Canada has achieved much in the past year in addressing interprovincial and territorial trade barriers in the face of economic threats from U.S. President Donald Trump. But most of this progress has bypassed our health-care system.
Regulatory red tape continues to stifle both the mobility and recruitment of the hundreds of thousands of domestic and foreign-trained regulated health professionals in the country.
At a time when the OECD tells us that Canada ranks 18th of 37 countries in productivity and we continue to face existential tariff and sovereignty threats from our biggest trading partner, surely we can end these most obvious and fixable internal trade barriers that hurt us all.
Too many barriers for foreign professionals
To illustrate the problem, let’s say you are a British family physician interested in moving to Canada. You already know that Canada has only 2.8 doctors for every 1,000 people and that 5.9 million Canadians don’t have a family doctor, nurse practitioner or primary care team they see regularly.
With no language barrier, you can easily imagine being welcomed into a friendly Commonwealth country where your expertise and experience are sorely needed.
But when you consult the British Medical Association’s guide, Working as a doctor in Canada, you find it runs to more than seven pages of fine print, describing a complex, expensive and time-consuming bureaucratic obstacle course.
A bewildering maze
Welcome to the last frontier of getting rid of Canada’s interprovincial trade barriers – the thicket of 13 separate sets of provincial and territorial agencies whose rules and regulations govern the certification, licensing and practice standards for health-care professionals.
They reduce labour mobility by deterring foreign-trained individuals from emigrating to Canada and they make it more difficult for qualified health-care professionals to move between the provinces and territories.
The past year has seen some real progress in tearing down internal barriers respecting trade in goods as Canada realized we were fighting the Trump tariff onslaught with one hand tied behind our back as long as those barriers persisted.
Good but not good enough
In November, a major step forward was achieved with the federal, provincial and territorial governments signing the Canadian Mutual Recognition Agreement on the Sale of Goods.
What “mutual recognition” means here is that products allowed for sale in one jurisdiction can be sold in another without needing additional standards, certifications or regulatory requirements.
That’s good but not good enough because modern economies operate through millions of daily transactions of two types – goods and services.
Most of the gains in reducing interprovincial trade barriers so far have dealt with goods. Services? Not so much. In fact, the biggest services sector – health care, which employs 1.9 million people – is not covered by the new agreement.
Professor Trevor Tombe of the University of Calgary argues that the separate requirements for professional licensing and certification maintained by provinces and territories cost Canada about $200 billion per year.
In January, a report from the International Monetary Fund agreed, concluding: “Policy-related barriers within Canada average the equivalent of about a 9 per cent tariff nationally. These costs are mainly concentrated in services – which account for the majority of interprovincial trade – with barriers in some sectors, including educational and healthcare services, exceeding the equivalent of a 40 per cent tariff.”
Tombe also estimates there are roughly 700 regulatory bodies of this type – typically colleges of physicians and surgeons, nurses, psychologists, dentists, pharmacists, medical laboratory technologists, etc. – in Canada, “which dampens labour mobility and prevents individuals from offering services across jurisdictions.”
Unnecessary restrictions
This means different rules, pathways and timelines for doctors, nurses and other regulated health professionals, depending on where a person trained, their specialty and the province in which they live. All of this takes reams of paperwork, reference letters, professional documents, money and time.
Worse still, although the requirements are nearly all the same, approvals are not portable from one jurisdiction to another, with the limited exception of Ontario. Otherwise, if you’re qualified in one province and want to move to another, you must go back to the beginning and prove yourself all over again.
In fairness, the provincial and territorial regulators play an essential role. The licensing of physicians, nurses and other health professionals needs to be thorough and rigorous to protect Canadians.
But rigid rules sometimes create ludicrous and self-defeating unintended consequences. For example, when wildfires forced the evacuation of Yellowknife in 2023, the doctors who accompanied their patients to British Columbia were not allowed to treat them there because they were not licensed to practice medicine in that province.
Demands go unfulfilled
One unified and portable system of national licensing for physicians would solve this problem but so far it has proven too complex and challenging for provinces, territories and regulators to move decisively in that direction.
Despite education and training being virtually the same across this country’s 18 medical schools, doctors continue to face Byzantine regulatory processes, thousands of dollars in fees and long delays to be allowed to practise in another province or territory.
Not only is this an unnecessary waste of time and money, but it also deters the delivery of seamless health care across the country.
Rays of hope
Some signs of sanity are emerging. Through its “As of Right” framework, Ontario already allows doctors and nurses certified in other provinces or territories to begin working in Ontario within 10 working days, with provisional authorization lasting up to six months while they complete full registration.
An extension of that legislation that took effect in January grants immediate practice rights to 16 additional groups of health professionals, including dentists, optometrists, pharmacists, midwives, and medical radiation and imaging technologists.
A few barriers to interprovincial trade have fallen, but what comes next?
The changes also recognize U.S. board-certified physicians and nurses, thus providing an additional channel to fill Ontario vacancies, especially in remote and underserviced communities.
Ontario’s changes are important because national shortages are driving provinces to compete for staff. Across the range of health occupations, it is estimated that system-wide vacancy rates “rose from 3 per cent in 2019 to 5.5 per cent in 2023, and then to 5.8 per cent in 2024.”
Shortages persist
The Canadian Institute for Health Information (CIHI) estimates that meeting Canada’s current demand for physicians would require a 49-per-cent increase in their numbers nationwide.
Statistics Canada reports that nursing job vacancies have nearly tripled since 2016, increasing to 5.8 per cent from 2.1 per cent. According to the CIHI, there has been a decline over the last decade in the supply of registered nurses and registered psychiatric nurses, as well as a recent drop in licensed practical nurses.
The CIHI also reports a recent decline in the supply of pharmacists, despite rising demand for medication management and expanded scope of practice.
The impact of these human resource shortfalls has also been seen in scores of closures of hospital emergency departments due to lack of critical staff.
Many of these vacancies in the health-care sector are being filled by foreign-trained professional immigrants.
Last September, Immigration, Refugees and Citizenship Canada reported that overall, immigrants trained in other countries accounted for 25 per cent of registered nurses, 37 per cent of physicians, 43 per cent of pharmacists and 45 per cent of dentists.
It’s time to act
But here’s where our 13 separate provincial and territorial professional accreditation systems really bite.
The National Newcomer Navigation Network reports that in 2023, there were an estimated 259,695 internationally trained health professionals in Canada – the majority of whom were not being employed in their field of study. Even when they are working in health care, many are in jobs below their qualification level.
It’s time to act.
The COVID-19 pandemic taught developed countries about the value of mutual recognition and regulatory reliance on each other’s safety and efficacy studies of new vaccines and therapeutic treatments to save lives.
It’s time to extend the same approach to the certification and licensing of health-care professionals across Canada.
