As Canada and other wealthy countries scramble to hire nurses from overseas, there are growing concerns that the exodus of health-care workers from developing countries will push their stretched medical systems closer to a crisis point.
The federal government and provinces are spending millions of dollars trying to entice foreign-trained nurses to Canada — with overseas hiring campaigns, priority immigration pathways and monetary grants to individual nurses.
But Canada has strong competition from Europe, the U.S. and other countries that are also mounting aggressive recruitment campaigns touting high wages and immigration opportunities: health workers can get cheap U.K. visas, while the Australian state of Victoria offers "relocation packages" for foreign nurses, equivalent to as much as $11,670 Cdn.
"We've seen a significant uptick in international recruitment of nurses from the beginning of this year, overwhelmingly driven by probably six or seven high-income countries," said Howard Catton, chief executive officer of the International Council of Nurses (ICN), naming Canada as one of those countries.
"[They're] in a rush to get a quick fix to their own nursing shortage, because they haven't invested enough in educating their own nurses, and because the nurses that they have, in many cases, are exhausted and burnt out."
WATCH | Developing countries fear health worker crisis due to nurse exodus:
Countries worry they'll lose specialist nurses
Early in the pandemic, a joint report from the ICN and World Health Organization (WHO) warned of rich countries raiding developing countries' nursing workforces to make up for their own failure to train and retain the health-care staff they need.
At the time, the Americas had about 83 nurses per 10,000 people, while in Africa, there were fewer than nine nurses per 10,000 people, according to the report.
Two and a half years and one global pandemic later, Catton says the situation has only worsened for lower-income countries struggling to hold onto their health-care workers as wealthy countries ramp up recruitment drives.
These countries are very concerned they'll lose experienced nurses with specialist skills — like intensive care nurses or specialist cancer nurses, he told CBC News in an interview from Geneva.
"You might only lose one or two specialist nurses, but that can mean that the service no longer exists."
Canada's push to hire from overseas
In Canada, internationally educated health workers make up about nine per cent of nurses and 26 per cent of physicians. Over the past year, provinces have rolled out a hodge-podge of incentives meant to recruit more, including targeted immigration streams.
Newfoundland and Labrador has set up a recruitment desk in India, Saskatchewan will hold a health-care job fair in the Philippines later this month, and British Columbia, New Brunswick, Quebec and Manitoba all offer thousands of dollars to cover licensing for international nurses and other costs, which can include childcare, transportation and living expenses.
Those kinds of incentives are hard for nurses in developing countries to turn down.
"If we are pushing out more of our [nursing] professionals, then very soon … we will not have enough of them to take care of ourselves," says Perpetual Ofori-Ampofo, president of the Ghana Registered Nurses and Midwives Association.
Ghana has about 44,000 nurses to care for its population of 31 million — a number just above Africa's average. And low pay means "some live hand to mouth," she said.
"It is much, much better for them to travel and work abroad than to stay here," Ofori-Ampofo said, noting those workers may be better off in Canada, where they receive regular paycheques and the opportunity for overtime.
Bilateral deals a more ethical approach
However, Ofori-Ampofo wants to see wealthy countries like Canada take a more ethical approach to overseas recruitment.
Instead of targeting individual nurses through recruitment agencies that may not serve their interests, she says governments should make bilateral deals with countries the nurses are from — an approach WHO also endorses.
Ghana recently began deploying nurses to Barbados under a bilateral agreement that has seen about 240 nurses sent to the island for two-year terms.
Such deals make it safer for nurses to leave their home countries, knowing their salaries and other conditions of employment are clearly spelled out before they arrive, she said.
Both Ofori-Ampofo and Catton say wealthier countries also should do more to give back to countries where they're recruiting.
"I hear a lot of [recruiting] countries who say 'Look, we want to share knowledge, and there'll be opportunities for people to learn and to share as a result of migration,' and that's true, but I'd like us to be more ambitious, more specific in terms of what we're going to do," Catton said.
He suggested, for example, that countries like Canada could give money to build nursing schools or help pay to educate the nursing workforce in developing countries.
Canada's federal government does not have any bilateral agreements with other countries for the international recruitment of health workers, as provinces and territories were responsible for that work, said Health Canada.
The agency noted the federal government funds education programs for health workers in developing countries, including a pediatric nursing program in Ghana led by Toronto's SickKids hospital.
'A complete waste'
Experts see another major flaw with Canada's international recruitment: thousands of the foreign health-care workers who come here don't end up working in their profession — potentially as much as 47 per cent.
Some migrate only to discover their qualifications and language skills don't meet Canada's requirements, while for others, lengthy and expensive licensing and registration processes can delay their ability to work in their field — sometimes for years.
"We poach people, but we do it very badly," said Professor Arthur Sweetman, the Ontario Research Chair in Health Human Resources at McMaster University in Hamilton.
Sweetman says private recruitment agencies are part of the problem because they bring workers to Canada without ensuring they have the right skills to be able to work in their medical fields.
"It's the worst of both worlds: we don't benefit, the source country doesn't benefit. Nobody benefits. It's a complete waste."
This year's federal government budget included funding to help thousands of internationally-educated health workers have their foreign credentials recognized and find jobs in their medical fields each year.
Room for better co-ordination
While the federal government and some provinces have announced new measures to help internationally-trained nurses get licensed and registered faster, Sweetman says different levels of government should also co-ordinate their recruitment efforts.
"One of the problems is that the [immigration] selection is done by the federal government, and employment in the health-care sector is almost always done by provincial governments."
In a statement, Health Canada says it welcomes "open dialogue" with different levels of government, health-care workers and others on ways to address health worker shortages and ensure ethical international recruitment.
The agency said it encouraged efforts aligned with WHO's code of practice on international recruitment, which urges countries not to actively recruit from a "red list" of the world's most short-staffed countries, which includes Ghana.
However, the U.K. alone has hired thousands of workers from red-listed countries in recent years.
A WHO spokesperson told CBC News an expert advisory group is currently reviewing if anything more can be done to safeguard developing countries from unethical recruitment efforts, with more details set to be announced before the end of January.