European Observatory on Health Systems and Policies


Health Systems in Transition (HiT) profile of Canada

4.2 Human resources

4.2.1 Health workforce trends

During the past decade, P/T government decision-makers throughout Canada have expressed concerns about health human resource shortages, in particular doctors and nurses. In response, these governments implemented policies to increase educational enrolments as well as recruit professionals from outside their respective jurisdictions and from other countries. This shift contrasts with the period in the early to mid-1990s when governments were concerned about surpluses and actively worked with the professions and postsecondary institutions to curtail the supply of both physicians and nurses as well as reduce the number of new entrants into these professions (Tuohy, 2002; Chan, 2002a; Evans & McGrail, 2008).

At a minimum, these efforts have produced higher health sector remuneration and inflation (CIHI, 2011b). They are also increasing the per capita supply of nurses and doctors. However, it is important to note that while doctor density surpassed 1990 levels by 2009, nurse density continued to decline substantially after 2000, and had not recovered to 1990 levels even by 2009 (see Table4.7).

Other health professions were not affected by the budgetary constraints of F/P/T governments in the early to mid-1990s. Since dental care is largely private in Canada, dentists were not affected by public-sector expenditure cutting in the 1990s. While prescription drugs are a mixed sector subject to both public and private coverage and, therefore, insulated to a limited degree by public budget cutting, the more salient factor affecting the number of pharmacists has been the rapid increase in drug utilization during the past two decades.

Due to geography, population dispersion and differences in health systems and policies, there are significant variations in the density of the health professions among provinces and territories. As illustrated in Table4.8, the RN density in the Northwest Territories and Nunavut is considerably higher than the Canadian average, while the physician density is considerably lower. This is a product of dispersed Arctic communities that rely heavily on nurse-based primary care provided in publicly administered health centres rather than on family physicians. With the exception of a large presence in the three northern territories, the populations of which suffer most from dental disease, the dental professions tend to concentrate in the four most urbanized provinces in Canada – Ontario, Quebec, British Columbia and Alberta.

During the 1990s, physician supply grew at an annual average of 1.1% – a rate that would more than double from 2004 to 2009 due in part to the rapid expansion of places in Canadian medical schools and the influx of international medical graduates (Watanabe, Comeau & Buske, 2008; CIHI, 2011b). As a consequence, the number of physicians per capita has begun to rise in recent years, a trend already apparent in Australia, France, Sweden, the United Kingdom and the United States well before the increase in Canada (Fig4.2).

When comparing Canada with its five OECD comparators in terms of the number of nurses per 1000 population, it appears that only Australia witnessed a comparable decline in the density of nurses in the 1990s. By 2005, the trend had reversed in Canada, and the ratio of nurses to population has increased since that time (Fig4.3).

The trend in the number of dentists per 1000 population shows a marked contrast with that of nurses. The density of dentists has grown steadily since 1990, a trend shared by only Australia among the countries in the comparator group (Fig4.4).

When it comes to the density of pharmacists, Canada again shows steady growth in the last two decades. As can be seen in Fig4.5, this density level is similar to the comparator countries. The one exception is France, where the population has historically been among the largest consumers of prescription drugs in the world (Chevreul et al., 2010).

Physician Assistants (PAs) were introduced in Ontario as a new health care professional (outside military use) in May 2006, as part of a new health human resources strategy of the Ontario Ministry of Health and Long-Term Care. PAs were introduced as part of a multi-faceted strategy with the explicit goals of: decreasing wait times; increasing access to care; achieving team and patient satisfaction; and improving team recruitment and retention. Ontario PAs are not autonomous health professionals, but work under the direct supervision of a physician who delegates particular tasks to the PA, including controlled acts governed by the Ontario Regulated Health Professions Act. The supervising physician retains liability for the PA's work.

While PAs have worked for several decades in the Canadian Forces and in the US, their use in a civilian capacity is new to Canada. PAs have a unique scope of practice that varies depending on the individual physician-PA relationship, although this relationship is guided by a National Competency Profile that defines how and under what circumstances the PA may work. PAs may take patient histories, conduct physical examinations, order and interpret tests, diagnose and treat illnesses, counsel on preventative health care, and develop additional specialized skills while working with a supervising physician.

In 2012, approximately 125 PAs were working in Ontario, although it is difficult to establish exact numbers and demographic information because Ontario PAs are unregulated with no mandatory government licensing records kept. Ontario PAs applied for status as self-regulated health professionals, but the Health Professions Regulatory Advisory Committee recommended that PAs not become licensed at this time, instead suggesting a compulsory registry to be designed and administered by the College of Physicians and Surgeons of Ontario. This has not yet been implemented.

The Ontario Ministry introduced PAs by initiating a demonstration project that included salary support for new PAs, the establishment of two PA education programs at McMaster University and the University of Toronto, and an evaluation component. This demonstration project was scheduled to end in 2009, but the Ministry has continued to renew salary support funding, with current contracts scheduled to end in 2015.

The fate of PAs in Ontario is uncertain once Ministry salary support is discontinued. There is no data available on the number of PAs who are employed without Ministry funding and it is unknown whether current employers will find ways to continue to employ PAs should the government funding end. Contributing to this uncertain future is a lack of Ontario-specific evidence about the effectiveness, cost, and safety of PAs as well as vocal opposition from other health professional groups (e.g. Registered Nurses Association of Ontario). Supportive factors include the alignment of the PA role with Ontario health system priorities (e.g. reducing wait times, ameliorating physician shortages), the support of physician groups, good enrolment in the PA education, and the apparent success of the role in the United States.

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4.2.2 Professional mobility of health workers

Physicians are highly mobile in Canada and the competition for physicians among and within provincial and territorial health systems has been intense since the late 1990s. This has resulted in significant inter-provincial mobility. Two-thirds of physicians who leave a province or territory move to another part of Canada rather than abroad (CIHI, 2010d). When doctors do move abroad, most move to the United States. As can be seen in Table4.9, there has been a steady net migration of doctors into Canada for the past three decades largely due to the influx of international medical graduates (IMG).

Although the overall impact of migration appears to have had a marginal impact on the overall domestic supply of physicians, Table4.9 obscures the extent to which some provinces are highly reliant on IMG: for example, in the past decade, almost 50% of new physicians in Saskatchewan are foreign educated, the majority from developing countries, especially South Africa. Indeed, some ministries of health in association with the provincial medical bodies have established programmes to facilitate and speed up the licensure of IMG, many of whom, at least initially, migrate to underserviced areas in the country (Dumont et al., 2008).

Nurses are also mobile and the shortage of nurses has intensified competition among the provinces, territories, RHAs and independent hospitals over the past decade. As a consequence, salaries and wages have risen well above the rate of salaries outside the health sector (CIHI, 2011b). In the 2000s, approximately 7–8% of the nurse workforce was originally educated outside Canada. Some jurisdictions and health organizations have actively recruited nurses from other countries, such as the Philippines (CIHI, 2010d; Runnels, Labonte & Packer, 2011).

The hiring of international medical and nursing graduates has raised concerns about the impact of this practice on developing countries. Estimates of the public cost of educating a doctor in nine sub-Sahara African countries, for example, range from a low of $21 000 in Uganda to a high of US$58 700 in South Africa (Mills et al., 2011). These are countries with great health needs and limited resources to educate and train doctors, which has led to the charge that such foreign recruitment may be unethical (McIntosh, Torgerson & Klassen, 2007; Runnels, Labonte & Packer, 2011).

4.2.3 Education and training of health workers

In terms of educating and training health providers, provincial ministries of health work in tandem with provider organizations to set or alter the number of “seats” or entry positions in professional programmes in postsecondary institutions. Since education is exclusively within the jurisdiction of the provinces and almost all education in Canada is financed publicly, provincial governments determine the funding for the postsecondary education of the health professions that is delivered by universities, colleges and technical institutions (Tzountzouris & Gilbert, 2009). Table4.10 sets out the educational and training requirements for 22 health occupations.

There are 17 medical programmes offering a medical doctorate (MD) in Canadian universities. The programmes vary in length from three years (McMaster University and University of Calgary) to the more typical four-year programme including the clinical practicum (CIHI, 2011a). After graduating, medical students enter a residency programme in family practice or some specialization and complete their training – a minimum two-year residency programme in the case of family practice and four or more years in other specialties in medical, surgical and laboratory medicine. As in most countries, the number of physician specialties has grown over time. As of 2011, there were 28 specialties, 36 subspecialties and two special programmes for a total of 66 individual study and training programmes. A small number of physician assistants (250 as of 2011) work in Manitoba and Ontario, the two provinces that also offer university-based programmes for these physician extenders.

While undergraduate education and the awarding of undergraduate medical degrees (the basic “medical doctorate”) is the purview of the 17 medical schools in Canada, the RCPSC is responsible for overseeing the graduate education and training of physicians. As such, the RCPSC accredits 17 residency programmes, all run by the university-based medical schools. Specialists are also certified by the RCPSC, which is recognized by all province medical licensing authorities except for Quebec, where the Collège des médecins du Québec is the primary certifying body (Flegel, Hébert & MacDonald, 2008; Bates, Lovato & Buller-Taylor, 2008; CIHI, 2011a).

Educational requirements for nurses have increased dramatically over the last two decades, with a major shift from two-year diploma programmes to four-year bachelor degree programmes. Nurse practitioners are RNs whose extra training and education entitles them to an “extended class” designation. Their scope of practice – which includes prescribing certain classes of prescription drug and ordering some diagnostic tests – overlaps with that of family physicians. More importantly, given the evidence of the declining comprehensiveness of the primary care offered by physicians since the late 1980s, the range of health services offered by nurse practitioners has been of interest to primary health care reform advocates and provincial ministries of health (Chan, 2002b; College of Nurses of Ontario, 2004; CIHI, 2011c). In addition to their RN education and training, nurse practitioners must get additional training from accredited institutions that are offered in all ten provinces. The length of these programmes, including the clinical practicum, vary from one year to slightly in excess of two years (CIHI, 2011a).

To practise in Canada, a pharmacist must hold a bachelor’s degree in pharmacy from an accredited programme, pass the qualifying examination administered by the Pharmacy Examining Board of Canada, and register with the appropriate P/T regulatory body. Ten universities offer programmes in Canada. All are four-year programmes, including clinical practicum, with the exception of a five-year programme at Memorial University of Newfoundland. There have been between 705 and 1075 pharmacy graduates a year from these Canadian universities between 2000 and 2009 (CIHI, 2011a).

Chiropractors in Canada must have a doctorate of chiropractic (DC) from an accredited programme, pass the Canadian Chiropractors Examining Board National Competency Examination and register with a provincial or territorial regulatory body as required. There are two accredited chiropractic programmes in Canada: a four-year programme at the Canadian Memorial Chiropractic College in Ontario, and a five-year programme at the Université du Québec à Trois-Rivières in Quebec, which together have produced between 188 and 218 graduates a year between 2000 and 2009 (CIHI, 2011a).

Dentists practising in Canada must have a doctor of dental medicine (DDM) or a doctor of dental surgery (DDS) degree from an accredited programme, pass the National Dental Examining Board of Canada Written Examination and Objective Structured Clinical Examination as well as register with the pertinent P/T regulatory body. There are ten accredited programmes, all four years in length. There is considerable competition for entry into Canada’s ten dental schools, five of which are located in Quebec and Ontario. Canadians are among the world’s highest spenders on dental care, in part due to the prevalence of private dental insurance – largely through employment-based benefit plans. As with physicians, a number of specializations requiring two to three years of higher education and residency have emerged over time including (but not limited to) orthodontists, periodontists, endodontists and paediatric dentists. A number of allied dental professionals support dentists and dental specialists in their work, including dental assistants, dental hygienists and dental therapists. Provincial dental organizations are responsible for licensing and self-regulating various professional subgroups, although the Royal College of Dentists of Canada plays a role similar to the RCPSC in setting standards for postgraduate education and training.

4.2.4 Career paths

There are few formalized managerial and policy career paths for clinicians, including doctors and nurses, within the health system. This is despite the fact that, increasingly, clinicians are asked to take on managerial roles within health systems. As a consequence, career paths are being developed but in an ad hoc and varying manner by individual health care organizations.

Originally established in 1970, the Canadian College of Health Leaders – originally known as the Canadian College of Health Service Executives – provides professional support including a journal, professional programmes and services. It also offers a competency-based “Certified Health Executive” programme for its members, some of whom include existing and former clinicians.

Following the example of other provinces, the Minister of Health and Social Services in Quebec proposed an amendment bill to the Pharmacy Act in June 2019. This bill aims to enhance the scope of practice of pharmacists to promote better and timely access to health care and services by allowing pharmacists to prescribe and administer certain medications, such as vaccines. With this move, the Quebec government wishes to increase the efficiency, accessibility and cost-effectiveness of its health care system by preventing unnecessary medical consultations and expanding access to services closer to patients. It remains to be seen whether Quebec will be able to build on lessons learned from the mixed results of a similar reform in Ontario that started in 2009.