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INAN Committee Report

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Mr. Andy Fillmore
Chair, House of Commons Standing Committee on Indigenous and Northern Affairs
House of Commons
Ottawa, ON K1A 0A4

Dear Mr. Filmore,

The Government of Canada would like to thank the members of the Standing Committee on Indigenous and Northern Affairs for their report, titled Declaration of Health Emergency by First Nations Communities in Northern Ontario, tabled on May 19, 2016.

As you know, the Government is committed to a renewed nation-to-nation relationship with Indigenous peoples based on recognition of rights, respect, co-operation, and partnership, and rooted in the principles of the United Nations Declaration on the Rights of Indigenous Peoples.

The Government agrees that more needs to be done to address gaps in health services for First Nation peoples in Northern Ontario and First Nations and Inuit across Canada. The Government is determined to work with First Nations and provincial partners to provide effective, sustainable, and culturally appropriate health programs and services to improve health outcomes and support greater control of the health system by First Nations.

Improvements to a broader range of social determinants of health (e.g., employment, education, physical environment) are critical to bringing about sustained improvements in health outcomes. As a first step in addressing the needs of First Nation communities, Budget 2016 proposed to invest an unprecedented $8.4 billion over five years to improve the socio-economic conditions of Indigenous peoples. This includes investments in education, housing, safe drinking water, and social infrastructure, including health facilities on reserve.

Health Canada funds and/or delivers a number of health services and supports for First Nations, with a focus on primary care, community-based health promotion and disease prevention programs, and supplementary health benefits. Health Canada also supports community-based primary care services for First Nations people living on reserve, with a focus on communities that are remote and/or isolated. Services are provided by nurse-led teams, based in local nursing stations on reserve. 

In addition to primary care services and community-based programs, Health Canada provides supplementary health benefits for eligible First Nations and Inuit through the Non-Insured Health Benefits Program (NIHB). NIHB provides coverage to eligible First Nations and Inuit (regardless of place of residence) for drugs, medical equipment, dental care and vision care.  NIHB also covers short-term mental health counselling and support for medical transportation costs associated with accessing medically necessary health services that cannot be obtained in the community of residence.

As you know, the Committee report included four recommendations:

  • That, as part of the Government’s comprehensive response to this report, Health Canada include a progress report on steps taken to address the findings of the Spring 2015 audit of the Auditor General of Canada on access to health services for remote Indigenous communities.
  • That Health Canada immediately ensure that all nursing stations are capable of providing essential health services to remote Indigenous communities.
  • That Health Canada take immediate steps to ensure that medical transportation benefits are available to all residents of remote Indigenous communities and, where appropriate, that residents be entitled to bring an escort.
  • That Health Canada take note of the recommendations provided to this Committee by witnesses, as appended to this report, and respond to them in the Government’s comprehensive response to this report.

Office of the Auditor General (OAG) Audit on Access to Health Services

In spring 2015, the OAG released the findings of an audit which examined whether Health Canada had reasonable assurance that eligible First Nations individuals living in remote communities in Manitoba and Ontario had access to clinical and client care services and medical transportation benefits. The audit identified 11 recommendations to support improvements in a number of key areas: training for nurses; health infrastructure; documentation of Medical Transportation Benefits access; comparable access to clinical and client care services; and, inter-jurisdictional coordination. Health Canada is addressing the issues identified in the audit findings.

A comprehensive progress report on steps taken to address the findings has been provided as part of the Government’s response to the report of the House of Commons Standing Committee on Public Accounts, titled Chapter 4, Access to Health Services for Remote First Nations Communities, of the Spring 2015 Report of the Auditor General of Canada. 

Key areas of progress include:

  • A Nurse Recruitment and Retention Strategy was launched by Health Canada in 2014;
  • A National Education Policy has been developed to help nurses maintain the enhanced skills needed to provide primary care services in remote and isolated communities;
  • Interdisciplinary health teams are in place in some communities and are being established elsewhere. This includes adding complementary health professionals, such as Nurse Practitioners, who are qualified to perform a broader scope of practice, as well as other professionals (e.g., paramedics);
  • Health Canada is working with First Nations communities to communicate what services each nursing station provides;
  • An analysis of clinical care access is being undertaken to ensure that First Nations living in remote communities have comparable access to Clinical and Client Care services as other provincial residents living in similar geographic locations;
  • A module on Clinical and Client Care is being finalized, and an accompanying toolkit will be developed by September, 2016; 
  • Health Canada has undertaken trilateral engagement with First Nations and the province to identify challenges and opportunities in clinical care delivery, which will inform further engagement between Health Canada and key partners on integration and addressing identified challenges;
  • Health Canada is working with First Nations to ensure that issues discovered in building inspections are better tracked and shared;
  • The Department is working with partners to establish effective coordinating mechanisms to respond to priority health issues and related inter-jurisdictional challenges;
  • To promote registration under the Indian Act, in order to access NIHB, Health Canada has placed registration forms and brochures about the process at nursing stations; and,
  • Health Canada is engaging with First Nations to redesign the Health Planning Guide to better support communities in their overall health planning process to capture community priorities, capacity, and service tools available to deliver programs and services.

Essential Services in Nursing Stations

In order to address gaps and ensure access to essential services at all nursing stations, Health Canada has undertaken a comprehensive mapping exercise of nursing stations where Health Canada delivers services. This work is being done in partnership with First Nations.

Budget 2016 also invested $82.3M in 2016-17 and $81.9M in 2017-18 to support the construction, repair and improvement of community health facilities (including nursing stations and health centres) to protect the health and safety of clients and health professionals.  Quality health facilities are critical to the offer of quality health services, retention of health professionals, and the integration of health services into those provided by the provinces.

Non-Insured Health Benefits

With respect to NIHB access and concerns raised in the Committee’s report, further work is required to improve communications of eligibility and entitlement available under the program. The NIHB Program is available to First Nations clients if they are registered with Indigenous and Northern Affairs Canada, and children under the age of one can access the NIHB Program using a parent’s eligibility. When a child living in a remote community has not yet been registered, and travel to access medical services is required on an urgent (but non-emergency) basis, there are processes in place to permit the child and an escort to travel under the parent’s NIHB eligibility. Escorts are covered for all clients who require one for medical or legal reasons, including those who require one for reasons of age (children, minors), language barriers, high risk pregnancies, or requirements for physical or cognitive supports when travelling for medical purposes.

The NIHB Program will continue working to improve communications regarding available benefits, processes and policies in order to increase client awareness and promote access to benefits. Furthermore, the NIHB Program will continue to work in partnership with First Nations and Inuit organizations to make real improvements to the services provided. A multi-year Joint Review of the Program with partners at the Assembly of First Nations (including First Nations representatives from Ontario) is underway, with the goal of improving service delivery to make NIHB more responsive to First Nations client needs. The Joint Review is expected to be completed in March, 2017.

Broader Health System Improvements

Witnesses covered a range of issues such as NIHB, clean drinking water, and access to health services. Health Canada continues to make progress on these issues, in collaboration with partners.  In Ontario specifically, the Minister of Health continues to engage with the province and with First Nations leaders to discuss how to work together more effectively, in the immediate and longer-term, to meet the health needs of First Nation communities. For example, federal and provincial officials are working with the Nishnawbe Aski Nation leadership as part of a joint action table to address the pressing issues that have been identified and to develop longer-term plans.

Many of the issues raised by witnesses will be part of Health Canada’s ongoing and future engagement and collaboration with Indigenous partners on a longer-term strategy to improve Indigenous health in Canada. To support this effort, the Minister of Health has committed to work with provinces and territories and Indigenous leaders over the coming year, as part of the development of a new Health Accord. These efforts will determine areas of shared priority to inform improved coordination, continuity, quality and appropriateness of health services for Indigenous peoples.

The Government recognizes that this approach must include measures to address the acute mental wellness needs of First Nation communities in Northern Ontario and across Canada. To this end, on June 13, 2016, following a meeting with a delegation of youth from Northern Ontario, the Prime Minister announced an investment of $69 million over 3 years to meet immediate mental wellness needs for First Nations and Inuit communities. This interim investment will enhance capacity at local and regional levels to provide essential mental health services that respond to current crises. Four Mental Health Crisis Intervention Teams will be created, including two in Ontario, and 32 new Mental Wellness Teams will be put in place across the country. Investments will also support training for front-line workers, access to culturally safe 24-hour crisis line service, and Inuit-specific approaches to mental wellness.  Health Canada will continue to work with First Nations partners to implement the First Nations Mental Wellness Continuum Framework, with the goal of ensuring access to a comprehensive continuum of mental health supports.

In addition, the Government has pledged to implement the recommendations of the Truth and Reconciliation Commission, many of which have implications for health and include themes such as: addressing the physical, mental, emotional and spiritual harms caused by residential schools; setting measureable goals to identify and close the gaps in health outcomes; supporting the recruitment and retention of Indigenous health professionals; improving cultural competency in health care delivery; and recognizing the value of Indigenous healing practices. The Government also fully supports the recent ruling from the Canadian Human Rights Tribunal and is fully committed to ensuring that First Nations children on reserve have access to the health and social services they need.

In closing, the Government recognizes the scope and significance of the health and mental health issues that exist in some First Nation communities, and will work with provincial and First Nations partners to take meaningful action to ensure that First Nation communities and individuals receive a range of health programs and services that are responsive to their needs.

Sincerely,

Hon. Jane Philpott, M.D., P.C., M.P.