Fifteen years after the World Health Organization (WHO) released its Global Code of Practice on International Recruitment of Health Professionals, Health Canada released its Ethical framework for the recruitment and retention of internationally educated health professionals. Based on the WHO code, the framework articulates a set of six principles to guide an ethical approach for the recruitment, retention and integration of internationally educated health professionals (IEHPs) in Canada.
The framework, which covers both actively recruited IEHPs and those immigrating to Canada under more traditional pathways, is needed since Canada is one of many countries facing a shortage of health-care workers and is relying increasingly on IEHPs to sustain its health-care workforce.
At the same time, practices linked to recruiting, integrating and retaining IEHPs in Canada have resulted in widespread skills underutilization. In 2020, nearly half (47 per cent) of immigrants who received their health-care education abroad were unemployed or underemployed. Analysis from 2023 showed that a significant proportion of internationally trained nurses, physicians, pharmacists and dentists in Canada were not working in their chosen fields.
This issue is pressing given that Canada is actively recruiting health professionals from abroad while also receiving IEHPs through more traditional, or “passive”, immigration pathways. As a result, there is a substantial pool of highly trained health professionals already here whose experience and expertise remain underused or entirely untapped. These realities present serious ethical concerns, what Margaret Walton-Roberts refers to as a “transnational social justice matter.”
The framework is centered on six principles: global approach; health workforce sustainability; accessible and accurate information for IEHPs; fairness; anti-racism and diversity, equity and inclusion (DEI); and collaboration. As with the WHO code, the framework is non-binding, and adoption is voluntary.
As is so often the case, however, the challenge now lies in moving from aspiration to execution. Among the challenges:
- Voluntary uptake/implementation: The framework’s implementation depends entirely on voluntary adoption. This significantly limits the framework’s influence on real-world practices.
In Canada’s highly decentralized health and immigration policy landscape, responsibilities are distributed between federal, provincial, territorial and, in some instances, First Nations actors. Voluntary guidance is therefore likely to result in uneven uptake or selective application. This is already the case, for example, in the way provinces have unevenly implemented Fair Registration Practices legislation to guide regulatory practices that are transparent, objective, impartial and fair.
In reality, employers facing immediate staffing pressures may prioritize speed and cost savings over ethical considerations, while jurisdictions with fewer resources might struggle to operationalize the framework’s principles at all. Without accountability mechanisms or incentives, the framework risks functioning primarily as a reference document rather than a driver of consistent policy and practice.
- Limited engagement with reference to international best practices: The framework includes a range of reference resources and examples that highlight important services, programs, legislation and collaborative initiatives from across the country. However, concrete lessons from the European Union or other OECD countries are limited to a single example from the United Kingdom pertaining to bilateral agreements with source countries on health and social care workforce recruitment.
Some countries have moved beyond high-level principles to more operational models. The U.K. has established a code of practice that sets benchmarks for employers and international recruitment agencies, and NHS Employers maintains an Ethical Recruiters List of “organizations, agencies and collaborations that operate in accordance with the revised code of practice.” Organizations that fail to report data on recruitment activity risk being removed from the list, limiting their ability to participate in further international recruitment processes. While Canada’s federal structure would require adaptation, similar approaches could be embedded within federal-provincial-territorial (FPT) health workforce strategies or linked to federal funding and reporting requirements.
- Blurring of “active” and “passive” recruitment pathways: IEHPs arrive in Canada through a wide range of immigration pathways, and the distinction between “active” and “passive” recruitment of health professionals is sometimes blurred. Health Canada notes that “the distinction between “active” and “passive” recruitment may require a judgment call based on the specific circumstance.”
Active recruitment typically involves efforts to attract health professionals from other countries through recruitment missions or targeted immigration streams; for example, category-based selection of individuals in health care occupations through Express Entry or skills-based immigration streams available through Provincial Nominee Programs.
Passive recruitment, by contrast, reflects the reality that many health professionals immigrate to Canada through economic immigration streams, as spouses of principal applicants or through refugee or family reunification pathways.
In practice, many IEHPs in Canada arrive via passive recruitment. For example, an internationally educated nurse who arrives as a permanent resident accompanying a spouse may not immediately begin the process of professional re-entry or may spend years navigating requirements related to credential recognition, language testing or licensing exams without having ever been “recruited” by a Canadian employer.
When ethical recruitment is framed primarily as employer-driven or connected to agency-driven practices, accountability for individual outcomes may become diffuse or unclear. We risk overlooking where ethical responsibilities lie in immigration policies and selection, settlement supports, regulatory processes and workplace integration, not merely the recruitment itself. Reducing the ambiguity between active and passive recruitment is vitally important to designing policies that address lived realities.
- Weak health workforce data limit monitoring and enforcement: Health Canada’s framework also notes that federal-provincial-territorial governments need to collaborate to support reporting on implementation, and that the development of metrics is “recommended,” but Canada’s health workforce data infrastructure remains fragmented, outdated and incomplete. There is very limited visibility into IEHP pathways from arrival to practice.
For example, it is impossible to say with certainty how many internationally educated nurses are not working as nurses in Canada as this data are not systematically collected. In Data matters. What we don’t know about health care in Canada, the Canadian Medical Association notes that “Canada has no coherent national approach for collecting and sharing crucial health data,” and lists a number of factors that are unknown, including fundamental questions such as where physicians and other health care workers are needed most and what specializations are needed and where.
Canada has a long way to go in terms of developing baseline metrics, standardized indicators and public reporting mechanisms. Without this kind of data, the principles outlined in the framework cannot be meaningfully monitored or evaluated.
Here’s the good news: By considering the structural and practical limitations of the framework, it becomes easy to identify where there are clear opportunities for improvements.
First, clearer coordination across immigration, health and labour policy systems. These systems are fundamentally intertwined, yet long-term, strategic coordination remains limited between federal ministries, federal-provincial-territorial governments and other system stakeholders (regulators, post-secondary institutions and so on) that play a role in recruitment, training, licensing, integration and retention of IEHPs. A whole-of-society approach that engages all stakeholders and includes lived experience perspectives is necessary to support effective governance, implementation and monitoring.
Second, Canada has opportunities to develop implementation tools informed by international best practices. These could include federal codes of practice linked to public funding or health system reporting requirements, employer accreditation schemes, mechanisms to embed robust mutual supports into bilateral agreements or mandatory reporting requirements on international recruitment activities, to name a few.
Third, sustained investments in health workforce data infrastructure are critical. The work of Health Workforce Canada (HWC) provides a promising foundation. In March 2026, HWC published the Pan-Canadian Health Workforce Data Strategy, which has a clear focus on improvements to IEHP data. It is imperative that health workforce data strategies and subsequent health workforce planning strategies align closely with the Health Canada framework.
International recruitment can help to address health workforce shortages, but it is not a panacea. The WHO code emphasizes that countries should strive for self-sufficiency in their health workforce through training and retention. Supporting job quality and retention in the context of health system collapse is a key consideration, as is leveraging the skills and experience of IEHPs already in the country.
With one of the highest volumes of migrant intake in the world, Canada has both a responsibility and an opportunity to demonstrate leadership in ethical recruitment and for policymakers to support implementation of WHO code-aligned policies and practices.
