A hospital in Toronto in April, 2021. The government has been unequivocal about accelerating the recruitment of internationally educated health workers to address national shortages.Frank Gunn/The Canadian Press
Veena Sriram is an assistant professor and Canada Research Chair in Global Health Policy at the University of British Columbia (Point Grey)
Katrina Plamondon is an associate professor and co-director, Equity Science Lab at the University of British Columbia (Okanagan)
The World Health Assembly concluded last week in Geneva amidst a resurgence of global attention to public health, in light of Andes hantavirus and Ebola outbreaks.
One agenda item from the Assembly has received limited attention in our domestic context – a review of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a voluntary framework adopted in 2010. Inconsistency characterizes the last 16 years of Canada’s implementation of this Code. In particular, Canada’s recruiting practices are incoherent with a national ethical framework, which suggests we ensure “benefits to the health system of source countries that are commensurate and proportional to the benefits accruing to destination countries.” While Canada has addressed some aspects of the Code, our persistent recruitment from the Global South, without proportional benefits to source countries, causes the very harm the Code was designed to avoid.
The Canadian government has been unequivocal about accelerating the recruitment of internationally educated health workers to address the health workforce shortages nationally. Provinces have developed bilateral deals with source countries, such as those between Manitoba, Saskatchewan and Alberta respectively with the Philippines to support recruitment of Filipino nurses. Canada is not alone in this; the number of migrant doctors in OECD countries has grown by 50 per cent in a decade, and more than 12 per cent of the nursing workforce globally works outside their country of birth.
Ebola outbreak declared global emergency by WHO after 88 deaths in Congo
Ethical debates abound on this approach, particularly in terms of balancing cost efficiencies gained by wealthy countries, with the damage and disruptions to Global South health systems. To be clear, our source countries also include Australia, Ireland, and the United States. The impacts, however, of recruiting health workers from Global South countries with under-resourced health systems – without strategies that substantively invest in those systems – are devastating.
Numerous indicators play this out. Globally, 4.6 billion people lack access to essential health services. Global South countries experience a greater share of the disease burden and global population, but account for a fraction of health workers, with wealthy countries having approximately 6.5 times more health workers per capita than low-income countries. In Global South countries, government health spending has fallen to or below pre-COVID levels, exacerbated by cuts to foreign assistance.
The drivers of health worker migration from the Global South are also connected to other domains of Canadian foreign and environmental policy. The climate crisis has been fundamentally reshaping mobility amongst health workers, for example, by accelerating migration out of countries experiencing climate shocks. Attacks against health workers have been increasing in conflict areas, reflecting a global weakening of international law and norms protecting these workers from violence.
Canadian isolating in B.C. tests ‘presumptive positive’ for hantavirus
Canada must grapple with two ethical and accountability challenges for the impacts of our actions on health systems strengthening in the Global South. First, the Canadian government has reduced overseas development assistance, with $2.7-billion cut in 2025.
It is simply not possible to “co-invest” in health systems in the Global South and ensure proportionate benefits to source countries of health workers without actual investment. Second, the decentralized nature of workforce planning in Canada means that it is unclear how Canadian efforts around proportional benefits to source countries are co-ordinated. Political realities between federal and provincial governments undoubtedly make an already opaque scenario complex.
So, what needs to be done? At a basic level, we cannot continue to shut our eyes to the underlying hypocrisy of this moment. Canada needs to reflect on what we can meaningfully do to honor commitments in the Code around supporting financial and technical investments and exchange with source countries. This must begin with an acknowledgement of the ways in which our recruitment and official development assistance policies are irrevocably linked. Canada can build on recommendations by the Expert Advisory Group on the Code through a robust program that directly addresses the systemic nature of health systems strengthening in source countries. Examples of proportional benefits include long-term investments across the health workforce pipeline, sustained financing for systems strengthening, infrastructure improvements, and safeguards during crisis, as source countries have long demanded.
The human rights questions underpinning this issue should be enough to move our position. But for those concerned about Canada’s domestic priorities, consider this: Current outbreaks only underscore what has long been known and underscored by COVID-19; our health is collective and interdependent. Canada can lead by example, by finally aligning health workforce recruitment with the rights-based approaches that we have long stood for.