hand, and changes in immigration policy on the other, have prompted provincial governments to rethink their policy on credentials for international medical graduates (IMGs). The main objective is to ease and accelerate their accreditation in order to put human capital to use in Canada and provide fair treatment to immigrants. Constraints are of an ethical nature (not poaching poorer countries) as well as financial (cost of re-training IMGs).

Purpose of health policy or idea

The main purpose of the health policy idea is to facilitate the integration of international medical graduates (or IMGs) to set up practice and treat patients. IMGs are medical doctors who live in Canada and graduated outside of Canada and the US. They can be foreign-born or Canadian-born (they went abroad to study and came back). If they want to practice in Canada they must undergo a costly and protracted re-training process. Several provinces are now thinking of streamlining the process, making it more accessible for IMGs, less expensive, and less uncertain. Another objective is to increase the number of positions in medical schools for IMGs.

  

Main points

Main objectives

The general objectives are as follows:

  1. To address the perceived shortage of health care professionals: Canada is unique among OECD countries for having kept its ratio of physician per population constant over the 1990s (at 2.1 per 1,000) while the OECD average went from 2.2 to 3.0 per 1,000 between 1990 and 2005. Over the same period the density of nurses went down from 11.1 to 9.6 per 1,000 in Canada (and increased from 7 to 8 on average in the OECD).

  2. To address the uneven distribution of physicians across regions: rural areas and some newly created urban areas have a much lower ratio of physicians per population than the average - residency positions for IMGs are usually opened in under-serviced areas.

  3. To reduce barriers to access to care for immigrants to Canada: some cultural and language barriers would be reduced if more foreign-born IMGs were allowed to serve patients from their own community (18 percent of the Canadian population is foreign born).

  4. Implement a change in immigration policy from a principle of occupation-based selection to a principle of human capital: under the previous policy (Immigration Act, 1976) health care professionals could not apply to immigration as qualified workers; the act was replaced in 2002 by the Immigration and Refugee Protection Act and medical graduates were granted access to permanent residence.

  5. To use available human capital without "poaching" less developed countries where medical doctors (and nurses) are in a shortage.

Type of incentives

Types of incentives: there is a tension between using available skills in the health care sector and abiding by general principles of freedom to immigrate to Canada without attracting health care professionals from less developed countries. Other incentives are meant to find the resources to re-train IMGs (mostly to help them adjust to provider-patient relationships in the Canadian context).

The Federal Canadian government has allocated CAN $75 million over five years in 2005 to advance the assessment of health care professionals trained abroad.

As an illustration, the cost was set at CAN $130,000 per IMG and per-year for re-training by the government in Ontario in 2004. The same provincial government also created IMG Ontario, a centralized resource for IMGs seeking information on re-training and certification.

Groups affected

International Medical Graduates, Health care professionals & Medical schools, Patients in underserviced areas or ethnic minority groups, Doctors and their patients in less developed countries

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-dependent system-neutral

Opening the medical professions to IMGs from a variety of countries in order to abide by a broader immigration policy aimed at using human capital available or willing to come to Canada is new in Canada and seems to put Canada in a small group of countries (e.g. Israel) with bold immigration policies in health human resources. It is not too controversial at the political level even though the Canadian Medical Association objects to the re-training aspect of the programme and would favour more openings to Canadian graduates in Canada's medical school.

I have rated the impact as rather fundamental because it might affect several areas that are systemically important for health care in Canada: the ratio of physicians to population, the cultural competence of physicians serving patients from ethnic minorities, and, potentially, the geographic distribution of physicians in the country.

The issue of IMGs per se does not have much visibility (even though the larger issue of health human resources is very sensitive in the general public in Canada). It is largely system-dependent because Canada is the country which experienced the toughest restrictions on the number of new medical positions in the past 20 years and it is also one of the countries with the highest immigration rate (among rich countries).

Political and economic background

The main drivers are as follows:

  1. A perceived shortage of health human resources in all provinces, fed by surveys showing a growing proportion of Canadians report being unable to find a family doctor and having to rely on walk-in clinics, as well as discussions on waiting lists and waiting times (to see a specialist and for elective surgery). The 2005 "Chaoulli decision" from the supreme court stating that Québec was not respecting the rights of its citizens by making private insurance to cover services under the Canada Health Act illegal and, at the same time, not providing elective surgery in a timely manner has been a turning point in the political debate about shortages and rationing in the Canadian health care system. It is important to keep in mind that this is a perceived shortage: that there is a shortage is disputed and some point to the fact that the ratio of physicians to population has not actually declined from the early 1990s. The ratio of nurses per population has decreased but is still at a higher level than the OECD average.

  2. A change in (federal) immigration policies from occupation-based to skill-based selection criteria for the skilled worker permanent immigration program, which meant that health care professionals cannot be barred on a priori grounds from applying to permanent immigration to Canada.

Change of government

There was a change of government at the federal level in 2006, from liberal to conservative but this did not affect the decided change in the immigration policy. The number of immigrants allowed in Canada has not been cut either.

Complies with

The World Medical Association's recommends: "Every country should do its utmost to educate an adequate number of physicians (...) A country should not rely on immigration from other countries to meet its need for physicians."

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Origins of health policy idea

IMGs are anything but new in Canada - the proportion of IMGs was much higher in the 1970s (it peaked at 30 percent in 1980) and has decreased significantly since then. The proportion of physicians in Canada who were trained abroad now stands at approximately 22 percent (2005). IMGs used to come from the UK and Ireland. They now come from South Africa, the Philippines, India, Pakistan, and Egypt.

The number of positions in post-graduate institutions for IMGs has gone up from 291 in 1999 (for Canada as a whole) to 1065 in 2006 (source CMA, 2008).

Even though Canada had relied on IMGs in the past the context was radically different. Nobody was concerned with depleting the UK of its doctors at the time and the issue was mostly a lack of resources in Canadian medical schools to train the health human workforce the country needed. The issue today is framed as an immigration issue in a multicultural society as much as one of quantitative shortages in health human resources. Another difference is that IMGs today have to go through a complex, expensive (estimates are that the total cost of re-training and accreditation in Ontario is close to CAN $10,000 over the course of five years) and uncertain process (source, Office of the Fairness Commissioner, 2008, Study of Registration Practices of the College of Physicians and Surgeons of Ontario). Canadian medical schools might use fewer resources training US and Canadian medical graduates than re-training IMGs (there is no evidence on this latter point, but it appears that re-training is more about cultural competence than medical training per se, an area in which medical schools would have to invest in order to re-train significantly larger cohorts of IMGs.

Similarly the idea that a plan was needed to tackle the looming health human resources issue has emerged in 2004. At the time, though, the connection with IMGs was not very strong.

Two Commissions (one Senatorial, the Kirby Commission; one Royal, the Romanow Commission) yielded opposite conclusions about IMGs: according to Romanow Canada had a moral obligation to self-sufficiency (training all the doctors it needs), whereas Kirby argued for making good use of the skills of IMGs already present in Canada.

Initiators of idea/main actors

  • Government: Provincial MoHs are leaders in provinces and territories

Approach of idea

The approach of the idea is described as:
new: What is new is the convergence of an immigration policy based on skills and a health human resources policy addressing a perceived shortage.

Innovation or pilot project

Else - Ontario has opened 200 positions in medical schools to retrain IMGs. Ontario signed the ?Increasing Access to Qualified Health Professionals for Ontarians Act?. Québec has signed special agreements with francophone countries to ease accreditation.

Stakeholder positions

The idea is still to be fully developed and implemented in details - of course each province will have its own interpretation and way of implementing the general rule of easing access to re-accreditation to IMGs.

The 2008 Ontario Act streamlins the direct-to-practice procedures for doctors already practicing in countries with comparable health and medical education systems and provides a transitional or restricted licence to internationally-trained doctors that allows them to begin supervised practice. The Act also facilitates the assessment process for non-Canadian qualifications.  

Physicians are not openly against the idea but their colleges do not show much enthusiasm detailing proposals to make sure IMGs will adjust to Canada.  The Ontario government has decreed that it is a "matter of public interest, that the people of Ontario have access to adequate numbers of qualified, skilled and competent regulated health professionals" and established that it "is the duty of the College (of Physicians and Surgeons) to work in consultation with the Minister to ensure "that this occurs, continued under a health profession Act". The Canadian Medical Association (CMA) is not supportive and would prefer self-sufficiency through Canadian medical schools.

Medical schools try to make the point that re-training implies resources and will advocate for more resources if they are to re-train more IMGs.

So far the academic community seems to be supportive of the idea even though some fear that Canada will start poaching poor countries in need of nurses and doctors (this is not the case now, Canada's main sources of IMGs are not countries in need of doctors even though South Africa claims that emigration of its doctors to Canada raises an issue).

Actors and positions

Description of actors and their positions
Government
Provincial MoHsvery supportivesupportive strongly opposed
College of Physicians & Surgeons (Ontario)very supportivesupportive strongly opposed
Federal Task Forcevery supportivevery supportive strongly opposed
Canadian Medical Associationvery supportiveopposed strongly opposed

Influences in policy making and legislation

There does not seem to be much opposition between political parties in any province regarding the two intermingled issues involved (immigration and health human resources). As a result legislations aimed at favoring integration of IMGs in the Canadian health workplace should be rather consensual in most provincial parliaments.

As often in Canada the main issue will be that of federal - provincial relationships: federal legislation regarding immigration might clash with provincial willingness to limit re-training or positions for IMGs in medical school. Whether it is acceptable from the perspective of the federal laws on immigration to link re-training of IMGs to some kind of contract (e.g. agreement to practice in underserviced areas for a given number of years after graduation) remains to be seen.   

Legislative outcome

success

Actors and influence

Description of actors and their influence

Government
Provincial MoHsvery strongvery strong none
College of Physicians & Surgeons (Ontario)very strongneutral none
Federal Task Forcevery strongstrong none
Canadian Medical Associationvery strongstrong none
Federal Task ForceCollege of Physicians & Surgeons (Ontario)Provincial MoHsCanadian Medical Association

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Beside federal-provincial relationship and conformity to immigration laws the main issues will be as follows:

Compensation for medical schools: schools are now complaining that provincial governments do not compensate enough for re-training, especially in the complex issue of cultural competence

Cap on total spending on physicians payments in case more doctors are admitted in a province: if more doctors are admitted through an IMG expansion programme and budgets remained fixed the fee-for-service payment scheme still prevalent in most provinces will be under pressure and caps on the number of service per provider might be re-established (as was the case in 1995-1999) in some provinces.

Contract of service for IMGs after re-training: the quid-pro-quo for re-training IMGs is sometimes a contract of services according to which IMGs work for several years (usually five) in a given area or specialty. This might be deemed contrary to equality of treatment since Canadian medical graduates, who also benefit from subsidy of their medical education, do not have to submit to these contracts.  

Monitoring and evaluation

It is never mentioned anywhere.

Review mechanisms

n/a

Expected outcome

More IMGs will be admitted to Canada and more IMGs will set up independent practice in the more active provinces.

Whether this will ease the perceived shortage or geographic maldistribution of doctors, or improve the cultural match of doctors and ethnic communities remains to be seen.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low neutral very high

The quality of services might be affected if more physicians per population makes access easier and more equitable (cultural competence).

Cost efficiency: it is hard to know whether re-training IMGs costs more or less than training Canadian graduates. Saving on the cost of medical training is NOT the main driver of that policy though.

References

Sources of Information

Bourgeault, Ivy (2006) On the move: The migratio of health care workers to Canada, HRSDC, Skills Research Initiative Working Paper D-08.

Canadian Medical Association (2008) International Medical Graduates in Canada, Canadian Collaboration Centre for Physicians Resources, Brief, January.

Dumont, J. et al. (2008) International Mobility of Health Professionals and Health Workforce Management in Canada: Myths and Realities, OECD Health Working Paper #40.

Kirby, M. (2002) The health of Canadians: The federal role, Final report.

Korolko, Mikhail, Draft research proposal on IMGs in Canada -- Master's in Health, Aging & Society, 2010.

Reddock, Jennifer, (2010), The long policy path for international medical graduates working in Canada and the story told along the way, unpublished paper, Health Policy PhD, McMaster University.

Romanow, R. (2002) Building on values: The future of health care in Canada.

Task Force 2, (2006), A Physicians Human Resources for Canada, Final Report, March.

 

Author/s and/or contributors to this survey

Michel Grignon

Suggested citation for this online article

Grignon, Michel. "Health Human Resources & Foreign Medical Graduates". Health Policy Monitor, May 2010. Available at http://www.hpm.org/survey/ca/a15/1