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First Nations & Inuit Health

Ten Years of Health Transfer First Nation and Inuit Control

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Table of Contents

Picture of a child

List of Tables and Figures

Message from the Assistant Deputy Minister

The period 1989 - 1999 marks ten years since Treasury Board approved authorities and resources to support the transfer of Indian and Inuit Health Services to First Nation and Inuit control. This report is intended to summarize the activities and accomplishments of the first ten years of First Nations and Inuit Transfer initiatives.

The mandate of Health Canada with respect to First Nations and Inuit people is to ensure the availability of, or access to, health services for First Nations and Inuit. Health Canada also assists First Nations and Inuit in addressing health inequalities and disease threats in order that they may attain a level of health comparable to that of other Canadians living in similar locations. Health related services to First Nations and Inuit include programs in community and family health, prevention and treatment of substance abuse, injury prevention, disease prevention and control, environmental health, non-insured health benefits, and treatment services.

The focus of Health Canada's work is to support First Nations and Inuit in attaining autonomy and control of their health programs and resources within a time-frame to be determined in consultation with First Nations and Inuit people. First Nations and Inuit communities and organizations have expended $112 million to further their vision, and enhance their capacity to manage and administer their health services based on their community needs and priorities. After ten years; 244 communities, or 41% of the eligible communities have signed Health Services Transfer Agreements. In addition, 84 communities have also signed Integrated Agreements and 8 communities have signed Self-Government Agreements which include health services.

This report provides us with an opportunity to reiterate the mission of First Nations and Inuit Health Branch: A renewed relationship with First Nations and Inuit that is based on the transfer of direct health services and a refocused federal role that seeks to improve the health status of First Nations and Inuit. The Branch's strategic directions for future years continues to be the transfer of control of health programs to First Nations and Inuit, to address the health inequities found in the Aboriginal population, and to develop sustainable Aboriginal systems that are well integrated into the Canadian health system.

These accomplishments speak for themselves. The progress made is a direct result of the cooperation and joint initiatives between First Nation and Inuit communities and organizations and FNIHB in meeting the challenges of First Nation and Inuit peoples' aspirations for self-determination.


Paul F. Cochrane
Paul F. Cochrane,
Assistant Deputy Minister
First Nations and Inuit Health Branch
Health Canada

Introduction

Picutre of Native woman
First Nations and Inuit people occupy a unique status in this country as it relates to society, political association, cultural identity and relation with the federal government. There are more than 600 First Nation and Inuit communities that speak more than 51 languages. Each Band has its own culture, history and identity. No two Bands are exactly alike, what is good for one Band is not necessarily what is good for another. Consequently, there is no one simple solution to the many challenges facing First Nations and Inuit today. Although only two or three generations away from a life of hunting, fishing, gathering, sowing, etc., First Nations and Inuit people today occupy all professional fields, they are doctors, nurses, teachers, lawyers, police, firefighters, foresters and surveyors. They are fathers and mothers who work to straddle values between two different worlds, their culture and the current social system of the dominant society. They traverse between the dominant society and their culture as citizens and productive members of both. Still First Nations and Inuit people today proudly maintain an independent cultural identity.

History of Transfer

Ten years ago, on June 29, 1989, Treasury Board approved authorities and resources to support the transfer of Indian health services from Medical Services, Health and Welfare Canada (now Health Canada) to First Nations and Inuit wishing to assume responsibility. This decision did not spring spontaneously from a well of bureaucratic decision-making. Rather, it constituted the singular most significant outcome of decades of effort and activity by First Nation and Inuit peoples to regain control of their lives and destinies.

To put Health Transfer in context, it is useful to understand from a historical perspective how First Nations and Inuit and the Federal Government have worked together to respond to First Nations and Inuit expressed desire to manage and control their own health programs.

Please refer to page 21 for a chronology of achievements and events.

Picture of Native nurse

1969 White Paper

Federal Government Policy Paper which proposed to remove the status of treaty individuals under the Indian Act and to discontinue special services so identified, advocating the increased assimilation of Native people into Canadian Society.

1970 Red Paper

First Nations' response to the White Paper emphasizing federal responsibility for health care to First Nation peoples and emphasizing plans to strengthen community control of their lives and of government-delivered community programs.

1975 Federal Government/Indian Relationships Paper

The White and Red Papers served as an impetus for the collaborative effort of the Federal Government and First Nations to begin serious planning for the future.

This resulted in the 1975 paper, The Canadian Government/The Canadian Indian Relationships, which defined a policy framework for strengthening Indian control of programs and services. In the health sector, under contribution agreements 75% of the Bands became responsible for such programs as the Native Alcohol and Drug Abuse Program and the Community Health Representative Program.

1979 Indian Health Policy

Picture of ceremonial dancerThe Federal Indian Health Policy is based on the special relationship of the Indian people to the Federal Government, a relationship which both the Indian people and the Government are committed to preserving. It recognizes the circumstances under which many Indian communities exist, which have placed Indian people at a grave disadvantage compared to most other Canadians in terms of health, as in other ways.

The stated goal of the Indian Health Policy adopted by the Federal Government on September 19, 1979, is "to achieve an increasing level of health in Indian communities, generated and maintained by the Indian communities themselves". In this regard the policy recognized the historic responsibilities of both federal and provincial governments in providing health services to First Nations and Inuit people, and it removed the issue of treaty rights from health policy considerations to where it rightly belonged - Indian Affairs. The policy reasoned that improvements to the health status of the Indian population should be built on three pillars: (1) community development, both socio-economic and cultural/spiritual, to remove the conditions which limit the attainment of well-being; (2) the traditional trust relationship between Indian people and the federal government; and (3) the interrelated Canadian health system, with its federal, provincial, municipal, Indian and private sectors.

A further important aspect of the new policy was the recognition that First Nation and Inuit communities could take over any or all aspect(s) of the administration of their own community health programs, at their discretion and with the support of the Department of National Health and Welfare.

1980 Report of the Advisory Committee on Indian and Inuit Health Consultation (Berger Report)

The Berger report recommended methods of consultation that would ensure substantive participation by First Nations and Inuit people in the design, management and control of health care services in their communities.

1983 Report of the Special Committee on Indian Self-Government (Penner Report)

The Penner Report recommended that the Federal government establish a new relationship with First Nations and Inuit people and that an essential element of this relationship be recognition of Indian Self-Government. The report identified health as a key area for takeover.

1983-86 Community Health Projects

First Nations and Inuit Health Branch sponsored demonstration projects for First Nations. The experiment was initiated to provide both Federal and First Nation authorities with the same substantive information with respect to First Nation control of health services.

1986 The Sechelt Indian Band Self-Government Act

The Sechelt Indian Band Self-Government Act was passed by Parliament in 1986. In April of the following year, the British Columbia Legislative Assembly unanimously passed a bill to give the Sechelt community municipal status. Consequently, the Sechelt Indian Band signed the first Self-Government agreement in which a First Nation community assumed control of their health services.

1988 Cabinet Approval for Health Transfer
South of the 60th Parallel

In order for First Nations and Inuit Health Branch to proceed with health transfer to First Nations as part of administrative reform, the policy framework, authorities and resources had to be developed and secured. A Subcommittee on the Transfer of Health Programs to Indian Control was established with representation from First Nations with experience in health care. The Subcommittee incorporated the experiences from the Community Health Projects and recommended a developmental and consultative approach for health transfer. These recommendations were then used to finalize the health transfer policy framework.

On March 16, 1988, the Federal Government Cabinet approved the health transfer policy framework for transferring resources for Indian health programs south of the 60th parallel to Indian control through a process which:

  • permits health program control to be assumed at a pace determined by the community, i.e., the community can assume control gradually over a number of years through a phased transfer;
  • enables communities to design health programs to meet their needs;
  • requires that certain mandatory public health and treatment programs be provided;
  • strengthens the accountability of Chiefs and Councils to community members;
  • gives communities:
    • the financial flexibility to allocate funds according to community health priorities and to retain unspent balances;
    • the responsibility for eliminating deficits and for annual financial audits and evaluations at specific intervals;
  • permits multi-year (three to five year) agreements;
  • does not prejudice treaty or Aboriginal rights;
  • operates within current legislation;
  • is optional and open to all First Nation communities south of the 60th parallel.

1989 Treasury Board Authorities for Transfer

In 1989, Treasury Board approved the financial authorities and resources to support pre-transfer planning and to fund community health management structures.

Health Transfer

A Defined Structure for Transfer

Figure 1: Mechanisms for delivery of health servicesReaffirming the three pillars of the 1979 Indian Health Policy, a specific mission for Indian Health Services is to increase community participation in all aspects of the health program, and encourage and support the transfer of control of health programs to Bands, Tribal Councils or other First Nation authorities prepared to accept such authority and responsibility. For Northern Health Services, a specific mission was to effect the orderly transfer of health services to the Territorial Governments, in full consultation with First Nation and Inuit authorities.

The 1988 Indian Health Transfer Policy provided a framework for the assumption of control of health services by First Nations people, and set forth a developmental approach to transfer centred on the concept of self-determination in health. Through this process, the decision to enter into transfer discussions with Health Canada rests with each community. Once involved in transfer, communities are able to take control of health program responsibilities at a pace determined by their individual circumstances and health management capabilities.

Transfer of health services, which is entirely optional, includes three phases: Pre-Transfer Planning, Bridging and Transfer Implementation. The process is designed to occur within the present funding base of federal health programs for First Nation and Inuit peoples, and First Nation and Inuit communities are required to provide certain mandatory programs such as communicable disease control, environmental and occupational health and safety programs, and treatment services.

Initially, the enthusiasm for this process was varied. For some, it was seen as an important link to Self-Government where the community plans and controls health programs in their communities according to its own priorities. It was seen as a way to develop programs relevant to a community's own cultural and social needs. Others took a more hesitant approach. As the uptake of control of health services by First Nations increased, the Indian Health Transfer Policy began to be seen increasingly by First Nations people as a stepping stone towards the inherent right of Self-Government.

Figure 1 shows the various ways that delivery of health services is being administered in First Nation and Inuit communities. As the extent of control by the community increases the higher the community is on the ladder. First Nations and Inuit communities interested in having more control of their health services can decide from among Health Services Transfer, Integrated Community-Based Health Services, and Self-Government, based on their eligibility, interests, needs and capacity.

Progress Over Time

Transfer became the cornerstone of Health Canada's relationship with First Nation and Inuit communities. Health Services Transfer Agreements between Health Canada and First Nation and Inuit provided the opportunity for communities or First Nation and Inuit organizations to manage their own health programs and services. At first, Transfer was the only option communities had for increasing their control over health programs and services beyond Contribution Agreements. Although many communities were interested in assuming increased control over health services and programs, not all communities were ready to move into this level of control so quickly. It became increasingly apparent that one design could not fit all the diversity of readiness. Some communities expressed interest in alternative strategies which would also give them increased control of resources.

Pathways To First Nations Control

Figure 2: Diagram of Pathwasy to First Nations Control

Each year brought pressures for change and restructure in the transfer approach. First Nations and Inuit Health Branch searched for ways to respond to communities desiring to increase their control of community resources, either through the transfer process, or through other initiatives. This movement was further supported by a decision of the Departmental Executive Committee of Health Canada on March 15, 1994, which directed First Nations and Inuit Health Branch to commence planning all activities toward the following goals:

  • the devolution of all existing First Nations and Inuit Health Branch Indian health resources to First Nation and Inuit control within a time frame to be determined during consultations with First Nation and Inuit communities;

  • moving First Nations and Inuit Health Branch out of the health care service delivery business;

  • the transfer of knowledge and capacity to First Nation and Inuit communities so that they can manage and administer their health resources;

  • a refocused role for First Nations and Inuit Health Branch; and a refocused role for Health Canada which will take into account First Nations and Inuit Health Branch's strategic direction.

In further support the search for alternative pathways to transfer, in late 1994, Treasury Board approved the Integrated Community-Based Health Services Approach as a second transfer option for communities to move into a limited level of control over health services.

1995 saw the distribution and implementation of Pathways to First Nations Control Report of Project 07 Strategic Planning Exercise. This cornerstone document set the essential differences between The Integrated Approach and Transfer. The Integrated Approach is an intermediate measure which provides more flexibility than Contribution Agreements, but less flexibility than the Transfer Agreement.

In 1995, the federal government announced the Inherent Right to Self-Government Policy. This policy recognizes First Nations and Inuit have the constitutional right to shape their own forms of government to suit their particular historical, cultural, political and economic circumstances. The policy thus introduced a third option for communities to further increase their control of health services.

Self-governance gives Bands more flexibility to establish program priorities in response to tribal needs rather than following Federal program objectives. Bands are able to expand, consolidate and create new programs to improve services to their communities and to make certain laws governing their community with respect to health. Furthermore, the range of resources for health programs which can be included in a Self-Government arrangement is greater than those included in a Health Service Transfer arrangement and may eventually include fixed assets and services under the Non-Insured Health Benefits Program. The flexibility in terms of how resources are allocated is also greater and reporting requirements are fewer.

First Nation and Inuit peoples will determine the pace at which Self-Government arrangements proceed. Putting the arrangements in place will of course take time. The process will require intense local or regional negotiations between First Nation and Inuit peoples, the federal government and the provincial or territorial government concerned. Figure 3 depicts the status of First Nation and Inuit control activities at the close of the first decade of transfer, March 31, 1999. The uptake of transfer has steadily increased over the past decade the maps on figure 3 present a progressive overview of the rate of uptake of transfer by First Nation and Inuit communities starting in year one.

Figure 3: First transfer in each region

The Community Workload Increase System (CWIS)

Picture of Native woman having eye exam.In the early years First Nations and Inuit Health Branch, First Nations and Inuit experienced rising concerns over the existing service levels and the ability of First Nations and Inuit to maintain the necessary level of essential health programs at the community level. A mechanism was needed to justify additional resources required to deliver essential health services due to workload increase at the community level.

Figure 4: Shows the allocation of dollars derived from the Community Workload Increase System Funding to First Nation and Inuit control activities.

CWIS is a mechanism capable of providing a variety of data which can be used to set health priorities and to develop new programs. The system continues to be maintained and First Nations and Inuit community population is updated on an annual basis. The CWIS was a mechanism to allocate additional resources received from Treasury Board related to population growth and workload. All resources received for this purpose were allocated to First Nations and Inuit. Treasury Board ceased allocating resources for this purpose in 1995-96 but First Nations and Inuit Health Branch has maintained the system to monitor population growth and workload impacts, provide analysis for existing and new programs and to allocate additional resources if and when resources become available.

Second and Third Level Transfers

Picture of Native childrenCommunity-based programs are the 1st level of transfer. Second and third level services are those services provided at the zone and regional level. Generally, 2nd and 3rd level services are of a coordination, consultative and supervisory capacity. Some community-based programs include resources to carry out 2nd, and 3rd level services. In those few instances where resources for 2nd and 3rd level services were transferred, arrangements were usually made to buy back the services from First Nations and Inuit Health Branch.

First Tribal Council Transfer - Conseil Attikamek-Montagnais, July 1, 1989

In response to First Nation and Inuit organizations' expressed desire to assume delivery of 2nd and 3rd level services, First Nations and Inuit Health Branch developed a policy in 1998 which focussed on facilitating the transfer of mandatory and non-mandatory 2nd and 3rd level services to First Nation and Inuit organizations' control. The policy requires that First Nation and Inuit organizations first receive a mandate from each community on whose behalf the services are to be provided, and demonstrate it has the capacity to deliver the mandatory 2nd and 3rd level services.

In developing this policy, it was recognized that a management funding base was needed to enable First Nation and Inuit organizations to deliver these services on behalf of communities. First Nation and Inuit organizations would initially receive one-time supplemental funding in order to set up their management structure and to plan all aspects of the function. When the planning phase is completed, they would receive the management funding base needed to deliver 2nd and 3rd level services to participating communities.

Transfer of Hospitals and Non-Medical Residential Treatment Programs

Concurrent with the spirit of transfer, the opportunity for maximum First Nation and Inuit involvement in developing and managing programs to meet First Nation and Inuit health needs extends to the administrative transfer of hospital services and non-medical residential treatment programs (National Native Alcohol and Drug Abuse Treatment Centres and National Youth Solvent Abuse Treatment Programs). These transfer initiatives involve an administrative transfer between First Nations and Inuit Health Branch and the incorporated governing structure of the facility, as opposed to a community-based transfer with a Band or Tribal Council.

First Nations and Inuit Health Branch currently funds 53 National Native Alcohol and Drug Abuse Programs (NNADAP) Treatment Centres and 7 National Youth Solvent Abuse Treatment Programs (NYSATP). The first NNADAP treatment centre program transfer occurred in 1993. The first NYSATP transfer took place in 1997. To date 8 NNADAP treatment centres and 1 NYSATP have transferred.

As of March 31, 1999, First Nations and Inuit Health Branch operates 4 hospitals: Sioux Lookout Zone Hospital in Sioux Lookout, Ontario; Norway House Hospital in Norway House, Manitoba; Percy E. Moore Hospital in Hodgson, Manitoba; and the Blood Indian Hospital in Cardston, Alberta. Although originally established to serve First Nation peoples, these hospitals are available to anyone in need and they are linked to provincial health care systems. The distinctiveness of each hospital is a key factor in its transfer. Subsequently, the transfer of hospital services must be considered in the light of the individual circumstances of each hospital.

Joint FNIHB/DIAND Efficiencies and Effectiveness Initiatives

With the rapid pace of First Nations' desire to increase their control over their own programs, there is an increasing demand on Health Canada (First Nations and Inuit Health Branch) and Indian and Northern Affairs Canada to co-ordinate how business is conducted and to explore what actions could be taken to streamline funding mechanisms and instruments. As a result the Deputy Minister's Committee on Aboriginal Affairs, consisting of all Federal departments, the Efficiencies and Effectiveness Initiative was established with the full participation of First Nations and Inuit Health Branch to explore opportunities for administrative cooperation in the management of federal funding arrangements with First Nations and Inuit such as:

  • simplify the operating environment of First Nations and Inuit; through the use of consistent authorities and management systems;

  • reduce administrative burden on First Nations and Inuit and the federal government;

  • reduce the volume of diversity of terms and conditions faced by First Nations and Inuit, to bring into focus essential accountability requirements within a single comprehensive funding agreement;

  • improve accountability with respect to the collective impact of federal funding on the well-being of First Nations and Inuit.

A multi-departmental funding agreement was jointly developed by Health Canada (First Nations and Inuit Health Branch) Indian and Northern Affairs Canada and the Department of Justice for implementation during fiscal year 1999/2000. This funding mechanism, the Canada/First Nations Funding Agreement (CFNFA), is a new funding mechanism which may be used by First Nations who wish to have one agreement that includes several federal departments' programs, resulting in a reduced number of agreements and less administrative burden for both Bands and Federal Departments, thus these agreements generally cover a wider range of Federal programs.

The first CFNFA was signed in April, 1999, with Canim Lake in British Columbia. The community of Canim Lake is non-isolated and located in the south eastern part of the province. It is a small community with a population of 466 and a Health Station.

First Nations and Inuit Health Branch is committed to jointly develop further streamlining measures in order to accommodate ongoing administrative First Nations and Inuit issues. Some of the joint work that is currently underway is the development of a single standardized multi-departmental financial and non-financial reporting guide for First Nations and Inuit and the development of a multi-departmental third party management policy for First Nations and Inuit.

1999 Revised Policy - Health Management Funding, Bands with Multi-communities.

Health management funding is provided to First Nation and Inuit communities who enter into the Transfer initiative. This funding is provided on a one-time basis during the pre-transfer phases of Transfer (50%), and on an ongoing basis once the community has signed a Transfer Agreement (100%).

In the pre-transfer phase management funding was allocated by community and during the transfer implementation phase, funding was allocated by Band. This funding arrangement had a bearing on capacity building: that is, the availability of sufficient funding to manage health activities for multi-communities under Transfer. The policy was revised to deal with the management funding by community as opposed to by Bands.

Transfers North of the 60th Parallel

A 1954 Cabinet decision gave First Nations and Inuit Health Branch responsibility for the delivery of health services to all residents of the Yukon and Northwest Territories. The Cabinet decision stated that once territorial governments showed a desire, and had developed the necessary expertise, responsibility for health care delivery would be transferred to them.

Generally, the approach was to transfer responsibility in stages, starting with the transfer of hospitals. Early in the 1980s discussions were held with the Government of the Northwest Territories and the Inuit Tapiriit Kanatami with the aim of developing an arrangement for the transfer of the Frobisher Bay General Hospital in the Baffin Zone to the Government of the Northwest Territories, and for the administration by a local health board. Also discussed were the eventual transfer of universal medical and dental services to communities in the Baffin Zone.

An interim Regional Board of Management was established with representation from communities in the Eastern Arctic. In 1982, responsibility for the Frobisher Bay General Hospital was transferred to the administration of the local hospital board and to the Government of the Northwest Territories. The hospital was re-named the Baffin Regional Hospital. Other universal health programs and services were transferred to the government of the Northwest Territories during the 1980s. The transfer of the remainder of universal federal health services in the territories to the Government of the Northwest Territories was completed by March, 1988, and became effective on April 1, 1988.

The federal government retained the responsibility for the First Nation and Inuit targeted program, Non Insured Health Benefits. New federal health programs targeted to First Nation and Inuit remain the responsibility of the federal government and are administered by First Nations and Inuit Health Branch. Tripartite negotiations were initiated in the early 1990s between First Nations and Inuit Health Branch, the Council of Yukon Indians and the Yukon Territorial Government on the transfer of universal health services in the Yukon Territory. Discussions focused on the transfer of the Whitehorse General Hospital (Phase I) and the delivery of health services in the communities (Phase II). A Framework Agreement to guide the discussions was agreed on by officials representing Canada, Yukon and the Council of Yukon Indians. Phase I, the transfer of the Whitehorse General Hospital to the Government of the Yukon and the Yukon Hospital Corporation, was completed effective April 1, 1993. Phase II, the transfer of universal health services and facilities was completed on April 1, 1997.

Agreements

First Single Band Transfer - Sandy Bay, August 1, 1989Agreement templates change in order to deal with new issues as well as provide clarity on some existing clauses. Issues such as unforeseen circumstances, confidentiality and medical records, intervention, continuing responsibility of the Minister, dispute resolution process and growth to contribution agreements are now addressed in agreements. In addition, clauses dealing with evaluation, termination, Aboriginal/Treaty rights/Land Claims and mandatory programs are now clearly stated. The current agreements reflect government policies, legal opinions and input from First Nations and Inuit over a number of years. The following agreement templates have been revised to better address the concerns of all participating parties: Health Services Transfer, 1nd and 3rd Level Services, Canada First Nations Funding Agreement, National Native Alcohol and Drug Abuse Treatment and Prevention Programs, National Youth Solvent Abuse Treatment Programs.

Picture of Transfer ceremony, Kingfisher Lake, January 1994.

First Nation and Inuit Control of Health Services - Communities by Location

The resources required to deliver basic health services at the community level are a factor of the actual number of clients for each of these services. The range of basic services offered in communities varies with the degree of isolation and accessibility to health care. Four types of communities have been defined to reflect varying degrees of isolation and accessibility to health care:

  • Type 1: Remote-Isolated
    No scheduled flights, minimal telephone or radio services, and no road access;

  • Type 2: Isolated
    Scheduled flights, good telephone services, and no year round road access;

  • Type 3: Semi-Isolated
    Road access greater than 90 km to physician services;

  • Type 4: Non-Isolated
    Road access less than 90 km to physician services.

Figure 5 shows the Agreements by community location.

Figure 5: Diagram of Agreements by community.

Financial Highlights

Over the past 10 years First Nations and Inuit Health Branch has provided First Nation and Inuit communities and organizations with $72.3 million to cover planning, capacity building and start-up costs involved with the Health Services Transfer Approach and the Integrated Community-Based Health Services Approach. Of this total amount, $54.9 million was spent on pre-transfer planning. Globally, First Nations and Inuit Health Branch has spent $39.4 million on ongoing funding to First Nation and Inuit control to support Transfer and Integrated Agreements (Figure 6).

Figure 6: Pie chart of Funding to Support First Nation and Inuit Control

Figure 7 shows the total amount of funding in First Nation and Inuit control as of March 31, 1999 ($491 million). As more communities undertake Transfer and Integrated funding agreements, the "other contribution agreements" percentage will decrease. Other Contributions include NIHB contributions and NIHB pilots. Some FN/I have undertaken NIHB pilots as a step towards the transfer of NIHB.

Figure 7: Diagram of Resources Under First Nation & Inuit Control

Figure 8 shows the increase in funding available over the past decade for First Nation and Inuit communities. In the final year of the decade $53.4 million was the cumulative amount. The dip in resources spent on planning in the final year of the decade resulted from fewer pre-transfer agreements than in the previous year.

Figure 8: Graph of Funding to Support First Nation and Inuit Control

 

The trend has been that as First Nations and Inuit assume greater control of health services through mechanisms such as Integrated Agreements and Transfer Agreements, the involvement of First Nations and Inuit Health Branch in direct service delivery has steadily declined (Fig. 9).

Figure 9: Graph of Trends in First Nation and Inuit Control

Demographic Highlights - South of the 60th Parallel

Across Canada there are 638 communities. However, the transfer initiative has authorities for those communities south of the 60th parallel only, making the total number of communities eligible for transfer 599. At the end of the 10th year of Transfer, 244 communities, or 41% of the eligible communities, had signed Health Services Transfer Agreements. Of the 244 communities, 43% were individual community transfers and 57% were part of a multi-community transfer (Figure 10).

Figure 10: Diagram of Single and Multi-Community Transfers.

Nationally, on the basis of population, the total population of all eligible communities is 388,712 (599 communities), of which 193,060 or 46% are living in transferred communities. Table 1 below shows the distribution of population by community type, and those under First Nation and Inuit control.

Figure 11, depicts the distribution of eligible communities by population range and the percentage of those communities which have transferred. For example communities of 1001 - 3000 represent 21% of the eligible communities, 54% of those communities have signed Transfer Agreements.

Figure 11: Diagram of Communites by Population Size

Table 1: First Nation and Inuit Population by Community Type and Those Transferred
Nationally Non-
Isolated
Semi-
Isolated
Isolated Remote-
Isolated
Total
Total # of Communities
400
86
93
20
599
Population of Communities
257,897
40,040
83,618
7,157
388,712
Total # of Communities Under FN/1
Control
170
32
35
7
244
Population Under FN/1 Control
134,371
18,441
37,107
3,141
193,060
% of Communities Under FN/1
Control
43%
36%
38%
35%
41%
% of Total Population Under FN/1
Control
52%
46%
44%
44%
46%

Relationship with Communities

Over the past decade First Nations and Inuit Health Branch has forged new relationships with First Nation and Inuit communities through formal agreements to work together to develop, sustain and enhance their good health and well-being by promoting self-reliance. First Nation and Inuit communities assume control of their health programs and services in ways that their basic health needs are met. At the same time First Nations and Inuit Health Branch provides funding for program management so that these health programs and services can be sustained. By promoting and facilitating information exchange and by the provision of support services, transferred communities are assisted in pursuing initiatives and/or providing services that are supportive of their commitment to service to their people and the achievement of their health objectives.

After a transfer agreement is signed, the relationship between First Nations and Inuit Health Branch and the community is one of mutual support and shared responsibility. First Nations and Inuit Health Branch's role in this relationship is to facilitate capacity-building and information exchange, and to foster participatory roles for the community. For its part in this relationship, the community works with First Nations and Inuit Health Branch through regular reporting to support the Minister of Health in his or her accountability to Parliament for how effectively the transferred funds are being spent, and how the delivery of health services has improved the health status of community members.

Photo of Richard Legault & Joanne Dion

Evaluations of the Transfer Initiative

Picture of baby eatingIn 1989, Treasury Board approved an evaluation strategy for the Transfer Initiative which would examine how well transfer operated as a means of turning over control of health services to First Nation communities. This strategy consisted of a short-term evaluation (in year 3) and a long-term evaluation (in year 5) of Indian health transfer to document that transfer is accomplishing its goals and to identify areas of transfer that need revision or strengthening. The short-term evaluation was a formative evaluation which provided feed back on how the transfer process was working. The long-term evaluation was a summative evaluation and focused on whether transfer was meeting its specific objectives, and, thus, working toward the goal of the health program transfer. A good health program evaluation makes use of both types of evaluations.

The Short-Term Evaluation of Indian Health Transfer was undertaken in 1991. The evaluation findings were based on community case studies which were completed on the eight communities that had signed transfer agreements prior to March 31, 1991.

The evaluation made inquiry into four key areas of transfer: the transfer process, pre-transfer planning, post-transfer administration, and the impact of transfer on the transferred communities. The overall conclusion was that the process more than adequately enables First Nations to plan effectively for transfer, and that First Nations, although aware of the limitations of transfer, are generally supportive of the process.

The Long Term Evaluation of Transfer was initiated in June, 1994. The main focus of the long-term evaluation was to assess the overall success of the Transfer initiative. The three primary areas of study in this evaluation were: an assessment of whether or not Transfer achieved its objectives; an examination of the impacts and effects of Transfer; and an identification of alternatives to the Transfer process. The evaluation did not attempt to measure the impact and effects of transfer on the health status of Indian people since changes in health status is the result of many intervening factors, and occur over a broader time horizon.

Among the reported findings of the long term evaluation are: the objectives of transfer have been realized at the community level for communities that entered the post-transfer phase; community members had an increased awareness of health issues, and health care had become more of a priority in transferred communities; social and community development strategies were found to be in place using a variety of culturally sensitive and relevant methods of health delivery; and community health services were found to be integrated with other programs and services such as social services, mental health, home care, education and non-insured health benefits.

The following comments offered by communities emphasize the accomplishments of transfer:

  • "Taking responsibility for health has made people more responsive to change - they can see change as the basis for the future. This process has in turn helped with spiritual development".

  • "The emphasis on wellness and mental health has had a positive effect on (our) leadership. The community now demands a healthier lifestyle from their leadership".

  • "We are training some of our Elders and youth in different areas such as suicide prevention, family violence and others. They then become valuable resources in the community".

The Report of the Auditor General - 1997 (Chapter 13) concerning the Transfer of Health Programs to First Nation and Inuit Control was overall positive:

  • A sound framework for the transfer of health programs to community control has been developed and has allowed First Nations to start managing their own health programs.

The report also highlighted some post transfer activities which needed more work and commitment by First Nations and Inuit and First Nations and Inuit Health Branch. These activities included updating the Community Health Plans upon renewal; improving the performance reporting by focussing on results; ensuring that audit requirements are met; and ensuring that the evaluations determine the extent to which the transfer initiative contributes to improving the health of First Nation and Inuit people. First Nations and Inuit Health Branch has initiated an action plan to address all the concerns raised in the report.

Challenges

Picture of BC Aboriginal Network BuildingChanges are taking place. The future will be very important and challenging for First Nation and Inuit peoples and for First Nations and Inuit Health Branch. The challenges ahead include population growth, sustainability, accountability, the transition to Self-Government, and treaty land entitlements.

Population Growth

Increasingly, First Nation and Inuit people are taking control over the delivery of health services and programs. It is widely recognized that when responsibility for health is at the community level the health status of people improves. Nevertheless, health indicators for First Nation and Inuit people, though improving, still fall well below the national norm. The birth rate of First Nations and Inuit people is twice the Canadian average, and the on-reserve population is expected to grow by as much as 3.4% annually for the next several years. The needs of First Nation and Inuit peoples will continue to place tremendous pressure on health services and resources provided by both Federal and Provincial governments.

Sustainability

In order for First Nation and Inuit communities to respond effectively to pressing health problems they must be able to develop health programs which address their particular need. It is essential that they be able to draw up their own solutions, test them through implementation and to modify them for their own changing circumstances. Thus, health development at the community level includes a long range concern for the future; the term that captures this issue is sustainability.

Sustainability has become a serious issue for the federal government as well as the First Nations and Inuit. With the rapid First Nations and Inuit population increase and the increasing demand on services as well as the fiscal restraints within government, the challenge of stability and fiscal sustainability is a growing concern and has a direct impact on the Transfer Program and Self-Government. First Nations and Inuit are looking for certainty in relation to fiscal sustainability prior to taking on the responsibility of delivering programs and services to their membership. Health Canada will be initiating steps with funding agencies to deal with sustainability issues.

Accountability

Accountability is the obligation to take and demonstrate responsibility for performance based on agreed expectations and within the limits of budgets and existing authorities. Essentially, accountability is about ensuring a formal commitment to responsibilities by First Nations and Inuit Health Branch and First Nations and Inuit community members. As program delivery moves from federal direct delivery through Contribution, Integrated, Transfer and Self-Government Agreements, other perspectives on accountability become important: the accountability of Chief and Council to community members; the accountability of Chief and Council to the Minister of Health, the accountability of the Minister of Health to First Nation and Inuit communities, and the accountability of the Minister of Health to Parliament.

It is very evident that accountability is an important issue for all levels of government, including First Nations and Inuit, and for the Canadian public.

Today First Nations and Inuit manage a large portion of program funds and Chiefs and Councils have a dual accountability for its use. This primary accountability is towards their own membership for the effective management of programs and funds to meet community needs. They are also accountable to the governments, transferring the funds, for the use of those funds to meet community needs.

First Nations and Inuit Health Branch has initiated a process to develop an Accountability Framework.

As First Nations and Inuit Health Branch continues to transfer services and resources to First Nations and Inuit, there is a need for both parties to take a closer look at how they are adapting to this change. There is a need to demonstrate stronger accountability for services and resources.

Transition to Self-Government

There are many challenges for First Nations and Inuit and First Nations and Inuit Health Branch during the transition from administrative agreements to the Self-Government negotiations. Some of these challenges concern the accountability mechanisms, the treaty relationship, jurisdiction and program authorities and the fiscal capacity of First Nations and Inuit.

Treaty Land Entitlements

Many treaties between First Nations and the Crown contain land concessions. A treaty land entitlement (TLE) claim arises when a First Nation has not received all of the land it is owed under the treaty to which it adheres. At the present time there are a number of TLE claims in process. Under a TLE process, a First Nation would acquire additional land, with that land becoming Reserve land. This can, on occasion, become an issue to the Branch when the land to be acquired has an existing First Nation population base receiving community health services from the province.

There will be cases where funding issues will occur, resulting from populated lands acquired by First Nation Bands through the TLE process.

Integration of Services

A long term priority of the First Nations and Inuit Health Branch is to create an environment which would allow First Nations and Inuit Health Branch to facilitate/address anticipated proposals from First Nation and Inuit groups to integrate all health related services: federal, provincial and municipal. This will require the establishment of internal policies and structures, as well as, identifying funding requirements, sources and mechanisms. Key to this will be an examination of the feasibility of not only integrated health services delivery structures, but also the feasibility of integrating separate service delivery funding streams into one.

What's Next

New Models

First Nations and Inuit Health Branch is seeking alternative ways of facilitating greater First Nation and Inuit control. First Nation and Inuit organizations are now beginning to express a desire to provide a scope of service greater than the simple delivery of community-based health programs. First Nations and Inuit Health Branch needs to develop mechanisms to support an expanded scope of service such as those which have been identified by First Nation organizations wishing to undertake a more "holistic health approach" toward First Nation health service delivery. The challenge is to develop potential Health Authority Models, outside of existing Transfer models. This identification process will include a determination of types of health service delivery structures under which these models may operate.

Transfer of all Programs

In keeping with the vision of First Nations and Inuit Health Branch that "First Nations and Inuit people will have autonomy and control of their health programs and resources within a time-frame to be determined in consultation with First Nations and Inuit people", First Nations and Inuit Health Branch is working towards obtaining the appropriate authorities and developing the administrative processes to allow for the transfer of all programs (existing and new) to First Nation and Inuit control. For example, the transfer to First Nation and Inuit control of the Non-Insured Health Benefits program and the administration of Fixed Assets (health facilities).

Picture of wagmatcook Band members

Health System Renewal

The Federal Government's Gathering Strength initiative, in response to the report of the Royal Commission on Aboriginal Peoples, is an action plan focussing on a renewed relationship with Aboriginal peoples, with the following key objectives in mind:

  • Renewing partnerships;
  • Strengthening Aboriginal Governance;
  • Developing new fiscal relationships;
  • Supporting strong communities, peoples and economies.

The Branch, in keeping with the Gathering Strength initiative and its mission and vision statements, described above, has adopted a strategic direction that includes the following objectives:

  • Developing sustainable First Nation and Inuit systems that are well-integrated into the Canadian health system;
  • Building effective partnerships leading to meaningful change in the health system.

Capacity Building

One of the primary areas, as indicated by First Nations and Inuit is the capacity of communities to plan and manage their own First Nation and Inuit health system. Issues around training and development, management and professional skills, and health structures are predominant factors in addressing capacity building.

In the context of an accountability framework, and long term sustainability, First Nations and Inuit Health Branch is pursuing various opportunities and models to deal with capacity in First Nation and Inuit health care delivery. One such example is the development of a comprehensive health plan for all communities which will be a "living document" incorporating health priorities, health needs, resource implications, reporting requirements, and health outcomes to determine changes in health status.

Transfer Projection

Table 2: Current and Projected Transfers

Transfers by Region - Transferred as of March 31, 1999
Region Total Eligible
Communities
Number % of Total
Atlantic 40 17 43
Quebec 28 19 68
Ontario 124 36 29
Manitoba 62 25 39
Saskatchewan 83 59 70
Alberta 58 4 7
Pacific 204 84 41
Total 599 244 41
Transfers by Region - Projected to March 31, 2004
Region Total Eligible
Communities
Number Percent Total
Atlantic 40 17 43
Quebec 28 19 68
Ontario 124 36 29
Manitoba 62 25 39
Saskatchewan 83 59 70
Alberta 58 4 7
Pacific 204 84 41
Total 599 244 41

South of the 60th parallel there are a total of 599 transfer eligible communities. At the close of the Tenth Year of Transfer, Fiscal Year 1998/1999, 244 (41%) of these communities had signed Health Services Transfer Agreements, either as individual community initiatives or as part of a multi-community transfer.

An additional 77 (13%) of the eligible communities had signed Integrated Community-Based Health Services Agreements. North of the 60th parallel in the Yukon Territory, 7 of the 16 Yukon communities had signed Integrated Community-Based Health Services Agreements. As of March 31, 1999, 7 had moved to Self-Government Agreements.

Two of the 7 First Nations and Inuit Health Branch Regions south of 60th parallel (Saskatchewan and Quebec Regions) have more than 50% of their respective communities transferred. A simple straight line analysis indicates that the annual uptake of communities transferring since the inception of Transfer is 3.5%.

By the end of Fiscal Year 2003/04, a total of 349 communities (58% of the total eligible) will be transferred (Table 2). This forecast averages to an annual uptake of close to 3.5%. The forecast is subject to unknown variables/events that will occur over the next four years, resulting in variable rates of uptake. Full transfer will be achieved at different times in different Regions.

The table that follows on page 21, summarizes the major achievements and events during the ten years of health transfer to First Nations and Inuit control.

The centrefold that follows, presents a map and comprehensive listing of all communities, hospitals and treatment centres under various arrangements as of March 31, 1999.

Picture of the Akwesasne complex First Hospital Transfer, Fort Qu'Appelle, December 1, 1995
Picture of the Fort Qu'Appell hospital First NNADAP Transfer, Viginia Fontaine Memorial, December 1, 1993

Chronology of Achievements and Events

  1. Achievements and Events:1989-1990
    The Department of National Health and Welfare, First Nations and Inuit Health Branch, received Cabinet approval for transferring federal resources for Indian Health programs south of 60th parallel to Indian control.
    Treasury Board approved the financial authorities and resources to support pre-transfer planning and to fund community health management structures.
    In July 1989, the Conseil Attikamek-Montagnais (Quebec) representing 10 Montagnais communities became the first Tribal Council to sign a commemorative Health Services Transfer Agreement.
    In August 1989, Sandy Bay Ojibway Nation became the second Tribial Council to sign a Health Services Transfer Agreement.
    In September 1989, Kitigan-Zibi Anishinabeg (River Desert) signed the third Health Services Transfer Agreement.
    Indian Health Symposium, Saskatoon, Saskatechewan, funded by First Nations and Inuit Health Branch. Theme: Indian Control and Management of Health Social Development.
    170 delegates.
    First Nations Health Transfer Forum, Toronto, Ontario. Funded by First Nations and Inuit Health Branch. Over 300 delegates attended.
    Band Nurses Workshop on the Transfer of Health Services, Hull, Quebec. Funded by First Nations and Inuit Health Branch. 50 Band-employed nurses attended.
    Funding provided to the Assembly of First Nations to establish the National Indian Health Commission.

    Publications: Health Program Transfer Handbook (Revised in 1999)
    Health Transfer Newsletter: three editions

    Picture of George Bacon

    Photo: George Bacon, President of the Conseil Attikamek-Montagnais during ceremonies to mark the signing in 1989 of the first Health Services Transfer Agreemnet. Photo credit: ClÚment Allard.

  2. Achievements and Events: 1990/1991
    Five 1st Level Health Services Transfer Agreements signed.
    Dental Therapy 2000 Transfer Workshop, Toronto, Ontario. 75 Delegates attended.

    Publications: Health Transfer Newsletter: three editions

  3. Achievements and Events: 1991/1992
    Eight 1st level Health Services Transfer Agreements signed.
    Short-Term Evaluation of Health Transfer: a review of the program rationale and the transfer process. Overall conclusion: The transfer initiative is completing its short-term objectives of enabling First Nations and Inuit to design programs and allocate funds according to community priorities. Recommendations were made of ways to further improve the transfer process.

    Publications: Health Transfer Newsletter: three editions
    Short-Term Evaluation of Indian Health Transfer
    First Nations Health Board - Orientation Handbook. (Revised in 1995 and 1999 and incorporated in Health Transfer Handbook 2 - Appendix E: Guide to Management Structures for First Nations).
    A Handbook for Indian Communities on Evaluating Health Programs (Revised in 1994 and 1999).

  4. Achievements and Events:1992/1993
    Nine 1st level Health Services Transfer Agreements signed.
    Treasury Board approves Community Workload Increase System (CWIS) as the mechanism to request resource requirements for health services provided at the community level.

    Picture of signing ceremony

    Photo: Signing ceremony, Lac Laronge health services transfer agreement, May 11, 1993. From left to right - Jim Roll, Regional Director, FNIHB, Ken McGregor, Dean Norton, Regional Transfer Manager, FNIHB, and Chief H. Cook.

    Publications: What First Nations Should Know about Insurance.
    (under revision). A Guide for First Nations in Developing a Community Health Needs Assessment. (under revision).

  5. Achievements and Events:1993/1994
    Eleven 1st level Health Services Transfer Agreements signed.
    Virginia Fontaine Memorial Centre (NNADAP Treatment Centre - Manitoba) Health Services Transfer Agreement signed December 1, 1993.
    The transfer of the Whitehorse General Hospital to the Government of the Yukon and the Yukon Hospital Corporation is completed.

    Publications: Personnel Guidelines for First Nation Health Boards. (under revision).
    Discussing Employment with First Nations Health Employers: A Guide for Nurses.
    Control of Drugs and Medical Supplies by First Nation Under Health Transfer Agreements (under revision)

  6. Achievements and Events:1994/1995
    Ten 1st level Health Services Transfer Agreements signed.
    Authority received from Treasury Board for the Integrated Community-Based Health Services Contribution Program.
    The long-term evaluation of health transfer initiated.

    Publications: Pension & Benefits: A Guide for First Nation Health Board. (under revision).
    A Handbook for First Nations Evaluating Health Programs. (Revised in 1999); Formerly: A Handbook for Indian Communities on Evaluating Health Programs - 1991.

  7. Achievements and Events:1995/1996
    Sixteen 1st level Health Services Transfer Agreements signed.
    The federal government announced the Inherent Right to Self-Government Policy
    Fort Qu'Appelle Hospital (Saskatchewan) transferred to the Touchwood File Hills Qu'Appelle Tribal Council.
    Le Centre de RÚadaptation Wapan (NNADAP Treatment Centre - Quebec) Health Services Transfer Agreement signed January 1, 1996.

    Publications: Revision: Choosing Consultants and Making the Best use of their Services. (discontinued)
    Pathways to First Nations Control Report of Project 07: Strategic Planning Exercise. (Replaced by Health Transfer Handbooks 1 & 2 - see Year Ten)
    Long-Term Evaluation of Transfer.

  8. Achievements and Events: 1996/1997
    Nine 1st level Health Services Transfer Agreements signed.
    The Weeneebayko Health Ahtuskaywin assumed responsibility for the administration of Moose Factory Hospital.

    Picture of the signing of the Kapown transfer

    Photo: Signing of the Kapown Treatment Centre transfer on April 1, 1997. From left to right - Chairman Frank Halcrow, Ruth Jongerius, Director Community-based Planning and Development, FNIHB, Don Leduc, Zone Director Treat 8, Barry Nesbit, Director Kapown Treatment Centre, and Effie Anderson, Director of Finance, Kapown T.C.

    Publications: Your Environmental Health Program.

  9. Achievements and Events: 97/1998
    Twenty-one 1st level Health Services Transfer Agreements signed.
    2nd & 3rd level services transfer: Anishinaabe Mino-Ayaawin Inc. (Interlake Reserves Tribal Council, Manitoba).
    Yukon Territory assumed the administration and delivery of universal health programs. The Council of Yukon First Nations is a party to the agreement.
    Four NNADAP Treatment Centre Health Services Transfer Agreements signed (2 Alberta, 1 Manitoba, 1 Quebec).
    Sagkeeng Solvent Treatment Program Inc. (Youth Solvent Abuse Treatment Program - Manitoba) Health Services Transfer Agreement signed June 1, 1997.
    Yukon Territory resumed administration and delivery of universal health programs.

    Publications: The Registered Nurse's Legal Authority to Handle Drugs.
    The Medical Officer and Transfer.

    Picture of Nisga'a Valley Health Board

    Photo: Nisga'a Valley Health Board transfer signing ceremony, New Aiyansh, B.C. March 21, 1988. From left to right, Peter Squires, Chariperson Nisga'a Valley Health Board, J.D. Nicholson, then ADM FNIHB, and Chief James Gosnell.

  10. Achievements and Events: 1998/1999
    Twenty-four 1st level Health Services Transfer Agreements signed.
    2nd & 3rd Level Transfer: Union of New Brunswick Indians.
    3rd Level Transfer: British Columbia Aboriginal Network on Disability Society.
    Vancouver Island Inter-Tribal Health Authority (British Columbia) - 2nd & 3rd Level Services.
    Three NNADAP Treatment Centre Health Services Transfer Agreements signed. (2 British Columbia, 1 Manitoba)
    Gathering Strength set out commitments under four themes: renewing the partnerships; strengthening Aboriginal governance; developing a new fiscal relationship; and building strong communities, people and economies.
    The First Canada/First Nations Funding Agreement (CFNFA) signed: Canim Lake.

    Picutre of the Nanaimo First Nation Transfer

    Photo: Nanaimo First Nation Health Services Transfer ceremony, August 11, 1999. From left to right Keith Wilson (back to camera), Brain Wilson, FNIHB, Yousuf Ali, Regional Post Transfer Manager, FNIHB, Councillor Jeff Thomas, Henry Lazar, Regional Transfer Manager, FNIHB, Sandra Good, the late Bill Wyse, and seated are Chief John Wesley and Willie Seymour.Publications: Health Transfer Handbook 1 - An Introduction to Three Approaches (Formerly known as The Health Program Transfer Handbook 1989).

    Health Transfer Handbook 2 - The Health Services Transfer. (Formerly known as The Health Program Transfer Handbook 1989).

    Health Transfer Handbook 3 - The New Environment.

    A Guide for First Nations on Evaluating Health Program. (Formerly known as A Handbook for First Nations Evaluating Health Programs 1994).

    Guide to Health Management Structures (Formerly known as First Nations Health Board - Orientation Handbook 1991).