Evaluation of the Aboriginal Health Human Resources Initiative 2013-2014 to 2017-2018

Project Profile

Through contribution agreements, the AHHRI aims to increase the number of First Nations, Inuit and Métis workers in the health care field, and to ensure that community-based workers are trained and certified to improve the quality and consistency of health care services provided in First Nations and Inuit communities.

Prior to December 2017, the AHHRI was delivered by Health Canada through the First Nations and Inuit Heath Branch (FNIHB). In December 2017, FNIHB was transferred to Indigenous Services Canada. Despite this change in departments, FNIHB continues to deliver the AHHRI.

Evaluation Scope and Methodology

The evaluation was completed in 2018-19 by Health Canada's Office of Audit and Evaluation and approved by Indigenous Services Canada (ISC).

The AHHRI provides funding through two streams. The evaluation examined the relevance, performance and efficiency of AHHRI Streams 1 and 2 from 2013-14 to 2017-18. Specifically, all Stream 1 activities delivered across Canada and Stream 2 activities delivered in every FNIHB region except British Columbia were examined. In British Columbia, responsibilities for federal health programs for First Nations have been transferred to the First Nations Health Authority in 2011.

Program Resources

1. Stream 1 - ($3.0 million/year) – provides funding to Indspire, an Indigenous-led registered national charity, for scholarships and bursaries to First Nations, Inuit and Metis students in post‑secondary education programs that lead to health careers.
2. Stream 2 ($1.5 million/year) – provides funding for the training of community based health care workers and health managers (in non-registered professions) working in health promotion and disease prevention in First Nations and Inuit communities.

The results of this evaluation are based on information collected through:

• Document and literature review;
• A review of Indspire annual monitoring reports and surveys of recipients; and,
• Interviews with 31 key informants from FNIHB national and regional program staff, associations of Indigenous health professionals; national Indigenous organizations; university student support services; and regional and community-based Indigenous health services organizations.

Relevance

There is a continued need to increase the number of Indigenous health workers, address financial barriers to accessing health studies and continue developing the capacity of First Nations and Inuit community health workers.

AHHRI's objectives align with Indigenous priorities around increasing the ability of communities to control their health services; increasing the number of Indigenous health workers and increasing the capacity of health workers in Indigenous communities. As well, the Government of Canada has consistently reiterated similar priorities over the last couple of years. 

There exists a variety of other programs similar to AHHRI but there is no clear evidence of duplication as those other programs target very specific groups or geographic locations.

Performance – Stream 1

• Through Indspire, a total of 3,064 scholarships and bursaries were awarded over the evaluation period; helping approximately 765 Indigenous students per year to participate in health post‑secondary studies.
• The financial assistance covered approximately 17 percent of student's financial needs and is perceived helping to pursue their education. It is not known if students would have been able to access their health studies without AHHRI's funding.
• The majority of students helped through AHHRI Stream 1 worked in a field related to their studies and served Indigenous population as part of their work.
• The Indspire application process for financial assistance is seen as being difficult for students to complete, especially for the level of funding provided.
• Prospective students often don't have the prerequisite education to access health studies and there is a need to do more to prepare them for post-secondary health studies.

Overall, AHHRI is more focused on helping students to complete their studies as opposed to increasing the number of Indigenous students in health studies.

Performance – Stream 2

• AHHRI Stream 2 funding is seen as helping to increase the qualifications of health workers in communities as well as contributing to improve health services.
• AHHRI has contributed to improving the capacity of First Nations communities to influence and control their health services by funding the creation of the First Nations Health Managers Association and the establishment of its certification program for health managers. This certification program is seen as improving the management capacity within communities.
• Challenges related to the design and delivery of Stream 2 pertain to the limited amount of funding compared to the existing needs, and the types of training that are eligible for funding.

Efficiency

Approximately 80 percent of the contribution provided to Indspire was redistributed to students. Considering that Indspire is actively engaged in outreach activities and promoting studies, the delivery of Stream 1 activities by this organisation allows some leveraging of resources, which can contribute to achieving AHHRI objectives.

Practices have been put in place in FNIHB regions to coordinate decision making around allocation of funding with First National and Inuit organisations or provinces and territories. However, planning could be improved to meet community health resources needs.

Recommendations

The findings from this evaluation have led to the following two recommendations:

Recommendation 1:

ISC should work with Indspire to increase accessibility to post‑secondary education in the health field by:

1. Streamlining the application process to make it easier to complete;
2. Developing supports to help students complete prerequisite courses; and
3. Building on existing outreach activities to increase the promotion of health careers across communities.

Recommendation 2:

ISC should ensure that training activities meet the needs of communities by:

1. Engaging with communities to determine the best way to utilise the Stream 2 funding; and
2. Increasing the coordination of AHHRI training activities with other similar ISC initiatives.

2.1 Evaluation Scope, Approach and Design

The evaluation focused on Stream 1 and 2 activities from April 2013 to March 2018. It covered all Stream 1 scholarships and bursaries offered across Canada and Stream 2 training delivered in all FNIHB regions except British Columbia, where responsibilities for federal health on‑reserve programs have been transferred to the First Nations Health Authority through the 2011 British Columbia Tripartite Framework Agreement on First Nation Health Governance.

The evaluation's design and data collection methods were guided by Treasury Board's Policy on Results (2016). The Assembly of First Nations (AFN) and Inuit Tapiriit Kanatami (ITK) were consulted during the development of the evaluation framework and were provided with an opportunity to review and comment on the evaluation instruments, the preliminary findings, and the evaluation report.

Recognizing that AHHRI represents a small program investment, the evaluation team opted for a calibrated approach that focused on the use of qualitative data and existing monitoring data collected by Indspire, the recipient-organization responsible for delivering Stream 1 scholarships and bursaries. Overall, the evaluation employed the following:

• a review of documents and files, including internal documents, the 2013 evaluation, program and regional reports and financial data;
• a review of Indspire annual monitoring reports and surveys of recipients;
• a review of published literature on Indigenous health human resources; and
• interviews with 31 key informants from FNIHB national and regional program staff, associations of Indigenous health professionals; national Indigenous organizations; university student support services; and regional and community-based Indigenous health services organizations.

The use of multiple lines of evidence and triangulation increased the reliability and validity of the evaluation findings and conclusions.

2.2 Limitations and Mitigation Strategies

Most evaluations face constraints that may affect the reliability of findings. Table 2 outlines the limitations encountered during this evaluation as well as the mitigation strategies put in place to increase the reliability of the evaluation findings. Overall, due to the use of a calibrated approach and, challenges related to availability of data and the context in which this program operates (i.e., small program exist alongside a multitude of similar programs), this evaluation is not able to provide clear answers about the impacts AHHRI had in terms of helping Indigenous people to work in health careers and of increasing the capacity of community health workers. It does, however, provide various examples of the benefits of AHHRI for health students and First Nations and Inuit communities. 

3.1 Relevance: Continued Need for the Program

There is a continued need for more Indigenous health workers who can contribute to improving the quality of services for Indigenous People.

The recent evaluation of the FNIHB Clinical and Client Care Program found that there is an insufficient level of cultural sensitivity in the delivery of health care. As reported in the literature, internal documents and key informants, the lack of cultural considerations in the provision of health care can manifest itself, among other things, through difficulty in accessing traditional medicine, difficulty in receiving care in Indigenous languages, racism toward Indigenous people or perception that services are culturally unsafe. This lack of cultural consideration or sensitivity can represent a real or perceived barrier to accessing health care for Indigenous people. For example, research has shown that racism against Indigenous peoples can lead them to avoid using health care in anticipation that they may be victimized^{Footnote 1}.

AHHRI supports the greater inclusion of cultural competencies in health care through its objective of increasing the number of Indigenous health workers. Program documents, the literature^{Footnote 2} and a few key informants from both FNIHB and regional or community Indigenous originations reported that Indigenous health workers with cultural and community insight can help ensure a greater inclusion of cultural considerations in the provision of health care. However, Indigenous people continue to be underrepresented in health occupations. As outlined in the 2016 Census data, the proportion of Indigenous people working in health occupations is two percentage points lower than the proportion of non-Indigenous people working in those same occupations (i.e., five percent of Indigenous people employed in 2015. worked in health occupations as compared to seven percent of the non-Indigenous population)^{Footnote 3} This suggests that there is a continued need to support Indigenous people to train for health occupations.

There is a need to address financial barriers to accessing health studies

Indigenous people continue to experience lower educational attainment than the non Indigenous population. For example, the 2016 Census data show that 34 percent of the Indigenous identity population aged 15 years and older had less than a high school certificate/diploma compared to 18 percent for the non-Indigenous population^{Footnote 4}. As explained in an Indspire document^{Footnote 5}, Indigenous people are underrepresented in all areas of education and face numerous barriers to accessing studies. These barriers can be academic, cultural, personal, emotional, financial or, related to language or home situation.^{Footnote 6}

According to some key informants from Indigenous organisations and university support services, the provision of financial assistance can help address the financial barriers faced by Indigenous students. Reasons provided by key informants are that the student’s family may often not have the financial means to support the students, and that demands related to the studies can limit the ability of students to work part-time while attending classes. Similarly, health career students who received financial assistance through Indspire reported that financial burden is the second most significant barrier they faced after fatigue and stress.^{Footnote 7}

There is also a need to continue developing the capacity of First Nations and Inuit community health workers

A few key informants from FNIHB mentioned that First Nations and Inuit communities (especially those in remote or isolated regions) often face challenges in terms of offering consistent health care services. As explained by key informants, this challenge may be due to difficulty in recruiting or retaining workers. Furthermore, key informants from FNIHB, regional/community Indigenous organisations and Indigenous health associations noted a need to increase the number of health workers in areas such as nursing, midwifery, health addiction, mental health, early childhood education, community support, dentistry and health care management.

Program documents and many key informants from regional and community Indigenous organisations reported the need within Indigenous communities for more skilled and competent health workers. In fact, a few key informants from regional and community organisations explained that developing the skills and capacity of currently employed workers is one of the biggest challenges they are facing. AHHRI can contribute to addressing those needs through both Stream 1 and Stream 2 activities.

3.2 Relevance: Alignment with Indigenous Priorities

AHHRI's objectives align with Indigenous health priorities identified in recent calls for action from Indigenous governance organisations. Program objectives also align with priorities identified by Indigenous representatives interviewed for this evaluation.

The AFN's 2017 First Nations Health Transformation Agenda recognized the need to continue addressing shortages of health professionals, Indigenous representation in the health workforce, cultural safety and competency, educational barriers at the pre- and post-secondary level, pay equity, and continuing professional education and peer support.^{Footnote 8}One of the AFN's recommendations included a call to increase AHHRI funding to its 2005-2010 level.

The ITK 2011-2021 Inuit Health Human Resources Framework & Action Plan^{Footnote 9} and its 2017 report An Inuit-Specific Approach to the Canadian Health Accord^{Footnote 10} also outlined the need to address shortages of health professionals in communities, barriers to education, recruitment and retention, and the need to support community workers.

Both the AFN and ITK documents contain recommendations that are aligned with the 2015 Truth and Reconciliation Commission of Canada's Final Report, which through its Calls to Action number 23 called all levels of government to^{Footnote 11}:

• Increase the number of Aboriginal professionals working in the health-care field;
• Ensure the retention of Aboriginal health-care providers in Aboriginal communities; and
• Provide cultural competency training for all health care professionals.

The principle underlying the issues and actions identified in the Truth and Reconciliation Commission and in the AFN and ITK documents is the need to empower Indigenous communities to achieve greater control over the determinants of community and individual health and well-being. Read together, these documents make a series of recommendations in the following areas, which are all aligned to AHHRI's objectives:

• Increasing the number of Indigenous people studying for and working in health careers, including addressing financial barriers to education;
• Increasing the capacity of health workers in Indigenous communities through improved access to training; and,
• Retaining health workers in Indigenous communities.

As well, a 2016 presentation by the Métis National Council identified a need for specific measures to support the development and implementation of specific health human resources strategies for First Nations, Inuit and Métis.^{Footnote 12}

Finally, many Indigenous key informants interviewed for the evaluation identified priorities around increasing the ability of communities to manage and control funding and priorities for health services. They also reported priorities around building the capacity of health services staff.

3.3 Relevance: Alignment with Federal Priorities

AHHRI aligns with federal priorities to increase the representation of Indigenous people in the Canadian workforce, to support Indigenous post-secondary education and skills development and to improve the delivery of health services in Indigenous communities. Various priority setting or policy documents issued over the last couple of years consistently reiterated those priorities.

The Government of Canada has accepted the Truth and Reconciliation's Calls to Action and the United Nations Declaration of the Rights of Indigenous People with the principles of increasing the autonomy and authority of Indigenous communities, bettering access to health care services and improving health outcomes of Indigenous populations.

In addition, over the last few years, the Government of Canada has continued to support Indigenous communities to control and influence their health services through various initiatives. These include the 2011 Tripartite Framework Agreement on First Nations Health Governance that led to the creation of the First Nations Health Authority in British Columbia and the signing of the Charter of Relationship Principles Governing Health System Transformation in Nishnawbe Aski Nation Territory in 2017. This agreement includes the objective of increasing community capacity to plan and deliver health services.^{Footnote 13}

Furthermore, the 2017 federal/provincial/territorial negotiations on federal funding for health care services led all parties to endorse a Common Statement of Principles on Shared Health Priorities.^{Footnote 14} This included a commitment for federal/provincial/territorial governments to work with First Nations, Inuit and Métis to improve health services and outcomes, respecting Indigenous health priorities as identified in the First Nations Health Transformation Agenda, An Inuit-Specific Approach to the Canadian Health Accord and the Métis health agenda.

Federal budgets from the last five years, as well as the Ministerial mandate letters for Health Canada in 2015 and Indigenous Services Canada in 2017, include commitments to increase the representation of Indigenous people in the Canadian workforce, to support Indigenous post‑secondary education and skills development and to improve access, quality and safety of health services in Indigenous communities.  

More recently, in January 2018, the Minister of Indigenous Services Canada reiterated the Department's priorities around improving Indigenous health outcomes and supporting the number of Indigenous people entering health careers.^{Footnote 15}

3.4 Relevance: Alignment with Federal Roles and Responsibilities

The federal role in Indigenous health human resources stems from constitutional obligations for services for First Nations on-reserve and Inuit people. This role has been evolving in recognition of the shared jurisdictions for health and education and the objective of empowering Indigenous communities.

The federal role in providing health services to First Nations and Inuit communities has been evolving since the Indian Health Policy of 1979 with the growing recognition that Indigenous communities are best placed to identify needs and manage service delivery. In 2012, The First Nations and Inuit Health Branch Strategic Plan: A Shared Path to Improved Health^{Footnote 16} recognized the complex, dynamic nature of the provision of health services for First Nations and Inuit, noting that a web of interdependent jurisdictional governance for health is shared by First Nations and Inuit, provincial/territorial and federal governments.

Likewise, the federal government has responsibility for elementary and secondary education in First Nations communities and has taken up a role in supporting post-secondary education and skills training for Indigenous people.

The Government of Canada's role in supporting health services in Indigenous communities and in providing support for post-secondary education for Indigenous students has been reiterated recently in the 2017 Ministerial mandate letter for Indigenous Services Canada.

3.5 Relevance: Complementarity or Duplication of Efforts

While a variety of financial assistance opportunities exist to support Indigenous post secondary students, they do not appear to duplicate grants and scholarships offered under AHHRI Stream 1. Other programs are more targeted to specific groups of students or geographic areas. Likewise, for Stream 2, although other programs support training of health workers in communities, there is no clear evidence of duplication since they tend to target job specific requirements or competencies.

3.6 Performance: Achievement of Stream 1 (Scholarships and Bursaries) Outcomes

3.7 Performance: Achievement of Stream 2 (Training for community based health workers and managers) Outcomes

4.1 Program Budget and Expenditures

AHHRI expenditures have decreased from approximately $13.6 million in 2013-14 to $5.8 million in 2017-18. Actual spending on Stream 1 and 2 contribution funding approximated $3.5 and $1.5 million respectively in the last two years of the evaluation period.

As shown in Table 6, AHHRI expenditures have decreased over the evaluation period and planned spending has been reallocated to other program priorities within FNIHB. Program spending has remained relatively consistent since 2015-2016 and ranged between $5.7 and $5.8 million per year.

4.2.1 Use of third-party delivery of Stream 1

Approximately 80 percent of the contributions provided to Indspire were redistributed in scholarships and bursaries. Considering that Indspire is actively engaged in outreach activities and promoting studies, the delivery of Stream 1 through this organisation allows some leveraging of resources, which can contribute to achieving AHHRI objective.

The 2015-16 program data demonstrated that, of the contributions provided to Indspire, 80 percent was directly redistributed to students in scholarships and bursaries. While actual amounts for the remaining 20 percent of expenditures are unknown, budget documents outline that the remaining funds were to be used for outreach and marketing (approximately one percent); monitoring and tracking (approximately one percent) and the balance for staffing and administration costs (approximately 18 percent).

In comparison, a 2016 evaluation of the Canadian Institutes of Health Research's Canada Graduate Scholarships program demonstrated that the average overhead cost was 1.8 percent, but the report noted that this was underestimated, as it did not include award administration costs borne by universities, or other similar costs.^{Footnote 30} As well, the 2007 annual report of the Canada Millennium Scholarship Foundation showed that the ratio of administrative costs compared to the total of awards distributed was seven percent.^{Footnote 31}

It should be noted that Indspire undertakes outreach and marketing activities beyond activities funded under AHHRI Stream 1, which can contribute to achieving AHHRI's goal of increasing the number of Indigenous people working in health careers. In this way, program delivery through Indspire allows some leveraging of resources, which can contribute to AHHRI's objective. As previously discussed in this report, Indspire runs outreach programs to help elementary and secondary students build their vision of an education future and hosts an annual Awards gala that serves to publically recognize significant achievements among Indigenous people across Canada. AHHRI contributed funding in 2015-16 and 2016-17 to the Indspire Awards gala.

4.2.2 Coordination of Stream 2 programming

Practices have been put in place in FNIHB regions to coordinate decision making around allocation of Stream 2 funding with First Nations and Inuit organisations or provinces and territories. However, more could be done to coordinate the planning of AHHRI funding to better meet community health human resources needs.

Coordination between stakeholders on Stream 2 AHHRI funding decisions was observed in most regions. For example, in some regions, FNIHB and provincial government representatives were involved in funding decisions. In the northern region, as explained by some key informants, FNIHB held trilateral planning discussions with Inuit organizations and the Government of Nunavut (within the context of the Northern Wellness Agreement) in order to collectively identify priorities for how to use funding programs such as AHHRI.

In each of the Alberta, Manitoba, and Atlantic regions, annual Stream 2 funding was granted through a single contribution agreement in order to lower the administrative burden.

Although some level of coordination is taking place within the regions, a few internal and external key informants noted a lack of coordinated planning around the use of AHHRI funds to meet community health human resource needs and to ensure greater synergy with other FNIHB programs.

5.1.1 Relevance

There is a continued need for programming that aims to increase the number of Indigenous health workers, address financial barriers to accessing health studies and develop the capacity of First Nations and Inuit community health workers. AHHRI's objective is also aligned with Indigenous priorities around increasing the ability of communities to manage and control their health services; increasing the number of Indigenous people working in health careers and increasing the capacity of health workers in Indigenous communities. The Government of Canada has consistently reiterated similar priorities in recent years.

There are numerous examples of other programs that provide financial assistance to Indigenous students or training to First Nations and Inuit health workers. However, there is no clear evidence of duplication as those other programs target very specific groups or geographic locations.

5.1.2 Achievement of outcomes

Over the evaluation period, 3,016 AHHRI Stream 1 scholarships and bursaries have contributed to helping approximately 765 Indigenous students per year to participate in health post‑secondary studies. The financial assistance covered approximately 17 percent of student financial needs and is perceived as helping them to pursue their studies. Overall, the majority of students helped through AHHRI Stream 1 worked in a field related to their studies and served the Indigenous population as part of their work.

A few challenges were identified with respect to the design and delivery of Stream 1. In particular, the application process for the financial assistance is seen as being difficult for students to complete, especially for the level of funding provided. As well, a lack of prerequisite education is one of the biggest barriers faced by Indigenous people in terms of accessing health studies. Key informants identified a need to do more to help prospective student obtain the necessary skills to enroll in post‑secondary health programs. In this regard, evaluation findings suggest that AHHRI Stream 1 is focussed on helping students to complete their health studies as opposed to increasing the number of students enrolling in health studies.

AHHRI Stream 2 funding has supported the training for community-based workers in a variety of domains and is seen by key informants as helping to increase the qualifications of health workers in communities as well as contributing to improving health services. The evaluation has found compelling examples of how AHHRI has contributed to improving the capacity of First Nations communities to influence and control their health services. Specifically, AHHRI helped fund the creation of the First Nations Health Managers Association and the establishment of its certification program for health managers, which is seen as improving the management capacity within communities. Challenges related to the design and delivery of Stream 2 pertain to the limited amount of funding allocation compared to the existing needs, the eligibility criteria, which do not allow communities to get support for some training that could help increase the capacity of their health workers.

5.1.3 Efficiency

Approximately 80 percent of the contributions provided to Indspire were redistributed in scholarships and bursaries to students. In comparison, with other student financial assistance programs, overhead costs incurred by Indspire are high. However, considering that Indspire is actively engaged in outreach activities and promotion of studies, the delivery Stream 1 activities through this organisation allows some leveraging of resources, which can contribute to achieving AHHRI objectives.

Practices have been put in place in FNIHB regions to coordinate decision making around allocation of Stream 2 funding with First Nations and Inuit organisations or provinces and territories. However, more could be done to ensure that decisions around allocation of funding contribute to meeting community health resources needs.

Recommendation 1:

Indigenous Services Canada should work with Indspire to increase accessibility to post‑secondary education in the health field by:

1. Streamlining the application process to make it easier to complete;
2. Developing supports to help students complete prerequisite courses; and
3. Building on existing outreach activities to increase the promotion of health careers across communities.

Recommendation 2:

Indigenous Services Canada should ensure that training activities meet the needs of communities by:

1. Engaging with communities to determine the best way to utilise the Stream 2 funding; and
2. Increasing the coordination of AHHRI training activities with other similar ISC initiatives.